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An unusual case of chronic blood loss in the small intestine
  1. G Wurm Johansson,
  2. A Nemeth,
  3. J Nielsen,
  4. H Thorlacius,
  5. E Toth
  1. Department of Clinical Sciences, Skåne University Hospital, Malmö, Sweden
  1. Correspondence to Dr Gabriele Wurm Johansson, Skåne University Hospital, Department of Clinical Sciences, Endoscopy Unit, Entrance 44, plan 4, Malmö 205 02, Sweden; gabriele.wurmjohansson{at}skane.se

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Clinical presentation

A 62-year-old man presented with a 1-year history of fatigue and iron-deficiency anaemia. He had a history of ischaemic heart disease, chronic heart failure and hypertension. He reported normal appetite, normal bowel functions and denied weight loss. Physical examination revealed normal vital parameters, a non-tender abdomen without signs of organomegaly, and normal breathing sounds. Laboratory tests showed iron-deficiency anaemia with slightly decreased values of haemoglobin (115 g/l), mean corpuscular volume (MCV; 76 fl), ferritin (7.4 μg/l), iron (7 μmol/l), iron saturation (0.09), and increased levels of B-type natriuretic peptide (54 pmol/l). Haemoglobin in faeces was negative. Neither gastroscopy nor colonoscopy identified any pathological findings. Further work-up with videocapsule enteroscopy (PillCamSB; Given Imaging, Yoqneam, Israel) revealed a suspect elongated polyp-like tumour anchored with a stalk when the capsule had passed 70% of intestinal passage time (figure 1).

Figure 1

Videocapsule enteroscopic picture showing a polyp-like tumour in the small intestine.

Question

What is the diagnosis?

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Answer

From the question on page 773

Double-balloon enteroscopy identified a 4 cm long finger-like polypoid lesion 80 cm proximal to the ileocaecal valve with erosion on the top (figure 2A,B). Histology from the lesion revealed gastric mucosa confirming that this was a case of inverted Meckel's diverticulum (figure 3). This condition results from persistence of the omphalo-mesenteric duct and represents the most common congenital anomaly of the gastrointestinal tract with a prevalence of approximately 2%.1 It is usually located about 60–100 cm from the ileocaecal valve with a 4% life-time risk of complications such as acute haemorrhage, diverticulitis, perforation, intussusception and small-bowel obstruction.2 3 Chronic bleeding from a Meckel's diverticulum is uncommon.4 Mechanisms for acute and chronic blood loss in Meckel's diverticulum are erosions and ulcerations due to heterotopic gastric or pancreatic tissue, and repeated mucosal mechanical trauma due to intermittent intussusception.2 Treatment of symptomatic Meckel's diverticulum is surgical resection.

Figure 2

Double-balloon enteroscopic pictures showing a finger-like polypoid lesion with erosion 80 cm proximal to the ileocaecal valve.

Figure 3

Microphotograph of the biopsy from the small intestinal polypoid lesion showing gastric mucosa.

Diagnostic methods to investigate Meckel's diverticulum are enteroclysis, CT, magnetic resonance tomography, ultrasound, angiography and radionuclide Meckel's scan.5 New developments in small-bowel endoscopy, such as wireless capsule endoscopy and double-balloon enteroscopy, are currently changing the diagnostic strategies in small-bowel diseases. To our knowledge, this is the first case of an inverted Meckel's diverticulum detected by capsule endoscopy and double-balloon enteroscopy.

References

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Footnotes

  • Competing interests None to declare.

  • Patient consent Obtained.

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

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