The pathogenesis of the haemorrhage from this dilated ileum is unknown. Functional obstruction within the aperistaltic segment of ileum may cause stasis of intestinal contents, leading to localised mucosal ulceration and subsequently haemorrhage[9]. The patient presented above HDAC inhibitor had no evidence of localised bowel dilatation and no angiodysplasia was found on histology. He presented with life-threatening haemorrhage. Iron deficiency pointed towards prior undetected chronic intestinal blood loss. Laparotomy was undertaken due to cardiovascular instability. At laparotomy, we pursued a careful and systematic approach to isolate the bleeding segment of small bowel. By

marking the upper limit of intra-luminal blood and using a series of small bowel clamps, we were able to confidently identify the site of haemorrhage. Further evaluation using intraoperative enteroscopy could have been undertaken if clinically indicated at the time. Reported success rates using this method are good, with detection of angiodysplasia in up to 46% of cases. However, endoscope-related trauma may create confusing findings and experience of its use in the emergency situation is very

limited[3]. The precise pathophysiology of the bleeding in this case is uncertain. Histological examination showed dilated vessels within the jejunum wall, with erosions in the mucosal layer. This may have occurred due to localised hypertension, mechanically caused by the tortuosity of the blood vessels, kinking of the mesentery and venous congestion. There was no history DAPT supplier of NSAID use and no frank ulceration was seen at histological examination. The patient had a low ferritin, suggesting that he may Reverse transcriptase have suffered from episodes of chronic concealed haemorrhage. He also had a previous history of undiagnosed abdominal pain. CT scan had previously demonstrated diverticular

disease. At retrospective review of these scans after laparotomy subtle evidence of malrotation was noted, with signs of swirling superior mesenteric vessels and abnormal rotation of the proximal jejunum distal to the duodeno-jejunal flexure. An association has been reported previously between congenital malrotation presenting in adult life and chronic abdominal pain[10]. The successful resolution of the patient’s bleeding episode following operation encourages us to believe that release of the malrotated bowel and resection of the proximal jejunum was the correct course of treatment. Conclusion We believe this report highlights an important aetiology in patients with obscure gastrointestinal haemorrhage. If a high index of suspicion is maintained, malrotation may be detected easily on axial imaging, such as CT scan, or small bowel contrast series.