A 41-year-old North African woman with a history of chronic anemia with iron supplementation intake presented to our emergency department. She had massive rectal bleeding.
She had an iron deficiency anemia. She did not complete the investigations so the cause was not yet diagnosed. She had no chronic bleeding, neither gynecologic nor digestive. She was treated by oral iron with no regular follow up. She had no past surgical interventions, and no other medical condition. She had no contact with animals. There were no medical conditions in her family, no cancers and no current infections. No one in her family or neighborhood was diagnosed with tuberculosis.
In our admission unit, her hemodynamic parameters showed that she was in shock: her blood pressure was 80/40 mmHg and her pulse was up to 120 beats per minute. She was pale, her conjunctivas were discolored and her limbs were cold. While examining her, we found profuse rectal bleeding with clots. A quick abdominal and pelvis examination including proctologic examination appeared normal. She was transferred to our intensive care unit and monitored.
Noradrenaline was administered because the crystalloid fluids and the transfusion were not sufficient to compensate for her blood loss. Several blood tests were conducted, including blood count and clotting tests. Her hemoglobin was 8 g/dl and hematocrit was 29 %. The rest of the formula and the clotting tests returned normal results as shown in Table 1.
She first underwent an esogastroduodenoscopy, to identify the source of the bleeding. No abnormality was detected in the said procedure: the esophageal and gastric mucosa were normal, no ulcerations or traces of blood were found, and the duodenal mucosa was also explored and appeared normal. A colonoscopy could not be carried out because of the profuse rectal bleeding. She underwent a computed tomography (CT) of her abdomen which revealed a wall thickening in the terminal ileum with hypervascularization and regional adenomegalies (Figs. 1, 2, 3 and 4). This aspect suggested either a tumor or an inflammatory bowel disease.
Because her bleeding and her hemodynamic collapse persisted, it was decided to proceed with surgery with the aim of diagnosis and treatment. She underwent exploratory laparotomy immediately. It confirmed the wall thickening in her ileocecal junction. Her appendix was inflamed. An ileocecal resection was performed with an ileocolic anastomosis, removing 10 cm from her ileum. The specimen was sent for histological examination. Gross examination showed a round ulcer 5 cm from the ileal end, next to another ulcerative lesion; eight lymphatic nodes were found. The blood vessel under the deep ulcer was the origin of the profuse bleeding.
The histopathological examination showed an inflammatory ulcerative reaction with microabscesses (Figs. 5, 6 and 7). A granulomatous necrotic reaction was revealed in the examination of all eight nodes (Fig. 8). The pathologist's report concluded with diagnosis of an infection due to Yersinia enterocolitica.
Her immediate postoperative outcome was favorable, the bleeding stopped, and her hemodynamic parameters remained stable. She had a normal transit on the fifth day after the intervention. After receiving the pathologist's report, it was decided to treat her with fluoroquinolones 500 mg twice daily without discontinuing the iron supplementation, and a clinical control was scheduled. At the control 3 weeks later, she had no clinical symptoms, her diarrhea and bleeding had ended, and signs of anemia were diminishing. Antibiotherapy was discontinued.