History and clinical findings: In the course of 2 1/2 years a 72-year-old man had five episodes of intestinal bleeding with anaemia, but no cause was at first found by routine diagnostic tests. After the fourth episode a diagnostic laparotomy was performed at which a diffusely infiltrating growing tumour was found. As it encircled the mesenteric vascular axis resection was not possible. But because of threatened ileal obstruction by the tumour a segmental ileal resection was performed, but no intraoperative diagnosis could be established.
Investigations: Repeated oesophago-gastro-duodenoscopies and a coloscopy all revealed blood, especially in the upper gastrointestinal tract, but no bleeding source was found. Angiography suggested bleeding in the terminal ileum. Computed tomography demonstrated a tumour in the region of the mesenteric root.
Diagnosis, treatment and course: At a second laparotomy because of another bleeding, which required a blood transfusion, tuberculosis was diagnosed. Triple drug treatment was initiated and the patient has been free of symptoms and bleedings since then and fully active for 1 1/2 years.
Conclusion: This case clearly demonstrates the difficulty of diagnosis and the long delay until specific treatment, because the combination of "tumour", bleeding and stenosis of the small intestine by an infiltrative lesion at first pointed to malignant process.