although rare in singapore it is an important cause of morbidity in south eastern asia . the clinical presentation is of constipation followed by diarrhea with fever , headache , cough and relative bradycardia . gastrointestinal ( gi ) bleeding is not a common manifestation of typhoid fever and massive hematochezia less so . our case , the first reported in singapore , illustrates the importance of considering s. typhi as a cause of massive lower gastrointestinal hemorrhage . a 29 year old filipino female presented with a 10 day history of diarrhea and abdominal pain . the patient had been employed as a domestic aide in singapore for 2 years and had returned from a trip back to the philippines three months prior to admission . she was febrile to 39  c , had a heart rate of 98  beats per minute ( bpm ) , and a blood pressure of 98/55  mmhg . initial investigations revealed a hemoglobin of 10.6  g / dl ( reference range ( rf ) 11.714.7 ) , white cell count of 4.8 ( rf 3.29.8 )    10 and platelets of 133 ( rf 160398 )    10 . her renal function was normal and her liver function tests revealed , albumin 2.9 ( rf 3.84.8 )  g / dl , bilirubin 1.2  mg / dl ( rf 0.31.7 ) , aspartate aminotransferase ( ast ) 112 ( rf 1050 )  u / l , alanine aminotransferase ( alt ) 37 ( rf1070 ) u / l and an alkaline phophatase ( alp ) 543 ( rf 40130 )  u / l . although stool and urine cultures were negative , her blood culture grew s. typhi sensitive to ceftriaxone and ciprofloxacin . she underwent an ultrasound scan of her hepatobilliary system in view of her abnormal liver function tests and s. typhi bacteremia . there were no hepatic space occupying lesions , cholecystitis or biliary duct dilation although a small gallstone and some biliary sludge were present . she was treated initially with intravenous ceftriaxone and metronidazole , and her diarrhea , fever and abdominal pain resolved . her alp however remained elevated at 543  u / l which prompted a consideration of endoscopic ultrasound to further evaluate her biliary tract as an outpatient . she was seen in the emergency department the following day for a large lower gi hemorrhage . she was pale , dehydrated and had a blood pressure of 100/68  mmhg with a heart rate of 110  bpm . her hemoglobin had dropped to 6.1  g / dl and her coagulation screen was normal . she underwent an urgent sigmoidoscopy which revealed a large amount of blood in the rectum , sigmoid and descending colon . 1 ) but no bleeding source was detected . a subsequent colonoscopy revealed terminal ileitis with hypertrophic peyer 's patches , and multiple small ulcers with surrounding inflammation and submucosal hemorrhages ; similar changes were seen in the cecum and ascending colon . a biopsy taken from her sigmoid colon revealed mild focal active colitis . she continued to bleed actively , ct angiography with a view toward embolization or colectomy were considered in the event of hypotension , a surgical opinion was therefore sought . she required a total of 10 units of red cell transfusion and although her blood and stool culture was negative she received an additional fourteen days of intravenous ceftriaxone . the patient was discharged stable after completing her course of antibiotics , with a hemoglobin of 9.2  g / dl . she did not have a repeat colonoscopy and stool cultures remained negative two months after discharge ( fig . descriptions of typhoid related lower gi hemorrhage date back to sir william osler 's texts at the turn of the 20th century and a comprehensive analysis of 360 cases in 1946 , . a report from mexico in 1986 is also noteworthy . in a study of patients with hematochezia secondary to typhoid colitis , lee et al .   demonstrated that the terminal ileum was the most commonly involved site followed by the ileocecal valve , ascending colon , and transverse colon respectively . they also found that punched out ulcers were common and the left colon was spared . these findings are consistent with those in our patient although her ulcers were in the sigmoid colon . we postulate that her bleeding arose in the colon given the endoscopic finding of ulcers , however a terminal ileal source of bleeding is also a possibility . the possibility that the colonoscopic finding of ulcers portends bleeding should therefore be considered , although data are needed to validate this hypothesis . s. typhi is a gram negative bacillus which is transmitted via the fecal - oral route and modulates the host immune response to invade intestinal and colonic epithelia . it proliferates intracellularly , initially in the second part of the peyer 's patches from where it disseminates to the liver , spleen and reticuloendothelial system . further proliferation occurs in these organs over the next seven to 21 days following which organisms are released into the bile and re - infect the ileal lymphoid tissue leading to the classical bowel pathology associated with s. typhi infection . it is noteworthy that s. typhi bacteremia was reported in several patients with massive hematochezia , one series described three patients , all of whom were bacteremic . it is possible that disseminated s. typhi may be a risk factor for lower gastrointestinal bleeding , however more data are required to confirm this , especially since many of the older reports do not include blood culture results . it may also be of interest to ascertain the frequency of gastrointestinal bleeding with infection by different subtypes of the organism , another area with a paucity of clinical data . the management of gastrointestinal bleeding secondary to s. typhi is largely conservative and as in our patient , appropriate antimicrobial therapy with hemodynamic and transfusion support is usually adequate . the antimicrobial of first choice is ceftriaxone with fluoroquinolones a second option if a sensitive strain is detected . in cases of severe , life threatening hemorrhage , more invasive measures may be required to control the bleeding . the successful use of selective angiography and platinum coil embolization to manage massive lower gastrointestinal bleeding due to s. typhi has been reported from the united kingdom . given that enteric fever is largely a disease of the developing world , many centers may not have access to radiological intervention , possibly accounting for the lack of more data in this area . surgical intervention can be an important option and can be life saving if bleeding is refractory to conservative therapy . the pathological processes underlying the bleeding may have been in progress during or even before her initial admission . it should therefore be considered whether the events of the second admission could have been foreseen . bacteremia may be considered a predictive factor for colitis and bleeding given that some reports suggest an association . other potential predictive factors may include systemic inflammatory response syndrome criteria and hepatosplenomegaly , which indicate disseminated disease . bacteremic patients may therefore be considered for longer in patient observation and closer outpatient follow up after discharge . our case illustrates that s. typhi should be considered in the differential diagnosis of massive lower gastrointestinal hemorrhage , especially in the setting of recent travel in south or south east asia . early clinical suspicion and initiation of appropriate antibiotics could be crucial in the final outcome of patients affected by this unusual complication of typhoid fever .