S4721 Hidden Hemorrhage: A Case of Jejunal Diverticular Bleeding

Introduction: Small bowel diverticula (SBD) are rare, accounting for 0.9%-2.3% of gastrointestinal (GI) diverticula. SBD are often asymptomatic but can lead to significant complications, including diverticulitis, perforation, and hemorrhage. Bleeding from jejunal diverticula (JD) is difficult to diagnose given the location, and delays in diagnosis may lead to complications such as life-threatening bleed. We present a case of acute hypotensive hematochezia due to a JD bleed, successfully managed with double balloon enteroscopy (DBE) and hemostatic clipping. Case Description/Methods: A 76-year-old woman with peripheral artery disease, atrial fibrillation, and multiple prior GI bleeds presumed due to erosive gastropathy and small bowel angioectasias on video capsule endoscopy (VCE) 5 months prior initially presented with limb ischemia due to thrombosis of a right femoral artery graft. Hospital course was complicated by myocardial infarction, requiring stent placement and anti-thrombotic therapy. She then developed recurrent melena leading to hemorrhagic shock and intensive care admission. Computed tomography angiography failed to localize the bleed. DBE revealed an actively bleeding large mid-jejunal diverticulum. She underwent injection of epinephrine and hemostatic clip placement. Anti-thrombotics were resumed, and no further bleeding was noted. Discussion: JD form due to mucosal herniation at vasa recta sites, likely driven by dyskinesia, elevated intraluminal pressure, and chronic inflammation. Visceral neuropathy may also play a role in pathogenesis. While duodenal diverticula are more common and present with hematemesis, JD more often cause hematochezia, as in this case. JD bleeding is difficult to diagnose due to its location and frequent obscuration by mesenteric folds. Computed tomography angiography is the most effective modality in acute settings, as it may rapidly localize active bleeding. VCE, device-assisted enteroscopy, or tagged RBC scans may be useful in cases of chronic or intermittent bleeding. Management varies by clinical stability: supportive care may suffice for mild bleeding, however definitive control for persistent bleeds may require angiographic embolization or, if refractory, surgical resection. This case highlights the importance of considering JD bleeding in obscure GI bleeds. Early imaging and timely intervention may prevent severe complications and improve outcomes.