Endoscopy 2009; 41: E202-E203
DOI: 10.1055/s-0029-1214858
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

Acquired isolated diverticulum at the ileocecal valve presenting as massive hematochezia: an unusual location and cause of gastrointestinal bleeding

J.  Shim1 , J.  Y.  Jang1 , Y.  Hwangbo1 , S.  H.  Dong1 , H.  J.  Kim1 , B.  H.  Kim1 , Y.  W.  Chang1 , R.  Chang1
  • 1Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University, School of Medicine, Seoul, Korea
Further Information

J. Y. JangMD 

Department of Internal Medicine
Kyung Hee University Hospital

1 Hoegi-dong
Dongdaemoon-gu
Seoul 130-702
Korea

Fax: +082-2968-1848

Email: jyjang@khu.ac.kr

Publication History

Publication Date:
27 July 2009 (online)

Table of Contents

An acquired diverticulum in the small intestine is a rare condition and may be a cause of lower gastrointestinal bleeding [1] [2] [3]. We report a case of acquired diverticulum at the ileocecal valve presenting as massive hematochezia.

A 52-year-old woman was hospitalized with sudden-onset hematochezia. On admission, an urgent colonoscopy found no acute bleeding lesions in the large intestine. After passing the ileocecal valve, a small, actively bleeding diverticulum was noted just proximal to the upper lip of the ileocecal valve ([Fig. 1]). Its unusual anatomic location made endoscopic intervention impossible. Neither changing the patient’s position, nor attaching a transparent hood in the distal end, was helpful, and the bleeding was controlled by therapeutic angiography ([Fig. 2]). However, the patient had recurrent massive bleeding the next day, and 12 cm of the ileocecal region was surgically resected. The resected specimen contained a 5-mm diverticulum at the junction of the ileocecal valve and the terminal ileum, along the mesenteric border ([Fig. 3]). Histological examination of the specimen confirmed the presence of a false diverticulum consisting of mucosa and connective tissue associated with infiltrating inflammatory cells ([Fig. 4]). A small-bowel series showed no diverticula elsewhere. The patient recovered uneventfully and had no further gastrointestinal bleeding.

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Fig. 1 Endoscopic view of the actively bleeding diverticulum located just proximal to the upper lip of the ileocecal valve. A metal clip could not be applied because of the anatomic location of the lesion.

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Fig. 2 Angiographic view showing extravasation of contrast media at a branch of the ileocolic artery (arrow). A few metal clips are seen in the vicinity.

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Fig. 3 Gross view of the ileocecectomy specimen, showing the diverticulum (arrow) at the junction of the ileocecal valve (arrow heads) and the terminal ileum.

Zoom Image

Fig. 4 Photomicrograph of the diverticulum showing ulceration and infiltration of acute and chronic inflammatory cells. The diverticular wall consists of mucosa and submucosa (hematoxylin and eosin, low magnification).

Although colonoscopy can define the cause in most patients with lower gastrointestinal bleeding, no bleeding site is identified in 10 % – 20 % of cases [4]. In such cases, an important cause may be an incomplete workup that overlooked the ileocecal region [5]. Terminal ileal diseases, such as Crohn’s ileitis, Meckel’s diverticulum, ulcers, and vascular ectasia, are responsible for 2 % – 9 % of all lower gastrointestinal bleeding [3]. The present case highlights the importance of careful inspection of the ileocecal valve and terminal ileum in patients with lower gastrointestinal bleeding.

Endoscopy_UCTN_Code_CCL_1AD_2AF

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References

  • 1 Huguenin A, Tirveilliot F, Dell’Erba U. et al . Acquired jejunal and ileal diverticula (Meckel’s excluded).  Ann Chir. 1999;  53 522-526
  • 2 Spiegel R M, Schultz R W, Casarella W J. et al . Massive hemorrhage from jejunal diverticula.  Radiology. 1982;  143 367-371
  • 3 Zuccaro Jr G. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee.  Am J Gastroenterol. 1998;  93 1202-1208
  • 4 Green B T, Rockey D C. Lower gastrointestinal bleeding management.  Gastroenterol Clin North Am. 2005;  34 665-678
  • 5 Ohyama T, Sakurai Y, Ito M. et al . Analysis of urgent colonoscopy for lower gastrointestinal tract bleeding.  Digestion. 2000;  61 189-192

J. Y. JangMD 

Department of Internal Medicine
Kyung Hee University Hospital

1 Hoegi-dong
Dongdaemoon-gu
Seoul 130-702
Korea

Fax: +082-2968-1848

Email: jyjang@khu.ac.kr

#

References

  • 1 Huguenin A, Tirveilliot F, Dell’Erba U. et al . Acquired jejunal and ileal diverticula (Meckel’s excluded).  Ann Chir. 1999;  53 522-526
  • 2 Spiegel R M, Schultz R W, Casarella W J. et al . Massive hemorrhage from jejunal diverticula.  Radiology. 1982;  143 367-371
  • 3 Zuccaro Jr G. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee.  Am J Gastroenterol. 1998;  93 1202-1208
  • 4 Green B T, Rockey D C. Lower gastrointestinal bleeding management.  Gastroenterol Clin North Am. 2005;  34 665-678
  • 5 Ohyama T, Sakurai Y, Ito M. et al . Analysis of urgent colonoscopy for lower gastrointestinal tract bleeding.  Digestion. 2000;  61 189-192

J. Y. JangMD 

Department of Internal Medicine
Kyung Hee University Hospital

1 Hoegi-dong
Dongdaemoon-gu
Seoul 130-702
Korea

Fax: +082-2968-1848

Email: jyjang@khu.ac.kr

Zoom Image

Fig. 1 Endoscopic view of the actively bleeding diverticulum located just proximal to the upper lip of the ileocecal valve. A metal clip could not be applied because of the anatomic location of the lesion.

Zoom Image

Fig. 2 Angiographic view showing extravasation of contrast media at a branch of the ileocolic artery (arrow). A few metal clips are seen in the vicinity.

Zoom Image

Fig. 3 Gross view of the ileocecectomy specimen, showing the diverticulum (arrow) at the junction of the ileocecal valve (arrow heads) and the terminal ileum.

Zoom Image

Fig. 4 Photomicrograph of the diverticulum showing ulceration and infiltration of acute and chronic inflammatory cells. The diverticular wall consists of mucosa and submucosa (hematoxylin and eosin, low magnification).