Stepwise diagnosis and minimally invasive management of obscure gastrointestinal bleeding secondary to a Meckel's diverticulum: a case report.

Abstract

Background: Obscure gastrointestinal bleeding (OGIB) presents a significant diagnostic challenge for clinicians due to the anatomical characteristics and inaccessibility of the small intestine. Preoperative diagnosis is particularly challenging, and optimal management relies heavily on precise lesion localization. We report the successful diagnosis and minimally invasive resection of a bleeding Meckel's diverticulum using a multidisciplinary stepwise approach.

Case presentation: A 25-year-old Chinese man presented to the emergency department with melena that rapidly progressed to recurrent hematochezia. Initial esophagogastroduodenoscopy and an urgent colonoscopy were non-diagnostic due to significant blood retention obscuring the visual field. To non-invasively locate the bleeding source, abdominal computed tomography angiography (CTA) was performed, which identified a diverticular structure with segmental enhancement in the distal ileum. Guided by this structural roadmap, retrograde double-balloon enteroscopy (DBE) was successfully performed, revealing a Meckel's diverticulum accompanied by multiple irregular large ulcers with stigmata of recent bleeding. Endoclips were deployed around the lesion during the DBE procedure for preoperative marking. This endoscopic intervention facilitated a targeted, tissue-sparing laparoscopic segmental small bowel resection in the present case. Postoperatively, an enhanced recovery after surgery (ERAS) protocol was implemented, enabling early enteral nutrition. The patient's recovery was uneventful, and he was discharged on postoperative day 8 without recurrence.

Conclusions: For overt OGIB, a stepwise "CTA-DBE-Laparoscopy" pathway may be useful in selected patients. Non-invasive CTA provides an essential anatomical compass, while endoscopic marking prior to surgery facilitated targeted resection and reduced surgical trauma in the present case.