An often‐overlooked cause of gastrointestinal bleeding

A 24-year-old man presented to the hospital for 1 week of intermittent hematochezia without abdominal pain, coffee ground vomitus, or body weight loss. His hemoglobin level was 5.4 g/dL (lower normal limit: 13.3). The esophagogastroduodenoscopy, colonoscopy, contrast-enhanced computed tomography, per-oral route push enteroscopy, and capsule enteroscopy failed to identify the bleeder. The Tc-99m pertechnetate scan showed a faint, radioactive spot over the right lower abdomen. The double-balloon enteroscopy via the anal route revealed an out-pouching intestinal structure 60 cm away from the ileocecal valve (Figure 1A) with an ulcer within it (Figure 1B). The patient underwent laparoscopic resection of the small bowel segment (Figure 2A,B), and the pathology report confirmed the presence of ectopic gastric glands (Figure 2C,D), suggesting the diagnosis of Meckel's diverticulum. The patient had fair bowel movement after the operation, and he was discharged 6 days after the operation without recurrence of hematochezia. Meckel's diverticulum is the most common congenital gastrointestinal (GI) tract anomaly which may complicate with bleeding secondary to peptic ulcer within the diverticulum.1 Meckel's diverticulum is the leading cause of obscure GI bleeding in patients younger than 50 years old, with a low comorbidity index.2 The diagnosis of Meckel's diverticulum is challenging. In a prior investigation, abdominal CT emerged as the predominant diagnostic modality among patients with Meckel's diverticulum (89.1%). Despite its widespread use, the diagnostic yield of abdominal CT was found to be merely 14.6%.3 Tc-99m pertechnetate nuclear scans, the Meckel scan, are the recommended initial diagnostic study that allows imaging of the ectopic gastric mucosa. While a Meckel scan demonstrates approximately 85% sensitivity in pediatric patients, its sensitivity is notably lower in adult patients.3 For small bowel bleeding patients with suspicion of Meckel's diverticulum, a capsule endoscopy may miss the intraluminal lesions when bleeding stopped.4 Compared to the capsule endoscopy, balloon-assisted enteroscopy (BAE) provides a higher diagnostic accuracy for bleeding Meckel's diverticulum.4 BAE enables endoscopic access to the entire small intestine, providing a substantial improvement for both diagnosis and management. Chou et al. underscored the efficacy of BAE in detecting Meckel's diverticulum, surpassing conventional diagnostic methods.3 The identification of ulcers in a Meckel's diverticulum through endoscopy provides crucial evidence of gastrointestinal bleeding. BAE exhibited a diagnostic yield of 100% for patients with Meckel's diverticulum, outperforming the Meckel scan (35.7%) and capsule endoscopy (40.0%).3 In our case, a healthy young man with small bowel bleeding gave rise to the suspicion of Meckel's diverticulum. Timely diagnosis by Meckel scan and BAE and subsequent surgery precluded further complications. The authors declare no conflicts of interest. Written informed consent was obtained from the patient.