Keywords |
| Gastrointestinal bleed, jejunal diverticula, lower gastrointestinal tract. |
Introduction |
| Lower Gastro-Intestinal Bleeding (LGIB) is bleeding occurring distal to the ligament of
Trietz. It may present as hematochezia ranging from minor to severe, the latter being
occasionally lethal. Almost 20% of all severe gastro-intestinal bleeding may appear as cases
of LGIB.1 |
| Common causes of the condition include Inflammatory Bowel Disease, haemorrhoids, anal
fissures, neoplastic conditions and coagulopathies.2 A rare cause includes superior mesenteric
artery (SMA) dissection resulting in thrombosis and bowel ischemia. It may occur as a
complication of aortic dissection3. Uncommonly, small bowel diverticula may also present
with a similar picture. However, they are usually asymptomatic and difficult to treat and
diagnose.4 |
Case Report |
| A 40 year old man presented with severe, sudden onset of breathlessness, fatigue and bloody
stools for the past 10 days. Bleeding was fresh, profuse and constant with a frequency of 5
times per day. It was not associated with pain. He had undergone aortic valve replacement
last year and had been on warfarin therapy since then. |
| Examination revealed blood pressure of 100/60 mmHg, pulse 90/min, Temperature 99.2° F,
with marked pallor, raised JVP and systolic murmurs. Complete blood count revealed
haemoglobin of 7.1 mg/dl, total red blood cell count of 2.65x 1012/L and total leukocyte count
of 19.9x 109 /L. Neutrophils were 83%, serum urea was 11.5 mmol/L and creatinine was
142μmol/L. Coagulation profile was deranged. His blood pH and lactate levels were normal.
He was stabilized with transfused blood and Fresh Frozen Plasma (FFPs). Bedside echo
showed more than 5 cm dilatation of ascending and descending aorta. Upper GI endoscopy
revealed an ulcer in the proximal portion of duodenum with the histopathology report
showing a benign nature. Colonoscopy showed presence of fresh blood in the gut. CT
angiography was arranged which showed type “A” aortic dissection with extension into
superior mesenteric artery. |
| A provisional diagnosis of aorto-enteric fistula or ischaemic gut secondary to thrombosis due
to extension of dissection into superior mesenteric artery was made. Ct angiography showed
the same results. Exploratory laparotomy was done with the view to either resect gangrenous
bowel or carry out an aorto-mesenteric bypass in case of occluded SMA. However, it showed
normal superior mesenteric artery and its dependant bowel area, although multiple actively
bleeding jejunal diverticula were found on the mesenteric border. They were resected and
end-to-end anastomosis was done. |
| The patient was followed up after the procedure in the post operation ward. His bleeding had
stopped and his blood stats were improving. |
Discussion & Conclusion |
| Lower Gastro-intestinal Bleeding is an important cause of severe lethal bleeding and death in
adults. Aortic dissection is a rare cause of this condition. While it usually presents with chest
and abdominal pains, it may also manifest as lethal LGIB.3 This may occur as a result of
extension into Superior Mesenteric Artery (SMA) with the subsequent thrombosis causing
severe bowel ischemia in the tissue distribution of the vessel. Consequently, severe LGIB
may occur resulting in signs of shock.5 This was the suspected cause of LGIB in our patient.
He had previous history and confirmed diagnosis of aortic dissection type “A” extending to
SMA thus raising the likelihood of bleeding secondary to ischaemic gut. However, another
rare cause, jejunal diverticula must be kept in the differential diagnosis of such patients. They
are particularly difficult to diagnose both as a result of lack of routine bowel endoscopies and the low yield of the procedure 6, leaving laparotomy to be the diagnostic and therapeutic tool
in such cases.7,8,9 The latter procedure was carried out to determine the site of the ischaemic
gut in our patient. However, jejunal diverticula were found to be the most probable cause of
LGIB in the absence of any ischaemic gut. |
| This case report therefore highlights the importance of rare causes of LGIB in the adult
population including those mentioned in the above case discussion. It also goes to show that a
relatively benign condition such as jejunal diverticula may mimic the clinical presentation of
a more sinister cause such as SMA thrombosis and bowel ischaemic, the latter associated
with greater morbidity and mortality. Nonetheless, a high index of suspicion for these is a
must to effectively manage and save the patient’s life. |
Abbreviations used |
| LGIB: Lower Gastrointestinal bleed |
| SMA: Superior mesenteric artery |
Authors' Contributions |
| • Muhammad Usman Shah: Patient data collection, literature review and writing of
the manuscript. |
| • Moarij Amer Qazi: Patient data collection and literature review of the article. |
| • Mobasser Mahmood: literature review and writing of the manuscript. |
| • Ahsin Manzoor Bhatti: Selected the case report and presented the basic theme of
the article, supervised and corrected it. |
| Conflict of interest |
| None |
References |
- Kagir B, Katz J. Lower Gastrointestinal Bleeding; Background. Medscape https://emedicine.medscape.com/article/188478-overview; Published June 1, 2011. Accessed June 18, 2012.
- Kagir B, Katz J. Lower Gastrointestinal Bleeding; Etiology. Medscape https://emedicine.medscape.com/article/188478-overview#aw2aab6b2b4aa; Published June 1, 2011. Accessed June 18, 2012.
- Nath HP, Jaques PF, Soto B, Keller FS, Ceballos R. Aortic dissection masquerading as gastrointestinal disease. CardiovascInterventRadiol. 1986;9(1):37-41.
- Brasoveanu V, David L, Buga I, Popescu I. A rare cause of lower digestive hemorrhage--jejunal diverticulosis Chirurgia (Bucur). 2005 Jul-Aug;100(4):369-72.
- Sharifi M, Sorkin R, Lakier J, Chaitra S. Thoracic aortic thrombosis as a cause of bowel ischemia. A case report.Angiology. 1994 Nov;45(11):973-7.
- Brasoveanu V, David L, Buga I, Popescu I. A rare cause of lower digestive hemorrhage--jejunal diverticulosis Chirurgia (Bucur). 2005 Jul-Aug;100(4):369-72.
- Yamaner S, Akyüz M, Buğra D. Massive lower gastro-intestinal bleeding due to small bowel diverticula. A report of two cases.ActaChir Belg. 2006 Jul-Aug;106(4):427-9.
- Tan KK, Liu JZ, Ho CK. Emergency surgery for jejunal diverticulosis: our experience and review of literature. ANZ J Surg. 2011 May;81(5):358-61.
- Ríos A, Montoya MJ, Rodríguez JM, Parrilla P. Acute lower gastrointestinal hemorrhage originating in the small intestine. Rev EspEnferm Dig. 2006 Mar;98(3):196-203.
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