CT angiography can thereby pinpoint the location of the bleeding source, and direct further management [19, 20]. Figure 3 Diagnostic approach to gastrointestinal bleeding. Haemodynamically unstable selleck chemical patients with massive rectal haemorrhage should undergo emergency laparotomy . Although the colon is the most likely source of extensive rectal bleeding in patients above 50 years of age, a high index of suspicion of a small intestinal site of bleeding should be maintained. It is mandatory to systematically inspect the small intestine, and owing to the mesenteric location of the diverticula, the intraoperative recognition can be facilitated by jejunal insufflations using
manual compression . If no small intestine diverticula are found, a subtotal colectomy is recommended . When jejunal diverticula are identified as the bleeding source, either preoperatively or intraoperatively, partial resection of the involved segment of jejunum with primary anastomosis is the procedure of choice. A special challenge
is in patients with multiple diverticula along the small intestine, where it is not possible to remove all of them. In such cases it is easy and safe to perform an intraoperative endoscopy through an enterotomy, which effectively can localize the bleeding source . Another dilemma is that approximately 50% of patients with jejunal diverticula also have coexisting colonic diverticula. In such patients a preoperatively CT angiography can be helpful to pinpoint the bleeding source and thus avoid unnecessary colectomy. ATR inhibitor However, even when the preoperative studies implicate bleeding from colon, the finding of jejunal Thymidylate synthase diverticula selleck at laparotomy is justification for resection of the involved small intestine . Failure to identify and remove jejunal diverticula may lead to continued bleeding after blind colectomy. In our case, as in many others with bleeding from jejunal diverticulosis, pathologic examination of the resected bowel segment did not localize the bleeding site. We consider the immediate and long-term cassation of bleeding achieved by resection of the diverticula as a satisfactory confirmation of diagnosis
of jejunal diverticular haemorrhage . Conclusion Jejunoileal diverticulosis is an uncommon entity and a rare source of gastrointestinal haemorrhage. However, it should be considered in all patients with acute bleeding in the lower part of the gastrointestinal tract, especially in the elderly, because it may lead to life threatening complications and death. In case of massive ongoing rectal bleeding, CT angiography is an accurate, rapid, and non-invasive modality that may detect the bleeding site. If unstable or multiple jejunal diverticula, an intraoperative endoscopy can be performed safely via an enterotomy to localize the bleeding site. Surgical resection of the involved intestine and primary anastomosis is the treatment of choice.