Unusual cause for overt upper gastrointestinal bleeding.

To cite: Hatt J, Mills S. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2016214846 DESCRIPTION A 66-year-old woman with a history of aortic stenosis, ischaemic heart disease, chronic obstructive pulmonary disease and hypertension presented to accident and emergency department, with sudden onset haematemesis and melaena. Haemoglobin on arrival was 49 g/L. Following immediate resuscitation, she underwent upper gastrointestinal endoscopy. After futile attempts to control the bleeding, the procedure was abandoned due to what the endoscopist described as ‘profuse bleeding from D2’. Following discussion with the patient, an emergency laparotomy was performed. At operation, blood was evident throughout the gastrointestinal tract. Duodenotomy was performed, which revealed bile in D1 but no active bleeding nor ulceration. The duodenum was kocherised in order to further explore the possibility of a hepatopancreatobiliary source, but no obvious pathology was found. The entirety of the bowel was examined, with no obvious abnormality initially identified. At this point, blood was noted from the efferent limb of the duodenotomy. The D-J flexure was mobilised from the retroperitoneum, revealing a large posterior diverticulum full of clot (figure 1). The diverticulum was simply excised with a single fire from a linear stapler cutter, all clot evacuated and a noncrushing clamp applied distal to the presumed site of bleeding. After a haemostatic pause, no further bleeding was identified. The duodenotomy was closed and the patient went on to make a full recovery. Histology confirmed a 40×27×17 mm small bowel diverticulum with evidence neither of dysplasia nor of malignancy.