Obscure gastrointestinal bleeding persisting for a decade: a rare manifestation of a common disease
A 60-year-old lady was referred to us for melena of 12 years duration. She had earlier undergone repeat evaluations at multiple private hospitals. She was initially diagnosed with duodenal ulcer and underwent exploratory laparotomy with pyloroplasty and truncal vagotomy. However, she rebled and thereafter underwent antrectomy with retrocolic gastrojejunostomy. She also received proton pump inhibitors, and eradication therapy for Helicobacter pylori. Despite the aggressive treatment, the patient continued to have melena episodes and required multiple blood transfusions (~170 transfusions over a decade). Her esophagogastroduodenoscopy, colonoscopy and barium meal follow through did not reveal any abnormality. Contrast enhanced computed tomography (CECT) of abdomen and the technetium-99m red blood cell scan were also non-contributory. A capsule endoscopy was performed by placing capsule in efferent limb under endoscopic guidance (). It revealed multiple ulcers of varying sizes throughout the small bowel (). As there was no history of non steroidal anti inflammatory drugs (NSAID) ingestion, a possibility of chronic non-specific small bowel ulcers was kept. Antinuclear antibodies and anti-neutrophil cytoplasmic antibodies were negative. However, IgA anti-tissue transglutaminase and anti-gliadin antibodies were positive. Antegrade double balloon enteroscopy was performed and biopsies were obtained from ulcer edge as well as mucosal folds. Histological examination of the biopsies from the ulcer edge revealed chronic inflammation and from the mucosal folds revealed increased intraepithelial lymphocytes. She was started on prednisolone 40 mg daily along with gluten-free diet. The melena subsided and thereafter steroids were tapered off. She remains well after one-year follow up, there has been no recurrence of bleeding and her hemoglobin has risen to 13.4 mg/dL.