Case Presentation: A 24-year-old Caucasian man with no significant medical history presented with sudden onset of several episodes of bright red blood per rectum. He denied use of any NSAIDs and had no family history of inflammatory bowel disease. He reported having around 7 episodes of bright red bowel movements and a syncopal episode. He denied any abdominal pain, nausea, or vomiting. His abdominal exam was very benign. In the emergency room, he was evaluated and found to have hemoglobin of 9 and no leukocytosis, but tachycardia and slight hypotension. He was admitted to the ICU, and GI was consulted and took him for emergent endoscopy. He had normal EGD and colonoscopy. His blood counts improved with transfusion, but he continued to have intermittent bright red bleeding per rectum. He also underwent a tagged RBC scan, which didn’t show the source of the bleed. The diagnostic dilemma remained unresolved, so further evaluation was performed with a small bowel series and capsule endoscopy, which also turned out to be negative. Since all other workups had been negative, the patient underwent a Meckel’s scan, which was positive for Meckel’s diverticulum with positive gastric mucosa. The patient was referred to general surgery for surgical resection.
Discussion: Meckel’s diverticulum is true diverticulum, containing all layers of the bowel. It results from incomplete obliteration of the vitelline duct leading to the formation of a true diverticulum of the small intestine. The rule of twos is that Meckel’s occurs in approximately 2 percent of the population, is located within 2 feet from the ileocecal valve, and may be 2 inches in length, although the size can vary. Approximately 2 to 4 percent of patients develop a complication over the course of their lives, typically before the age of 2. It is a very rare cause of gastrointestinal bleeding, especially in adults. The most common presentation is obstruction. Symptomatic patients with either bleeding or obstruction should undergo surgical intervention.
Conclusions: Meckel’s diverticulum is an uncommon cause of gastrointestinal bleeding in the adult population, but it should be considered in all patients presenting with obscure bleeding. As this case has demonstrated, obtaining the correct diagnosis can be a challenging exercise. For patients who present with massive, painless lower-gastrointestinal bleeding without risk factors for bleeding and in whom endoscopy and colonoscopy fail to localize a bleeding site, Meckel’s diverticulum should be suspected and a nuclear Meckel’s scan should be performed.