SUMMARY Carcinoid tumour accounts for one per cent of all gastrointestinal neoplasms and has been reported in 0.5% of appendicectomy specimens. Local gastrointestinal complications occur infrequently and we report a case of repeated and massive gastrointestinal haemorrhage from a non-metabolically active carcinoid tumour of the distal ileum diagnosed by colonoscopy.Case report A 53 year old man was admitted to a local hospital in December 1980 with profuse rectal bleeding of sudden onset. He had no previous history of rectal bleeding and his only gastrointestinal complaint was constipation of six years duration. There was no family history of gastrointestinal disease or bleeding disorders. Physical examination revealed a tachycardia and hypotension. He had left iliac fossa discomfort and fresh blood was detected on rectal examination. Sigmoidoscopy revealed blood in the rectum and lower sigmoid colon, but the bleeding site was not identified. He was transfused with 8 units of blood and the bleeding spontaneously stopped. A barium enema showed no abnormality and the patient was subsequently discharged. In January 1982 he was readmitted with further rectal haemorrhage which necessitated transfusion with 2 units of blood. He had observed five episodes of rectal bleeding between the two admissions, but had not reported these to his family doctor. Examination revealed slight epigastric discomfort and blood in the rectum, but his haemoglobin, haematocrit, platelet count, prothrombin time, and liver function tests were normal. Gastroscopy revealed a hiatus hernia with no associated oesophagitis. Colonoscopy to mid transverse colon showed mucosal hyperaemia, but no evidence of a bleeding lesion. He was therefore transferred to Hope Hospital for assessment. At this time he was asymptomatic. Physical examination was normal, and sigmoidoscopy showed melanosis coli. Haemoglobin and serum iron were normal and faecal occult blood was not detected. A colonoscopy was performed which confirmed melanosis coli and detected first degree haemorrhoids. On entering the terminal ileum a 2 cm yellow polyp was observed 2 cm from the ileocaecal valve. The mucosa overlying this lesion was ulcerated (Figure) and a blood clot was visible within the ulcer. Biopsies were taken and histological examination showed carcinoid tumour. The remaining 5 cm of terminal ileum examined appeared normal. Urinary 5-hydroxy-indole acetic acid and a technetium liver scan were normal. At laparotomy the gastrointestinal tract appeared normal and a small bowel endoscopy was performed by introducing a colonoscope through an enterotomy. Apart from the polyp, no abnormality was detected and a right hemicolectomy with excision of the terminal 10 cm of the ileum was performed. Histology of the resected specimen confirmed carcinoid tumour near the ileocaecal valve invading the submucosa. The remainder of the ileum was normal and ascending colon showed melanosis coli only. After surgery the patient noticed altered blood in the stools on two occasions, but this spontane...
