Small bowel haemorrhage associated with partial midgut malrotation in a middle-aged man

Gastrointestinal haemorrhage is a common acute presentation to emergency hospital services. The commonest causes of bleeding from the upper gastrointestinal tract are secondary to peptic ulceration or complications of portal hypertension [1]. Colonic sources of bleeding include diverticular disease, neoplasia and angiodysplasia[2]. Initial treatment of these patients involves cardiovascular resuscitation, stabilisation of coagulopathy, followed by endoscopic examination of the upper gastrointestinal tract up to the second part of the duodenum and colonoscopy. Significant haemorrhage from the small intestine is relatively uncommon and may create difficulties in diagnosis and treatment[3].We present a case of small intestinal haemorrhage that was managed by emergency laparotomy, discuss the likely aetiology of the haemorrhage and the principles of management in these groups of patients.A 56 year old man presented to the Emergency Department after passing bright red blood mixed with dark clots per rectum. He had vague, crampy abdominal pains for the previous two days. Past medical history included hypertension, type 2 diabetes and ischaemic heart disease. One year previously, he was admitted to hospital with vague, intermittent central abdominal pain, which resolved following observation for 5 days.On admission, he was tachycardic and hypotensive, with no abdominal tenderness or palpable masses. Rectal examination revealed bright red blood and clots on the glove. Admission haemoglobin was 8 g/dl. Serum ferritin was low at 19 μg/L. He was resuscitated and stabilised with intravenous fluids. Computed tomography (CT) scan demonstrated uncomplicated sigmoid diverticular disease and no other pathology to explain his symptoms. He underwent urgent upper gastrointestinal endoscopy, which was normal to the second part of the duodenum, with no signs of haemorrhage. Subsequent colonoscopy showed a colon full of fresh blood and clots up to the caecum, with no obvious bleeding sour