interesting cause of massive small bowel bleed in a tropical country

Accepted Manuscript Interesting cause of massive small-bowel bleed in a tropical country Dr Tarun J George, MD, Resident, Dr T Pughazhendhi, MD, DM, Professor, Dr Kini Ratnakar, Assistant Professor, Dr Kani Shaikh Mohamed, Assistant Professor, Dr K Premkumar, Assistant Professor, Dr A Murali, Professor PII: S2468-4481(16)30091-1 DOI: 10.1016/j.vgie.2016.12.002 Reference: VGIE 52 To appear in: VideoGIE Received Date: November 2016 Revised Date: December 2016 Accepted Date: 13 December 2016 Please cite this article as: George TJ, Pughazhendhi T, Ratnakar K, Shaikh Mohamed K, Premkumar K, Murali A, Interesting cause of massive small-bowel bleed in a tropical country, VideoGIE (2017), doi: 10.1016/j.vgie.2016.12.002 This is a PDF file of an unedited manuscript that has been accepted for publication As a service to our customers we are providing this early version of the manuscript The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain ACCEPTED MANUSCRIPT Cover Page Interesting cause of massive small-bowel bleed in a tropical country SC TE D Dr Kini Ratnakar Assistant Professor Institute of Medical Gastroenterology Madras Medical College Mobile number - +919443435073 Email – gastrokini@gmail.com M AN U Dr T Pughazhendhi MD, DM Professor Institute of Medical Gastroenterology Madras Medical College Mobile number – +919962537100 Email – pugaka@rediffmail.com RI PT Dr Tarun J George MD Resident Institute of Medical Gastroenterology Madras Medical College Mobile number – +919940342198 Email – drtarunjgeorge@gmail.com AC C EP Dr Kani Shaikh Mohamed Assistant Professor Institute of Medical Gastroenterology Madras Medical College Mobile Number +919894865959 Email – drks1996@gmail.com Dr K Premkumar Assistant Professor Institute of Medical Gastroenterology Madras Medical College Mobile number +919841233327 Email - drpremgastro@gmail.com Dr A Murali Professor Madras Medical College Mobile number - +919841034656 Email – dramurali@yahoo.com ACCEPTED MANUSCRIPT Interesting cause of massive small-bowel bleed in a tropical country A 55-year-old male presented with recurrent episodes of melena with easy fatigability and shortness of breath for months Physical examination was unremarkable except for signs RI PT of anemia Routine investigations revealed hemoglobin 3.2 g/dL, hematocrit 16.4%, mean corpuscular volume (MCV) 65 fL, white blood cell count (WBC) 3100 with 21% neutrophils, 49% lymphocytes, 10% monocytes, and 20% eosinophils (Table 1) A guaiac test for stool SC was positive A stool test for ova and parasite were negative The patient was stabilized with M AN U packed red blood cell transfusions (total of units were transfused) EGD and colonoscopy showed normal results The patient underwent capsule endoscopy (CE) using the OMOM capsule endoscopy system to rule out a small-bowel bleed CE revealed multiple hookworms seen in the distal duodenum and jejunum The parasites were seen attached to the mucosa of the intestine, sucking blood with adjacent hemorrhagic spot indicating previous TE D attachment site (Figs 1A and B) He was treated with a single dose of albendazole 400 mg (Table 2) Legends EP and oral iron supplements His hemoglobin had normalized at his 6-month of follow-up visit AC C Figure A, Video capsule endoscopy (VCE) showing hemorrhagic spot indicating previous attachment site B, VCE showing multiple hookworms seen attached to the mucosa of smallbowel, withdrawing blood ACCEPTED MANUSCRIPT Result Hemoglobin (Hb) 3.2 g/dl (normal: 12-16 g/dL) Hematocrit (Htc) 16.4% (normal range: 38.8%-50%) White blood cell (WBC) 3100 (normal: 4000-10000/µL) Differential count Neutrophil 21%, 49% lymphocytes, RI PT Lab parameters 10% monocytes, 20% eosinophils 65 fL (normal: 80-96 fL/red cell) Platelet count 156000/mm3 (normal range: 150,000-450,000) Stool microscopy M AN U Guaiac test for stool SC Mean corpuscular volume (MCV) Positive Negative for ova and parasite AC C EP TE D Table1 Investigations at the time of presentation At presentation 3.2 g/dL After units of packed red blood cell transfusion during hospital stay 6-month follow-up; after anti-helminthic treatment and iron supplementation for months 6.9 g/dL 12.8 g/dL Table Hemoglobin at presentation and during course of treatment AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT