A tiny ingestible camera identified an otherwise elusive source of anemia in a 63-year-old man. The patient presented to an outside hospital with a 2-week history of generalized weakness, malaise, nausea, and loss of appetite. He denied rectal bleeding. His past medical history was significant for a Billroth II gastric bypass and prior gastric angioectasias. Initial laboratory studies showed that his hemoglobin level, at 7.3 g/dL, was lower than it had been 1 week earlier, when it was 9.9 g/dL, and that, in turn, was reduced from a baseline measurement of 13-15 g/dL, which had been obtained several months prior. Results were also remarkable for leukocytosis at 21.4 × 103 cells/mm3.
A rectal examination revealed brown stool that proved positive for blood with a Hemoccult test. Push enteroscopy, with intubation of afferent and efferent limbs of the patient’s Billroth reconstruction, showed mild erythema in the gastric remnant but no angioectasias, ulcers, or evidence of bleeding. Colonoscopy subsequently disclosed internal grade I hemorrhoids and melena throughout the colon and distal small bowel. No source of bleeding was evident. Five units of packed red blood cells did not produce an appreciable increase in his hemoglobin. He was then transferred to our hospital for further workup for a presumed source of bleeding in the small bowel.
Upon the patient’s presentation, his wife reported that he had been having dark-colored stools for the past 3-4 years. He had undergone upper endoscopy 1 year earlier and been diagnosed with an angioectasia. This was treated with argon plasma coagulation.
Assessment
On physical examination, the patient’s vital signs were stable with a blood pressure of 125/83 mmHg and a pulse of 81 beats/minute. His conjunctivas were pale, and his abdomen was soft, obese, nondistended, and nontender to palpation. Bowel sounds were normoactive. Several external hemorrhoids were evident, and the vault was without stool. Pertinent laboratory results were as follows: hemoglobin, 6.8 g/dL; white blood cell count, 9.6 × 103cells/mm3; platelets, 268,000 cells/mm3; international normalized ratio, 1.26; partial thromboplastin time, 29.4 seconds; ferritin, 12.3 ng/mL; and iron saturation, 6.5%. Other results, including an eosinophil count, were unremarkable.
Diagnosis
The patient underwent a computed tomography angiogram of the abdomen, which showed no definite evidence of a gastrointestinal bleed or retroperitoneal hematoma. Repeat upper endoscopy revealed mild nonerosive gastritis that was not thought to be the source of bleeding. A capsule endoscopy demonstrated multiple worm-like objects in the midjejunum, all with a similar curvature and large “heads.” The images were concerning for a hookworm infection. Upon further questioning, the patient reported that he frequently walked outside on his farm without shoes.
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-Jessica Seidelman, MD, Rena Zuo, MD, Krishna Udayakumar, MD, MBA, Ziad F. Gellad, MD, MPH
This article originally appeared in the February 2016 issue of The American Journal of Medicine.
