LOWER DIGESTIVE BLEEDING FROM THE SMALL INTESTINE

Case Presentation An 84-year-old female patient was admitted to the medical service with melena. Her medical history includes diabetes mellitus, systemic arterial hypertension, and diverticular disease of the colon. Additionally, she had right colon cancer 4 years ago, treated with right colectomy, ileotransverse anastomosis, adjuvant chemotherapy, and subsequent hospitalizations due to digestive bleeding with melena, with normal upper digestive endoscopy. During the current hospitalization, after performing upper digestive endoscopy, a CT scan, and colonoscopy, extensive diverticular disease was observed, along with abundant bleeding originating from the terminal ileum, but without lesions. The liver appeared heterogeneous with blunt tips and subcutaneous varices. Further investigation with angiotomography revealed neovascularization in the small intestine with a fistula between the lower epigastric vein and a branch of the mesenteric artery, requiring interventional radiology. A portography and ileal branch phlebography were performed, with a hemostatic valve inserted percutaneously via a transhepatic approach in the right branch of the portal vein. A polyethylene catheter was selectively positioned in the ileal branch, with contrast injections and imaging findings consistent with a portosystemic ileo-femoral shunt. Embolization was performed using histoacryl and lipiodol, achieving satisfactory devascularization of the main branches leading to the shunt. The patient continues to be monitored without further episodes of bleeding.

Discussion Lower gastrointestinal bleeding is primarily characterized by hematochezia or enterorrhagia and may be associated with hypovolemia. Causes include vascular lesions, such as arteriovenous malformations, common in the right colon, hemorrhoids, and diverticulosis. The small intestine is typically the site of obscure bleeding origins. A portosystemic shunt is a rare condition in humans, mainly associated with portal hypertension due to chronic liver disease. Both shunts and small bowel bleeding require precise imaging for diagnosis and treatment. Due to the potential for severe complications, stabilizing the patient and controlling the bleeding is essential.

Conclusion Lower gastrointestinal bleeding from the small intestine is a rare and complex condition to diagnose, especially with this particular adverse etiology. Prompt and accurate diagnosis is crucial for proper treatment, preventing multiple hospitalizations and complications with unfavorable outcomes.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025