(435) Sudden Onset of Massive Small Bowel Diverticular Bleeding Necessitating Exploratory Laparotomy

Introduction: Small bowel diverticula are usually asymptomatic and often discovered incidentally. Due to the nature of their presentation and their ability to evade diagnostic tests, they can result in serious complications, particularly in the case of hemorrhage.

Description: We report a case of a 79-year-old male with a history of coronary artery disease, atrial fibrillation, and hypertension. He presented to the emergency department with diffuse abdominal pain and nausea. Initial workup, including an abdominal X-ray, CT scan, and blood tests, suggested a possible large bowel obstruction. A Gastrografin enema was subsequently performed, revealing no evidence of obstruction. The patient received a bowel regimen over the next few days and showed signs of improvement. On hospital day five, he experienced bloody bowel movements and a significant drop in hemoglobin levels, requiring the transfusion of 5 units of blood. Further tests, including CT angiography (CTA), EGD, and colonoscopy, did not find any active source of bleeding. However, he continued to have bloody bowel movements and low hemoglobin, leading to an urgent exploratory laparotomy. During surgery, multiple hemorrhagic diverticula in the proximal small bowel were found, and a 135 cm segment was resected. Post-surgery, his condition improved, and hemoglobin levels stabilized.

Discussion: Small bowel diverticular bleeding is a rare diagnosis and poses a significant diagnostic challenge. An extensive investigation, including X-ray, CT, CTA, Gastrografin enema, EGD, and colonoscopy, was conducted throughout the patient’s hospital course. However, the source of bleeding remained unknown until exploratory surgery was performed, revealing multiple hemorrhagic diverticula in the small bowel. Although not routinely utilized, previous studies on CT enterography with contrast have shown promising efficacy in detecting small bowel diverticular bleeding. In cases where noninvasive diagnostic methods fail to identify the source of gastrointestinal bleeding, timely surgical intervention may become imperative to prevent massive blood loss and serious outcomes. Maintaining a high suspicion for small bowel diverticula as a differential diagnosis for gastrointestinal bleeding, along with close monitoring of hemodynamic changes, is essential.