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Wen PH, Hu B. Selective embolization can effectively alleviate bleeding symptoms in patients with anorectal hemangioma. World J Gastrointest Surg 2025; 17:100108. [PMID: 39872761 PMCID: PMC11757207 DOI: 10.4240/wjgs.v17.i1.100108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Revised: 10/23/2024] [Accepted: 11/08/2024] [Indexed: 12/27/2024] Open
Abstract
In this manuscript, I comment on the article by Pospisilova et al published in the recent issue of the journal, in which selective embolization was used to treat anorectal hemangioma, a rare disease causing lower gastrointestinal bleeding. Anorectal hemangioma can easily be mistaken; for example, the patient in this case was previously misdiagnosed with ulcerative colitis. Choosing the appropriate tests and understanding the typical manifestations of anorectal hemangioma under colonoscopy, computerized tomography, magnetic resonance imaging and other tests are beneficial for diagnosis. The patient presented with intermittent rectal bleeding despite treatment with azathioprine and mesalazine and required blood transfusions since the degree of rectal bleeding worsened. Selective embolization successfully alleviated the patient's bleeding symptoms and avoided the need for repeated blood transfusions. Tranexamic acid may be useful, considering that the patient still has bleeding symptoms and requires parenteral iron supplementation.
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Affiliation(s)
- Ping-Hua Wen
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology and Hepatology/Medical Engineering Integration Laboratory of Digestive Endoscopy, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Nagpal P, Dane B, Aghayev A, Fowler KJ, Hedgire SS, Bartel TB, Cash BD, Collins JD, Kirsch DS, Lo HS, Pietryga JA, Ripley B, Santillan CS, Kim DH, Steigner ML. ACR Appropriateness Criteria® Nonvariceal Upper Gastrointestinal Bleeding: 2024 Update. J Am Coll Radiol 2024; 21:S433-S447. [PMID: 39488353 DOI: 10.1016/j.jacr.2024.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2024] [Accepted: 08/31/2024] [Indexed: 11/04/2024]
Abstract
This document summarizes the relevant literature for the selection of the initial imaging in five clinical scenarios in patients with suspected or known nonvariceal upper gastrointestinal bleeding (UGIB). These clinical scenarios include suspected nonvariceal UGIB without endoscopy performed; endoscopically confirmed nonvariceal UGIB with clear source but treatment not possible or continued bleeding after endoscopic treatment; endoscopically confirmed nonvariceal UGIB without a confirmed source; suspected nonvariceal UGIB with negative endoscopy; and postsurgical or post-traumatic nonvariceal UGIB when endoscopy is contraindicated. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios of nonvariceal UGIB. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Prashant Nagpal
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Bari Dane
- NYU Grossman School of Medicine, New York, New York
| | - Ayaz Aghayev
- Panel Chair, Brigham & Women's Hospital, Boston, Massachusetts
| | - Kathryn J Fowler
- Panel Chair, University of California San Diego, San Diego, California
| | - Sandeep S Hedgire
- Panel Vice-Chair, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Twyla B Bartel
- Global Advanced Imaging, PLLC, Little Rock, Arkansas; Commission on Nuclear Medicine and Molecular Imaging
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Jeremy D Collins
- Mayo Clinic, Rochester, Minnesota; Society for Cardiovascular Magnetic Resonance
| | | | - Hao S Lo
- UMass Memorial Health and UMass Chan Medical School, Worcester, Massachusetts; Committee on Emergency Radiology-GSER
| | - Jason A Pietryga
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Beth Ripley
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | | | - David H Kim
- Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Jiang Y, Li Y, Xiong Z, Morelli JN, Shen Y, Hu X, Hu D, Li Z. Localization and etiological stratification of non-neoplastic small bowel bleeding via CT imaging: a 10-year study. Insights Imaging 2024; 15:189. [PMID: 39090483 PMCID: PMC11294299 DOI: 10.1186/s13244-024-01778-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 07/10/2024] [Indexed: 08/04/2024] Open
Abstract
