SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 21 CASE SERIES Figure 4. Definitions of OGIB and its subcategories. small bowel bleeding with a reported incidence varying between 7 – 10%. 6–8 The most common cause for SBU is Crohn’s disease. 9,10 Severe acute bleeding from SBU secondary to Crohn’s disease is even more rare. 10 Reported incidence ranges between 0.6 – 4%. 11 Medications associated with de novo SBU include NSAID’s, potassium and 6-Mercaptopurine. 9,12 Ulcerations usually result in chronic blood loss with overt bleeding underlying erosion into sizeable vessel, as was the situation in this patient, being extremely rare. Hence most of these lesions require video capsule endoscopy to make the diagnosis and medical therapy. Treatment options in the unremitting bleed include interventional natural orifice enteroscopy or as in this patient interoperative enteroscopy and segmental resection of the involved small bowel. Case 3 : Small bowel diverticulosis The third case in the series is a 73 year old female who was referred to our service for further workup following presentation to a district facility with an acute GI bleed and symptomatic anaemia. Work up at her base hospital included a gastroscopy which showed mild antral gastritis. Subsequently she had a repeat episode of GI bleeding requiring transfusion. At our facility, a CT Angiogram of the abdomen and pelvis was performed which revealed no evidence to support active GI haemorrhage. Of note there were incidental uncomplicated colonic diverticula present. Figures 3a, b and c. Intra operative images - Laparotomy for OGIB secondary to Small Bowel Diverticulosis. Large Jejunal Diverticulum (1), small bowel can be seen distended with blood (2). Light from the scope can be seen illuminating the segment (3). Bleeding point visible on closeup (4) Figure 3d and e. Intra operative endoscopy for OGIB secondary to Small Bowel Diverticulosis. D: Visible clot in diverticulum (arrow). E: Closeup of same. She was admitted for observation and had a further episode of GI bleeding with haemodynamic instability. The decision was made to perform a repeat upper and lower endoscopy in theatre to determine the site of the bleeding. Colonoscopy showed the colon to be filled with blood up to the caecum with no evidence of active bleeding. Gastroscopy was negative. The decision was then made to proceed with an exploratory laparotomy. A 70cm segment of jejunum, 30cm from the ligament of Treitz, with multiple diverticula as well as evidence of recent bleeding was identified. The small bowel was filled with blood and haemorrhagic stigmata were present on the surface of the bowel. (Figure 3a, b and c) A segmental resection and end to end anastomosis was performed. Her post-operative course was uneventful. Formal histology revealed diverticulosis with a foci of diverticulitis present in the resected segment. Small Bowel Diverticulosis (SBD) is itself a rare entity. Jejunal diverticula are incidentally found in approximately 2% of individuals and are usually asymptomatic. Symptoms are usually related to symptoms of GI disturbances such as diarrhoea and steatorrhea. 9 Bleeding from SBD is very rare and as such OGIB should not be attributed to identified SBD unless other causes have been excluded. SBD is thought to arise due to the same mechanisms as in colonic diverticulosis. During increases in luminal pressure, mucosal and sub mucosal layers herniate through the muscularis layer. When associated with overlying blood vessels they can become prone to bleeding. 13 Treatment in the symptomatic patient with active bleeding, will require segmental resection of the affected bowel. It is however exceeding rare that these diverticula will require emergency surgery due to hemodynamically unstable bleeding. 13 Discussion Obscure gastrointestinal bleeding (OGIB) is a diagnostic and treatment dilemma. Figure 4 shows The American Gastroenterological Association definitions and subcategories (occult and overt of OGIB). Patients presenting with GI bleeding undergo upper endoscopy followed by a lower endoscopy if the cause was not established. Thus, a more eloquent and formal definition of OGIB is that of persistent or recurrent bleeding from the gastrointestinal tract after negative evaluations with upper and lower endoscopies. 14 Common causes of OGIB of small bowel origin include angiodysplasias of the small bowel, Crohn’s disease, small bowel tumours andMeckel’s diverticulum. Dieulafoy lesions, ectopic varices and melanoma are other notable causes. Haemobilia accounts for less than 1% of all causes of OGIB and haemosuccus pancreaticus even less. 9,14 (Table 1) Overt OGIB is the subcategory related to all the patients in this