INTRODUCTION: Diverticulosis seldom causes life threatening hemorrhage and is frequently found in the large bowel. Rare cases of small bowel diverticula are most notably known to appear in the duodenum. Even rarer are severe small bowel diverticulum bleeds in the jejunum with one study noting approximately 50 cases reported in the literature. Due to the difficult location, many have gone unidentified and ultimately resulted in small bowel resections. We present a 58-year-old man with a life threatening jejunal diverticular bleed that was diagnosed and treated conservatively. CASE DESCRIPTION/METHODS: A 58-year-old Hispanic male with past medical history significant for upper GI bleed requiring multiple transfusions, chronic pancreatitis, and SMA thrombosis presented to the ED for recurrent melena. He was previously admitted for suspected GI bleed with no identifiable source on colonoscopy, EGD, and outpatient capsule endoscopy. On this admission, vitals were hemodynamically stable but labs revealed a hemoglobin of 3.3. After appropriate resuscitation, push endoscopy revealed a bleeding proximal jejunal diverticulum which was tattooed, coagulated with epinephrine and clipped. CTA of abdomen showed a stable dissecting aneurysm in between the origin of the inferior pancreaticoduodenal arcade and jejunal branches. He was stabilized and discharged with follow up. DISCUSSION: Small bowel diverticulosis is usually found incidentally in asymptomatic patients. Because jejunal diverticuli are novelty differentials, often forgotten, diagnosis becomes delayed even with the use of standard endoscopy, resulting in significant morbidity and mortality. Several noninvasive studies can be done initially to assess for bleeding. With advances in technology such as small bowel enteroscopy, specifically push enteroscopy, jejunal diverticulum can be diagnosed earlier and treated with clipping as opposed to surgical resection which has been the mainstay treatment for refractory bleeding. This case brings to light a rare manifestation of small bowel diverticuli where future research could be dedicated. There has been another case with similar presentation in which the patient also had history of a SMA clot. This poses the question of whether there is a correlation and if it could be explained by the compromised integrity of the small bowel wall due to the lack of blood flow making it easier for diverticuli to arise there. It also raises the question as to why certain patients are more predisposed to developing these outpouchings.

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INTRODUCTION: Lung cancer is the second most common cancer in both men and women. In 2019, the United States estimate number of lung cancer cases are 228,150 resulting in 142,670 deaths. The most frequent sites of metastasis include liver, adrenal glands, bone, and brain. The majority of patients have advanced disease at clinical presentation. There are very few reported cases of lung cancer metastasis to stomach and duodenum. Gastric metastasis account for only 4.5% and metastasis to the small intestine account for only 5.8%. There are very few reported cases of lung cancer metastasis to stomach and duodenum. In these previously described cases, lung cancer diagnosis was already known prior to the presentation of abdominal pathology. CASE DESCRIPTION/METHODS: In this case, 59 year old female with no significant past medical history presented to the gastroenterologists’ office for abdominal pain. On laboratory examination, patient was found to have iron deficiency anemia which led to full gastroenterologic work-up. EGD was performed that showed a gastric lesion. Biopsies were taken resulting in the diagnosis of poorly differentiated carcinoma. The patient returned for biopsy and lab results, and was found to be weak and fatigued with a hemoglobin of 6. Patient was sent to the emergency room where imaging revealed a 2.4 cm endobronchial and intraparenchymal mass in the right upper lobe with distant metastases, in the left adrenal gland. There was also a 5.5 cm left cerebellar mass. An endobronchial biopsy of the right upper lobe mass, disclosed the diagnosis of non-small cell carcinoma. The gastric and lung biopsies were compared and confirmed to be similar in histology. DISCUSSION: Previously reported cases of primary lung carcinoma metastasizing to the abdomen included symptoms such as melena, dysphagia, obstructive jaundice, or perforation in patients with known diagnosis of primary lung cancer. This case is unique from prior published cases because the patient was not aware of primary lung carcinoma and the only presenting symptom was generalized abdominal pain followed by anemia. Through this case we want to emphasize the atypical presentation of metastatic lung cancer. We would also like to highlight thorough endoscopic and laboratory work up of any patient with anemia and abdominal pain. All age related screening test should be performed to exclude all differential diagnoses.