OBJECTIVES The purpose of this study is to assess the diagnostic efficacy of contrast-enhanced CT scans for small bowel bleeding. METHODS This retrospective study evaluated patients diagnosed with non-neoplastic small intestinal bleeding (including duodenum) who underwent abdominal CT at our institution from December 2013 to March 2023. Patients were categorized into diverticulum and non-diverticulum groups based on the cause of bleeding. Active bleeding was defined on the CT images as extravasation of contrast material in the intestinal lumen during the arterial phase and/or progressive accumulation of contrast material during the venous phase. We have documented the original report (extracted from the medical record system and additional consultation opinions from senior radiologists), including the presence of active bleeding and its potential bleeding location. Furthermore, two radiologists reassessed the CT images, seeking consensus on the diagnosis between them. RESULTS The study included 165 patients, predominantly male, with a median age of 30 years. Active bleeding was identified in 48.3% of patients. Notably, all identified bleeding diverticula in the diverticulum group exhibited cul-de-sac termination. Among the identified causes of bleeding, Crohn's disease was most prevalent (46.7%, N of causes = 64). Significant differences were observed in the diagnostic methods between the diverticulum and non-diverticulum groups, with surgery predominantly applied in the diverticulum group, and endoscopy in the non-diverticulum group (n = 49 vs n = 15, p = 0.001). Contrast agent extravasation was significantly higher in the diverticulum group (n = 54 vs n = 16, p = 0.001), and Meckel's diverticulum cases appearing tubular were significantly higher than in other diverticulum cases (n = 25 vs n = 3, p < 0.001). CONCLUSION CT allows for a higher detection rate of diverticular bleeding, even if asymptomatic, guiding classification into multiple potentially clinically relevant categories. CRITICAL RELEVANCE STATEMENT Contrast-enhanced CT imaging is effective in determining the location and cause of non-neoplastic small bowel bleeding, especially diverticular bleeding. Therefore, the use of enhanced CT should be prioritized in the diagnosis and management of small bowel bleeding. KEY POINTS CT has potential value in the diagnosis of small bowel bleeding. CT imaging suggests possible surgical intervention for active bleeding detection. CT diagnoses and localizes small bowel bleeding, aiding in treatment and prioritizing in guidelines.
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Affiliation(s)
- Yuchen Jiang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuanqiu Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ziman Xiong
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - John N Morelli
- Department of Radiology, St. John's Medical Center, Tulsa, OK, USA
| | - Yaqi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xuemei Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Daoyu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Zhou X, Liu B, Guo X, Tang Y, Ma G. Application of indocyanine green lymphography combined with methylene blue staining in lymphaticovenular anastomosis of lower limb vessels: A prospective study. Phlebology 2023; 38:466-473. [PMID: 37339252 DOI: 10.1177/02683555231185449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND Methylene blue (MB) is a conventional lymphatic tracer. We evaluated the application of indocyanine green (ICG) lymphography combined with MB staining in lower limb lymphaticovenular anastomosis (LVA). METHODS A total of 49 patients with lower limb lymphedema were selected as the study subjects and divided into the research (n = 27) and control groups (n = 22). The patients were treated with LVA using ICG lymphography combined with MB staining and simple ICG lymphography as the positioning method, respectively. The number of lymphatic vessels anastomosed and the operating time were compared between the groups. Lower Extremity Lymphedema Index (LEL index) and Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) were used as prognostic indices; 6 months after LVA, both groups were evaluated for the symptomatic relief of lymphedema. RESULTS The number of anastomotic lymphatic vessels in the study group was higher than that in the control group (p < .05), and their procedural time was shorter than that in the control group. The two groups had no significant difference in lymphatic anastomosis time (p > .05). The LEL index and Lymph-ICF-LL of the research and control groups at 6-month follow-up after LVA were lower than those before the operation (p < .05). CONCLUSION The circumference of the affected limb is reduced after LVA in patients with lower extremity lymphedema with a favorable prognosis. ICG lymphography combined with MB staining has the advantages of real-time visualization and accurate localization.
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Affiliation(s)
- Xuchuan Zhou
- Department of Burn, Plastic, and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bin Liu
- Department of Burn, Plastic, and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiaowei Guo
- Department of Burn, Plastic, and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yueling Tang
- Department of Burn, Plastic, and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Gejia Ma
- Department of Burn, Plastic, and Cosmetic Surgery, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
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Qiao H, Ding N, Chen X. Combined methylene blue localization and laparoscopic surgery: A worthy treatment of recurrent small intestinal bleeding. Asian J Surg 2023:S1015-9584(23)00356-1. [PMID: 36964065 DOI: 10.1016/j.asjsur.2023.03.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/09/2023] [Indexed: 03/26/2023] Open
Affiliation(s)
- Hongliang Qiao
- The First College of Clinical Medical Science of China Three Gorges University, Yichang Central People's Hospital, Yichang, Hubei, 443000, PR China.
| | - Ning Ding
- School of Pharmacy, Xianning Medical College, Hubei University of Science and Technology, Hubei Key Laboratory of Diabetes and Angiopathy, Xianning, Hubei, 437100, PR China
| | - Xiaobo Chen
- China Three Gorges University, Yichang Central People's Hospital, The First College of Clinical Medical Science, Yichang, Hubei, 443000, PR China.
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Bhuller SB, Lieser M, Ismail N, Woods B. Obscure gastrointestinal bleeding localization using preoperative super-selective mesenteric angiography and intraoperative methylene blue injection: A case report and literature review. Int J Surg Case Rep 2019; 65:69-72. [PMID: 31689632 PMCID: PMC6838790 DOI: 10.1016/j.ijscr.2019.10.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/24/2019] [Accepted: 10/24/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Currently available diagnostic tests for localizing the source of gastrointestinal bleeding include esophagogastroduodenoscopy, colonoscopy, push enteroscopy, video capsule endoscopy, deep enteroscopy, nuclear scan, angiography, radiographic contrast studies of the small bowel, intraoperative enteroscopy, and computed tomography scanning. Despite these diagnostic modalities obscure gastrointestinal bleeding (OGIB) can be difficult to localize, making surgical intervention challenging. PRESENTATION OF CASE We report the case of a 78-year-old patient who presented with OGIB, melena and passing bright red blood per rectum, with a hemoglobin of 4.8 g/dl requiring multiple blood transfusions. Initially the source of the bleeding was difficult to identify. Eventually, a preoperative superior mesenteric angiogram was performed, identifying an arteriovenous malformation (AVM) within the small bowel as the source of OGIB. Intraoperative methylene blue was then injected through the previously placed angiogram catheter to further localize the bowel segment with the lesion. DISCUSSION Despite multiple diagnostic modalities, OGIB, especially originating in the small bowel, is challenging to localize, making surgical intervention difficult. Methylene blue is frequently used intraoperatively to properly identify anatomic landmarks. CONCLUSION In cases of OGIB, superselective mesenteric angiography (SSMA) with intraoperative methylene blue injection can be used as an adjunct to routine diagnostic modalities to guide surgical interventions for controlling hemorrhage and for limiting the extent of bowel resection.
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Affiliation(s)
- Sidra B Bhuller
- Department of Surgery, Sky Ridge Medical Center, 10101 RidgeGate Parkway, Lone Tree, CO 80124, USA.
| | - Mark Lieser
- Department of Trauma Surgery, Research Medical Center, 2316 E Meyer Blvd, Kansas City, MO 64132, USA
| | - Naveed Ismail
- Department of Surgery, Sky Ridge Medical Center, 10101 RidgeGate Parkway, Lone Tree, CO 80124, USA
| | - Bradley Woods
- Department of Trauma Surgery, Research Medical Center, 2316 E Meyer Blvd, Kansas City, MO 64132, USA
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Laproscopic treatment for small bowel bleeding after detection by double-balloon endoscopy: A case report. Int J Surg Case Rep 2019; 59:63-65. [PMID: 31108451 PMCID: PMC6526289 DOI: 10.1016/j.ijscr.2019.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/02/2019] [Indexed: 01/14/2023] Open
Abstract
The frequency of small bowel bleeding due to an arteriovenous malformation is rare. Localization of the bleeding location is required prior to laparoscopic resection. Double-balloon endoscopy enabled direct observation and preoperative tattooing. Endoscopic marking followed by laparoscopic resection might be optimal option. Introduction The frequency of small bowel bleeding is relatively low and the process for the diagnosis and treaVtment remains difficult. Here, we report a case of massive small bowel bleeding due to arteriovenous malformation (AVM), treated by a combination of double-balloon endoscopy and laparoscopic resection. Presentation of Case A 59-year-old man was admitted to our hospital due to a hemorrhagic stool. The patient presented transient hemorrhagic shock and contrast-enhanced CT revealed a hyper-vascularized tumor in the small bowel. India ink tattooing for the responsible lesion with double-balloon endoscopy was performed. The tattooed lesion was easily confirmed during the subsequent laparoscopic observation and segmental resection was done. Pathological examination showed arteriovenous malformation of the small bowel. Discussion Prior to laparoscopic resection, the localization of the responsible area might be a significant consideration when the lesion is invisible. Endoscopic marking with DBE enables intraluminal detection and laparoscopic observation from the serosal side. Conclusion Preoperative marking with the use of double-balloon endoscopy followed by laparoscopic resection might be an optimal option for the treatment of massive small intestinal bleeding.
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Turner GA, Pal A, Sharma PV. Bleeding small bowel: methylene blue guided resection. ANZ J Surg 2018; 89:1499-1500. [PMID: 30362221 DOI: 10.1111/ans.14909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/15/2018] [Accepted: 09/19/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Greg A Turner
- Colorectal Unit, Department of General Surgery, Christchurch Public Hospital, Christchurch, New Zealand
| | - Atanu Pal
- Colorectal Unit, Department of General Surgery, Christchurch Public Hospital, Christchurch, New Zealand
| | - Prashant V Sharma
- Colorectal Unit, Department of General Surgery, Christchurch Public Hospital, Christchurch, New Zealand
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Abstract
Gastrointestinal angiodysplasias (GIADs) have a wide variety of presentations, which can be significant and debilitating in a subset of patients. Endoscopic ablation is currently the most effective treatment for GIADs, however re-bleeding rates are high. Several medical have been used for GIADs and reported in the literature, however these medications have significant side effect profiles and randomized controlled trials are lacking. A relatively poor understanding of the pathophysiology of GIAD formation has limited the development of more effective treatments and improved diagnostic and prognostic markers for GIAD. However, recent advances in research in the area of angiogenesis have identified a potential role for certain angiogenic factors including Angiopoeitin 1 and 2, in the pathophysiology of GIAD. Areas covered: We performed an extensive pubmed search of all articles mentioning GIAD and summarized our findings focussing on patient management and prospects. We summarize the available literature regarding the medical, endoscopic, and radiological management of GIAD and the value of clinical prognostic factors. Expert commentary: Although the area of angiogenesis is a novel area of research in GIAD, it represents an exciting avenue for development with the potential to improve diagnostic and prognostic tools to improve patient outcome.
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Affiliation(s)
- Grainne Holleran
- a Department of Gastroenterology and Clinical Medicine , Trinity Centre for Health Sciences' Tallaght Hospital , Dublin , Ireland
| | - Deirdre McNamara
- a Department of Gastroenterology and Clinical Medicine , Trinity Centre for Health Sciences' Tallaght Hospital , Dublin , Ireland
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Abstract
Lower gastrointestinal bleeding entails a range of severity and a multitude of options for localization and control of bleeding. With experience in trauma, critical care, endoscopy, and definitive surgical interventions, general surgeons are equipped to manage this condition in various clinical settings. This article examines traditional and emerging options for bleeding localization and control available to general surgeons.
