Melena in an Adolescent Refusing Transfusion, a Complicated Diagnosis

Introduction: GI bleeding in a child requires swift and systematic management. Despite differences in the etiology of GI bleeding between children and adults, the standard management is similar for both groups. After stabilization with intravenous fluids and, if needed, blood transfusion, management typically proceeds with endoscopy for definitive diagnosis and potential therapeutic intervention. The evaluation and management of GI bleeding are challenging when endoscopy cannot be performed. Here we present a case of an adolescent with a GI bleed who could not undergo endoscopy because she electively refused blood transfusion despite critical anemia. By maintaining a broad differential diagnosis and relying on other diagnostic modalities, the diagnosis of Meckel’s diverticulum was revealed and successfully treated. Case Description: A 17-year-old female without significant past medical history presented to the emergency department complaining of seven days of presyncope, tarry stools, nausea, non-bloody emesis, pallor, and shortness of breath. She had had a wisdom tooth extraction one week prior to symptom onset and had been taking high-dose ibuprofen. She denied abdominal pain and bright red blood per rectum. Symptoms were overall concerning for upper GI bleed. Objective workup was notable for tachycardia and hemoglobin of 6.3. She and her mother were self-described “naturalists” and refused transfusions. Tachycardia and presyncope improved with intravenous fluids. Serial hemoglobin levels remained stable. Endoscopy was not pursued, however, due to the heightened risk of cardiovascular instability secondary to her anemia. Ethics was consulted and advised that the treating team abide by the family’s wishes. Second-line diagnostic modalities were therefore evaluated, resulting in a positive Meckel’s scan. Surgical laparoscopic exploration confirmed the diagnosis and Meckel’s resection was accomplished without the need for blood transfusion. Her hemoglobin at discharge was stable at 5.9. She was discharged with oral iron supplements. Discussion: When patients refuse standard diagnostic tests or standard-of-care treatment, evaluation and management of any complaint become challenging. It becomes important to consider alternative management plans tailored to the patient’s values. In this case, by systematically reviewing the causes of GI bleeding and remaining flexible in the diagnostic approach, the treating team achieved successful diagnosis and treatment. The patient’s age also made this case more challenging. Meckel’s diverticulum is often thought of as a diagnosis of young children and was initially lower on the treating team’s differential. Maintaining a wide pediatric differential in a patient who was nearly an adult was a key factor in achieving a successful diagnosis. Conclusion: This case highlights the importance of maintaining a broad, systematic differential in the diagnosis of GI bleed in an adolescent. It also reveals the importance of diagnostic flexibility in patients with factors that make standard diagnostic tools unusable.