Chronic anemia secondary to side-to-side distal small bowel anastomosis

Occult intestinal bleeding was diagnosed in a patient who underwent a distal small bowel resection. The resection was required for small bowel obstruction. She developed iron deficiency anemia four years later. Clinically she presented with melena. Colonoscopy, gastroscopy were unsuccessful in making the diagnosis. But a 99 mass Technetium (99m Tc) Labeled Red Blood Cell (RBC) scintigraphy, established the bleeding site in the gastrointestinal tract. Laparotomy identified an ulcerative lesion at the surgical side-to-side anastomosis. Histology demonstrated focal ulceration with chronic inflammation but did not show crypt abscesses, or granulomata. Medical therapy, including iron and Histamine-antagonists were ineffective. She was treated with resection of the anastomosis. Gastrointestinal bleeding due to anastomotic ulceration appears to be a late complication of small bowel resection with side-to-side anastomosis.