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Thinking out of the Gut: a case of obscure lower GI bleeding
  1. Frederick H Koh1,
  2. Hian-Li Chan2,
  3. Fredrik Petersson2,
  4. Choon-Seng Chong1
  1. 1Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, National University Health System, Singapore, Singapore
  2. 2Department of Haematology-Oncology, National Univeristy Hospital, National University Health System, Singapore, Singapore
  3. 3Department of Pathology, National University Hospital, National University Health System, Singapore, Singapore
  1. Correspondence to Choon-Seng Chong, Division of Colorectal Surgery, University Surgical Cluster, National University Health System, 1E Kent Ridge Road, Singapore 119228; choon_seng_chong{at}nuhs.edu.sg

Abstract

Clinical presentation A middle-aged man was admitted for episodes of fresh per-rectal bleeding, which were not associated with defecation. He was recently investigated for macrocytic anaemia in the outpatient haematology clinic. Examination of the perineum revealed grade 1 internal haemorrhoids with no signs of bleeding.

Initial laboratory tests revealed macrocytic anaemia (haemoglobin 10.5 g/dL, normal 12.9–17.0  g/dL; mean corpuscular haemoglobin 95.3 fL, normal 80.0–95.0  fL). Peripheral blood film showing blasts, dysplastic neutrophils, nucleated red blood cells and hypogranular platelets.

The patient underwent a sigmoidoscopy and rubber band ligation of the internal haemorrhoids after persistent fresh per-rectal bleeding. The bleeding persisted with the development of hypotension and a significant drop of haemoglobin to 4.8 g/dL requiring blood transfusions and intensive care monitoring. Repeated endoscopy, including intubation of the terminal ileum, revealed uncomplicated right-sided diverticulosis. CT mesenteric angiography performed during an episode of significant bleeding revealed extravasation of contrast in the ileum, but mesenteric angiography was unsuccessful, possibly due to a temporary cessation of bleeding. Bleeding subsequently recurred and in light of the persistent bleeding with no clear source and with a total of 12 units of packed cell transfused, exploratory laparotomy, on-table enteroscopy (figure 1) with small bowel resection was performed. Histopathological examination of the specimen was performed (figures 24).

Figure 1

Multiple ileal lesions with stigmata of recent bleed.

Figure 2

Area of ulceration associated with atypical mononuclear infiltrate.

Figure 3

Atypical mononuclear infiltrate composed of cells with enlarged, irregular nuclei containing variably prominent nucleoli.

Figure 4

Atypical cells displayed cytoplasmic expression of myeloperoxidase.

Question What is the diagnosis?

  • GASTROINTESTINAL BLEEDING

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Footnotes

  • Contributors FHK: study concept and design, acquisition of data, drafting manuscript and critical revision. FP: acquisition of data and critical revision. CSC: study concept and design and critical revision.

  • Competing interests None.

  • Ethics approval Approved by the National Healthcare Group Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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