A 56-year-old woman presented to the emergency department after a motor vehicle accident. She had no complaint except generalized musculoskeletal pain. No visible bleeding was noted, and dedicated computed tomographic (CT) imaging of the chest/abdomen/pelvis was negative for any evidence of blood loss or fracture. She reported occasional melena alternating with hematochezia in the last 4 years. She had been transfused with packed red blood cells (PRBC) for symptomatic anemia 4 years prior to presentation. Esophagoduodenoscopy (EGD) and colonoscopy done at that time were both normal. She had another normal EGD and colonoscopy 1 year prior and declined further workup for the source of her intermittent GI bleeding. Her past medical history was notable for a mesh repair of an abdominal wall hernia 10 years prior and chronic atrial fibrillation, which was treated with the anticoagulant warfarin.
On admission the patient appeared comfortable. Her vital signs were within normal limits, and the physical examination was normal except for mild bruising in the distribution of a seatbelt across her chest and abdomen. Her vital signs were within normal limits. Her labs were notable for low hemoglobin (5.4 g/dL) and subtherapeutic international normalized ratio (1.7). She received 2 units of PRBC at the time of admission. EGD and colonoscopy performed upon admission were both normal.
On the third day of admission, she had a large bloody bowel movement and became hemodynamically unstable. Repeat EGD was normal. She continued having bloody bowel movements with ongoing anemia and required transfusion of 5 additional units of PRBC. CT angiography of the abdomen revealed a paramedian ventral mesh located inferiorly on the right lower abdomen, and no evidence of contrast extravasation (Figure 1). A tagged red blood cell study suggested an active bleed in the right upper quadrant likely originating from the proximal small bowel (Figure 2). Selected angiography of the celiac and superior mesenteric artery failed to demonstrate any active bleeding. Due to persistent low hemoglobin, hemodynamic instability, and massive transfusion requirements (a total of 14 units of PRBC), surgical exploration was performed.
Exploratory laparotomy findings showed a synthetic abdominal mesh protruding into the mid portion of the ileum, extensive surrounding adhesions, and serosal tears. We resected 30 cm of the involved small bowel and performed primary anastomosis. Pathological findings were notable for dense mesh invading the bowel wall, blood in the ileum, and hyperemic mucosa with multiple areas suggestive of perforation. Postoperatively, anticoagulation was resumed, and she had no further episodes of melena or hematochezia. She was discharged 2 weeks later with a stable hemoglobin (8.3 g/dL).