interesting cause of massive small bowel bleed in a tropical country

Interesting cause of massive small-bowel bleed in a tropical countryDr Tarun J.. Pughazhendhi, MD, DM, Professor, Dr Kini Ratnakar, Assistant Professor, Dr Kani Shaikh Mohamed, Assistant

Interesting cause of massive small-bowel bleed in a tropical country

Dr Tarun J George, MD, Resident, Dr T Pughazhendhi, MD, DM, Professor, Dr Kini

Ratnakar, Assistant Professor, Dr Kani Shaikh Mohamed, Assistant Professor, Dr K.

Premkumar, Assistant Professor, Dr A Murali, Professor

PII: S2468-4481(16)30091-1

DOI: 10.1016/j.vgie.2016.12.002

Reference: VGIE 52

To appear in: VideoGIE

Received Date: 9 November 2016

Revised Date: 8 December 2016

Accepted Date: 13 December 2016

Please cite this article as: George TJ, Pughazhendhi T, Ratnakar K, Shaikh Mohamed K, Premkumar

K, Murali A, Interesting cause of massive small-bowel bleed in a tropical country, VideoGIE (2017), doi:

10.1016/j.vgie.2016.12.002.

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Cover Page

Interesting cause of massive small-bowel bleed in a tropical country

Dr Tarun J George MD

Resident

Institute of Medical Gastroenterology

Madras Medical College

Mobile number – +919940342198

Email – drtarunjgeorge@gmail.com

Dr T Pughazhendhi MD, DM

Professor

Institute of Medical Gastroenterology

Madras Medical College

Mobile number – +919962537100

Email – pugaka@rediffmail.com

Dr Kini Ratnakar

Assistant Professor

Institute of Medical Gastroenterology

Madras Medical College

Mobile number - +919443435073

Email – gastrokini@gmail.com

Dr Kani Shaikh Mohamed

Assistant Professor

Institute of Medical Gastroenterology

Madras Medical College

Mobile Number +919894865959

Email – drks1996@gmail.com

Dr K Premkumar

Assistant Professor

Institute of Medical Gastroenterology

Madras Medical College

Mobile number +919841233327

Email - drpremgastro@gmail.com

Dr A Murali

Professor

Madras Medical College

Mobile number - +919841034656

Email – dramurali@yahoo.com

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Interesting cause of massive small-bowel bleed in a tropical country

A 55-year-old male presented with recurrent episodes of melena with easy fatigability and

shortness of breath for 2 months Physical examination was unremarkable except for signs

of anemia Routine investigations revealed hemoglobin 3.2 g/dL, hematocrit 16.4%, mean

corpuscular volume (MCV) 65 fL, white blood cell count (WBC) 3100 with 21% neutrophils,

49% lymphocytes, 10% monocytes, and 20% eosinophils (Table 1) A guaiac test for stool

was positive A stool test for ova and parasite were negative The patient was stabilized with

packed red blood cell transfusions (total of 4 units were transfused) EGD and colonoscopy

showed normal results The patient underwent capsule endoscopy (CE) using the OMOM

capsule endoscopy system to rule out a small-bowel bleed CE revealed multiple hookworms

seen in the distal duodenum and jejunum The parasites were seen attached to the mucosa

of the intestine, sucking blood with adjacent hemorrhagic spot indicating previous

attachment site (Figs 1A and B) He was treated with a single dose of albendazole 400 mg

and oral iron supplements His hemoglobin had normalized at his 6-month of follow-up visit

(Table 2)

Legends

Figure 1 A, Video capsule endoscopy (VCE) showing hemorrhagic spot indicating previous

attachment site B, VCE showing multiple hookworms seen attached to the mucosa of

small-bowel, withdrawing blood

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Table1 Investigations at the time of presentation

Hemoglobin (Hb) 3.2 g/dl (normal: 12-16 g/dL)

Hematocrit (Htc) 16.4% (normal range: 38.8%-50%)

White blood cell (WBC) 3100 (normal: 4000-10000/µL)

Differential count Neutrophil 21%, 49% lymphocytes,

10% monocytes, 20% eosinophils

Mean corpuscular volume (MCV) 65 fL (normal: 80-96 fL/red cell)

Platelet count 156000/mm3 (normal range: 150,000-450,000)

Guaiac test for stool Positive

Stool microscopy Negative for ova and parasite

At presentation

After 4 units of packed red blood cell transfusion during hospital stay

6-month follow-up; after anti-helminthic treatment and iron supplementation for 6

months

3.2 g/dL 6.9 g/dL 12.8 g/dL

Table 2 Hemoglobin at presentation and during course of treatment

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