Impacted bone fragment in a small-bowel diverticulum: an extremely rare cause of obscure gastrointestinal bleeding

Obscure gastrointestinal tract bleeding (OGIB) is a common and challenging issue [1]. Here we present an extremely rare case of overt OGIB secondary to impacted bone fragment within a small-bowel diverticulum.

An 88-year-old man presented with hypotension and a 2-day history of maroon-colored stools. Initial hemoglobin concentration was 7.7 g/dL. Urgent upper endoscopy showed a large duodenal diverticulum with no signs of bleeding. Colonoscopy was also unremarkable. Capsule small-bowel study was attempted, but the capsule was retained in the duodenal diverticulum, requiring endoscopic retrieval. Mesenteric angiography was negative. Delayed images on Tc-99m-labeled red blood cell scan showed activity in the small bowel. Antegrade and retrograde single-balloon enteroscopy to the distal jejunum and proximal ileum showed large-mouthed diverticula but no signs of active bleeding. Intraoperative enteroscopy showed a segment in the mid-small bowel with multiple large-mouthed diverticula, including one diverticulum with a blood clot suggestive of recent bleeding ([Fig. 1], [Fig. 2]). Segmental resection of this small-bowel segment containing the bleeding diverticulum and surrounding large-mouthed diverticula (approx. 60 cm) was performed. Postoperatively, the patient’s hemoglobin levels remained stable with no further episodes of gastrointestinal bleeding. Examination of the resected small-bowel specimen showed large diverticula with a single diverticulum having an impacted 3-cm bone fragment with hemorrhagic changes in the surrounding mucosa ([Fig. 3]).

Fig. 1 Large-mouthed small-bowel diverticulum.

Fig. 2 Evidence of bleeding in a small-bowel diverticulum.

Fig. 3 a, b Small-bowel diverticulum with impacted bone fragment.

Most of the cases of OGIB are due to small-bowel pathology. Identifying and treating the etiology of OGIB can be challenging [2]. There are only few case reports of foreign body ingestion causing OGIB. Our case is the first report of a bone fragment causing OGIB [3] [4].

Endoscopy_UCTN_Code_CCL_1AC_2AH

• References

• 1 Singh A, Baptista V, Stoicov C et al. Evaluation of small bowel bleeding. Curr Opin Gastroenterol 2013; 29: 119-124
• 2 Raju GS, Gerson L, Das A et al. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology 2007; 133: 1697-717
• 3 Samyn I, Reynaert H, Op de Beeck B et al. Recurrent gastrointestinal blood loss of obscure origin: report of an exceptional case. Acta Gastroenterol Belg 1998; 61: 382-384
• 4 Nanavati SA, Opekun AR, Hacken-Bitar JB et al. Migrating shell fragment as a cause of recurrent obscure gastrointestinal bleeding. J Clin Gastroenterol 2004; 38: 137-138