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Case 52: Rectal bleeding

A previously fit and well 13 year old boy presented with massive bright red bleeding per rectum. He had mild lower abdominal discomfort only and after resuscitation a laparotomy was performed.

1. How does this abnormality cause bleeding?

A Meckel's diverticulum may contain heterotopic gastric mucosa. This mucosa secretes acid leading to ulceration of the adjacent ileal mucosa.

2. What imaging studies may make the diagnosis pre-operatively?

Imaging for small bowel bleeding such as a nuclear medicine labelled red cell sna or mesenteric angiogram may localise bleeding to the distal small bowel. This suggests A meckel's as the likely cause in the paediatric population. A nuclear medicine Meckel's scan can also be performed. In this instance the isotope is taken up by gastric mucosa. As such it will identify the culprit Meckel's but will not detect a Meckel's diverticulum without heterotopic gastric mucosa.

3. How would you manage this problem at operation?

In this instance the Meckel's need to be resected as does the bleeding ulcer in the ileum. As such a formal small bowel resection with anastomosis is usually required.