An uncommon cause of overt small bowel bleeding

An 84-year-old man with atrial fibrillation under Dabigatran and surgically-resected colorectal neo- plasia was admitted with 1-day hematochezia with hemodynamic stability. His past medical history was relevant for intermittent hematochezia episodes over several months with inconclusive conventional endoscopic study. Laboratory analysis revealed severe iron-deficiency anemia (Hg-5.4 (N:13-17g/dL)), aPTT 54.8 (N:25-34seconds) and INR 1.56. Upper and lower gastrointestinal endoscopy were non-diagnostic. A small bowel capsule endoscopy was performed showing a subepithelial lesion at the proximal jejunum (Fig. 1A). Subsequent antegrade double-balloon enteroscopy confirmed the presence of a caterpillar-shaped subepithelial lesion at the proximal jejunum with 20mm in diameter (Fig. 1B), which was tattooed with SPOT® (GI Supply, Camphill, PA, USA).