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JAMA Surgery Clinical Challenge
November 2016

Abdominal Pain Following Lower Gastrointestinal Bleeding

Author Affiliations
  • 1Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
JAMA Surg. 2016;151(11):1079-1080. doi:10.1001/jamasurg.2016.0994

A 67-year-old man was evaluated for lower gastrointestinal tract bleeding. He had been transferred from an outside institution with rectal bleeding requiring blood transfusion. The result of an upper gastrointestinal endoscopy performed at the referring institution was normal. A colonoscopy had been performed at the referring institution, but visualization was poor, with fresh blood and clots noted in the ascending colon. Endoscopic treatment of a right colon arteriovenous malformation with active bleeding was attempted. This was unsuccessful and bleeding persisted. The patient underwent urgent angiography and embolization of a right colic artery branch (Figure 1B). At angiography, no blush or bleeding vessel was evident. The decision to embolize the right colic branch was based on the endoscopic findings and the presence of pooling contrast in the cecum noted on a computed tomographic angiogram (Figure 1A) performed at the referring institution. He had no further bleeding episodes. Twenty hours after the procedure, he reported abdominal pain. Findings from computed tomographic scan of the abdomen and pelvis obtained at this time were unremarkable. He was treated with antibiotics and observed. He progressed to develop abdominal distension, vomiting, and significant right lower quadrant tenderness during the next 2 days.