Obscure bleeding colonic duplication responds to proton pump inhibitor therapy

Abstract

We report the case of a 17-year-old male admitted to our academic hospital with massive rectal bleeding. Since childhood he had reported recurrent gastrointestinal bleeding and had two exploratory laparotomies 5 and 2 years previously. An emergency abdominal computed tomography scan, gastroscopy and colonoscopy, performed after hemodynamic stabilization, were considered normal. High-dose intravenous proton pump inhibitor (PPI) therapy was initiated and bleeding stopped spontaneously. Two other massive rectal bleeds occurred 8 h after each cessation of PPI which led to a hemostatic laparotomy after negative gastroscopy and small bowel capsule endoscopy. This showed long tubular duplication of the right colon, with fresh blood in the duplicated colon. Obscure lower gastrointestinal bleeding is a difficult medical situation and potentially life-threatening. The presence of ulcerated ectopic gastric mucosa in the colonic duplication explains the partial efficacy of PPI therapy. Obscure gastrointestinal bleeding responding to empiric anti-acid therapy should probably evoke the diagnosis of bleeding ectopic gastric mucosa such as Meckel’s diverticulum or gastrointestinal duplication, and gastroenterologists should be aware of this potential medical situation.

Keywords: Colonic duplication, Gastro-intestinal duplication, Gastrointestinal bleeding, Hemostatic colorectal surgery, Proton pump inhibitor therapy

Core tip: Obscure lower gastrointestinal bleeding is a difficult medical situation and potentially life threatening. The collaboration between endoscopists and radiologists usually allow location of the source of bleeding, but some rare situations, such as gastrointestinal malformations, need surgical intervention to diagnose and concomitantly treat an obscure bleeding source. In terms of medical therapy, only proton pump inhibitor therapy has efficacy in peptic ulcer disease. Obscure gastrointestinal bleeding responding to empiric antacid therapy should suggest the diagnosis of bleeding ectopic gastric mucosa such as Meckel’s diverticulum or gastrointestinal duplication, and gastroenterologists should be aware of this potential medical situation.