MIDDLE GASTROINTESTINAL BLEEDING AS MANIFESTATION OF COMPLICATED COELIAC DISEASE IN A GLUTEN-FREE DIET RESPONDER: CASE REPORT

A 64-year-old male, with familial history of coeliac disease (daughter), recently diagnosed (in the past 2 months) with coeliac disease himself after an episode of diarrhea and bloating was referred to tertiary medical care for a history of 3 episodes of obscure upper gastrointestinal bleeding through hematemesis and melena in the past 7 months. Patient started the gluten-free diet immediately after being diagnosed with excellent compliance and clinical response. Baseline investigations revealed slight sideropenic anemia and an elevated erythrocyte sedimentation rate. Abdominal ultrasound revealed 8 mm mural thickening at the level of terminal ileum, with few lymph nodes around it measuring less than 6 mm. Upper gastrointestinal (GI) endoscopy showed typical aspect of coeliac disease: complete loss of duodenal folds with mosaic pattern. Histology confirmed coeliac disease Marsh-Oberhuber type 3a. Computed tomographic (CT) enterography was performed and showed the same mural thickening observed ultrasonographically situated at the level of aortic bifurcation. The lesion presented intense contrast enhancement in both arterial and venous phases. Radiologist opined for the colon appartenance of the lesion because of the presence of “haustra”. In the same day, lower GI endoscopy with ileoscopy of the last 10 cm of terminal ileum was performed and was normal. CT enterography reinterpretation along with ultrasound reevaluation concluded that the lesion was most probable situated at the level of jejunum. Therefore a spiral enteroscopy was performed which found a 5 – 6 cm length stenosis in the middle jejunum, with malignant features from where 5 biopsies were taken. Histologic examination was still in progress at the moment of abstract submission.