Catastrophic Gastrointestinal Bleeding: Always Consider Meck
An 18-year-old man presented to the emergency department (ED) with traumatic brain injury after syncope. He had a medical history of rectal bleeding in the last 3 months.
Abdominal examination revealed mild and tender abdominal distension, without rebound or guarding, and normal bowel sounds. Digital rectal examination revealed no mass or tenderness, but dark-red blood coated the examination glove. Another episode of syncope occurred after profuse haematochezia.The patient was treated with intravenous fluids, packed red blood cell (RBC) transfusion and intravenous proton pump inhibitors.

On the third day of admission, the patient developed haemodynamic instability due to the persistence of rectal bleeding, He was admitted to the intensive care unit because of hypovolaemic shock, and received fluids and transfusion support with RBC and fresh frozen plasma. However, GI bleeding continued, so mesenteric angiography was performed but did not show active contrast extravasation. A retrograde double balloon enteroscopy was also inconclusive After enteroscopy, the patient developed massive rectal bleeding with haemodynamic instability that progressed to haemorrhagic shock. An emergent laparotomy was performed to identify the cause of bleeding, and revealed a small bowel diverticulum on the antimesenteric border (Fig. 1). It was located 130 cm from the ileocaecal valve and had a wide base and a palpable mass at the tip. Downstream, the bowel was markedly dilated and filled with haematic content. An enteric segmental surgical excision encompassing the diverticulum was performed with a terminoterminal hand-sewn single-layered extra-mucosal continuous anastomosis.

In the post-operative period, the patient maintained haemodynamic stability with no evidence of blood loss and achieved restoration of bowel function on the 4th day.

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