JPGN Reports · 3 authors, 2 centres
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A 2-year-old with chronic abdominal pain developed acute anemia without visible gastrointestinal bleeding. Imaging revealed a cystic mass, which surgery confirmed as a Meckel's diverticulum with bleeding contained inside the diverticulum rather than into the bowel. This rare presentation highlights that Meckel's diverticulum should be considered in acute anemia even without hematochezia or melena.
**Background:** Meckel's diverticulum is the most common congenital gastrointestinal malformation, occurring in 2%-4% of the population. In pediatric patients, the most common presentation is gastrointestinal bleeding, typically manifesting as hematochezia or melena due to ulceration from heterotopic gastric mucosa. This case report describes an atypical presentation where bleeding was contained within the diverticulum itself, causing acute anemia without overt intraluminal bleeding.
**Methods:** This is a single case report of a 2-year-old male with a 1-year history of chronic abdominal pain. He presented with acutely worsening pain and anemia. Prior work-up included normal complete blood count, inflammatory markers, total IgA and tissue transglutaminase IgA, upper gastrointestinal series, abdominal ultrasound, esophagogastroduodenoscopy, and colonoscopy within the prior 3 months. On the day of presentation, initial emergency department evaluation showed hemoglobin (Hgb) 9.3 g/dL and hematocrit (Hct) 29.1%. After discharge and re-presentation with nonbloody emesis, repeat labs showed Hgb 7.8 g/dL, Hct 24.8%. At a pediatric emergency department, labs showed Hgb 7.1 g/dL, Hct 22.8%. No hematemesis, melena, or hematochezia was reported, but rectal examination revealed hemoccult-positive stool. Abdominal ultrasound showed a well-marginated ovoid lesion (4 × 2.7 × 3.8 cm) with gut signature. CT showed a thick-walled cystic lesion (4 × 3 × 4 cm) in the midright abdomen with free fluid and possible free air. The patient underwent diagnostic laparoscopy.
**Key Results:** Intraoperatively, hemoperitoneum and a large cystic structure arising from the ileum were found. The lesion was inflamed with a serosal defect, possibly a sealed perforation. Pathology confirmed Meckel's diverticulum with heterotopic gastric mucosa. The patient recovered well and was discharged on postoperative day 3. No other cases of intradiverticular bleeding without intraluminal bleeding were found on literature search.
**Clinical Implications:** This case demonstrates that Meckel's diverticulum can present with acute anemia due to bleeding contained within the diverticulum, without typical signs of gastrointestinal bleeding. Providers should maintain a high index of suspicion for Meckel's diverticulum in children with unexplained acute anemia, even in the absence of hematochezia or melena. Prompt imaging and surgical consultation are essential, as intradiverticular bleeding requires surgical intervention.