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A rare cause of recurrent meleana in an elderly women
  1. B Spencer,
  2. A Akpan,
  3. D King
  1. Department of Medicine for the Elderly, Wirral Hospital NHS Trust, Arrowe Park, Wirral, UK
  1. Dr B Spencer, Countess of Chester Hospital, Countess of Chester Health Park, Liverpool Road, Chester CH2 1UL, UK

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Answers on p 727.

A 77 year old woman with a medical history of peptic ulcer disease and irritable bowel syndrome presented with anEscherichia coli septicaemia secondary to a urinary tract infection, which was treated successfully with intravenous cephalosporins. During her recovery she had an episode of melaena during which her haemoglobin dropped to 67g/l from within the normal range. She was transfused, and was haemodynamically stable. Gastroscopy revealed atrophic gastritis, colonoscopy was normal to the splenic flexure, and a barium enema revealed diverticular disease. She had no further bleeding and was discharged. Four months later she was admitted with a further bleed, she was haemodynamically stable but her haemoglobin had dropped 30 g/l to 88 g/l. At this stage a diagnosis of angiodysplasia was considered but as she was no longer actively bleeding mesenteric angiography was not undertaken. She was transfused and discharged. Three months later she had a third episode of melaena, at this point further gastrointestinal imaging was performed.

At laparotomy there was a small 4 × 2 cm polypoid lesion on the serosal surface of the mid-small bowel. Subsequent histological examination revealed a tumour with a low mitotic rate, composed of both smooth muscle spindles and pancreatic glandular elements; this was consistent with a benign small bowel myoepithelial hamartoma. The patient has remained well and has had no further bleeds.

Questions

(1)
What is meant by the term “obscure gastrointestinal haemorrhage” and how would you investigate it?
(2)
What is shown in fig 1?
(3)
Figure 2 shows a laparotomy specimen consisting of a 4 × 2 cm polypoid lesion on the serosal surface of the mid-small bowel. Histologically this is a myoepithelial hamartoma. What are hamartomas?
Figure 1

Mesenteric arteriogram.

Figure 2

Laparotomy specimen.

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