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ACR Appropriateness Criteria ® Nonvariceal Upper Gastrointestinal Bleeding. J Am Coll Radiol 2017; 14:S177-S188. [PMID: 28473074 DOI: 10.1016/j.jacr.2017.02.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 02/20/2017] [Accepted: 02/21/2017] [Indexed: 12/18/2022]
Abstract
Upper gastrointestinal bleeding (UGIB) remains a significant cause of morbidity and mortality with mortality rates as high as 14%. This document addresses the indications for imaging UGIB that is nonvariceal and unrelated to portal hypertension. The four variants are derived with respect to upper endoscopy. For the first three, it is presumed that upper endoscopy has been performed, with three potential initial outcomes: endoscopy reveals arterial bleeding source, endoscopy confirms UGIB without a clear source, and negative endoscopy. The fourth variant, "postsurgical and traumatic causes of UGIB; endoscopy contraindicated" is considered separately because upper endoscopy is not performed. When endoscopy identifies the presence and location of bleeding but bleeding cannot be controlled endoscopically, catheter-based arteriography with treatment is an appropriate next study. CT angiography (CTA) is comparable with angiography as a diagnostic next step. If endoscopy demonstrates a bleed but the endoscopist cannot identify the bleeding source, angiography or CTA can be typically performed and both are considered appropriate. In the event of an obscure UGIB, angiography and CTA have been shown to be equivalent in identifying the bleeding source; CT enterography may be an alternative to CTA to find an intermittent bleeding source. In the postoperative or traumatic setting when endoscopy is contraindicated, primary angiography, CTA, and CT with intravenous contrast are considered appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Liu YY, Pop R, Diana M, Kong SH, Lègner A, Beaujeux R, Marescaux J. Real-time fluorescence angiography by intra-arterial indocyanine green injection to identify obscure gastrointestinal bleeding territory: proof of concept in the porcine model. Surg Endosc 2016; 30:2143-2150. [PMID: 26275550 DOI: 10.1007/s00464-015-4460-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 07/17/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Despite intensive preoperative localization workouts, intraoperative localization of the bleeding source in case of obscure gastrointestinal bleeding (OGIB) can be cumbersome and time-consuming. Our aim was to assess the feasibility of image-guided laparoscopic identification of the small bowel loop containing the bleeding source with and without near-infrared angiographic enhancement. MATERIALS AND METHODS Angiography of superior mesenteric artery (SMA) branches was performed in 11 pigs using a right femoral artery approach, followed by a three-port laparoscopy, using a near-infrared-equipped laparoscope. Two pigs were used to identify the optimal intra-arterial indocyanine green (ICG) dose. Eight pigs were divided into two groups: ICG near-infrared angiography-assisted laparoscopy (n = 4) and fluoroscopic-assisted laparoscopy (n = 4). Finally, in one pig, a novel OGIB model was created and used to evaluate the ICG enhancement pattern in the presence of active bleeding. RESULTS Mean time to identify the fluorescence signal from the small bowel segment fed by the catheterized SMA branch was 13.75 ± 7.8 s, which was statistically significantly shorter than the time required to identify the tip of the catheter by fluoroscopic guidance, i.e., 243.25 ± 107 s (p = 0.02). CONCLUSIONS Near-infrared fluorescence angiography using intra-arterial ICG injection provides a fast image-guided intraoperative localization of the small bowel loop fed by the arterial territory identified as bleeding by digital subtraction angiography and could help target the bleeding source during OGIB surgery.
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Affiliation(s)
- Yu-Yin Liu
- IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France
- Department of General Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Raoul Pop
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Michele Diana
- IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France.
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France.
| | - Seong-Ho Kong
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Andras Lègner
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Rémy Beaujeux
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
| | - Jacques Marescaux
- IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France
- IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France
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Chen YT, Sun HL, Luo JH, Ni JY, Chen D, Jiang XY, Zhou JX, Xu LF. Interventional digital subtraction angiography for small bowel gastrointestinal stromal tumors with bleeding. World J Gastroenterol 2014; 20:17955-17961. [PMID: 25548494 PMCID: PMC4273146 DOI: 10.3748/wjg.v20.i47.17955] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To retrospectively evaluate the diagnostic efficacy of interventional digital subtraction angiography (DSA) for bleeding small bowel gastrointestinal stromal tumors (GISTs).
METHODS: Between January 2006 and December 2013, small bowel tumors in 25 consecutive patients undergoing emergency interventional DSA were histopathologically confirmed as GIST after surgical resection. The medical records of these patients and the effects of interventional DSA and the presentation and management of the condition were retrospectively reviewed.
RESULTS: Of the 25 patients with an age range from 34- to 70-year-old (mean: 54 ± 12 years), 8 were male and 17 were female. Obscure gastrointestinal bleeding, including tarry or bloody stool and intermittent melena, was observed in all cases, and one case also involved hematemesis. Nineteen patients required acute blood transfusion. There were a total of 28 small bowel tumors detected by DSA. Among these, 20 were located in the jejunum and 8 were located in the ileum. The DSA characteristics of the GISTs included a hypervascular mass of well-defined, homogeneous enhancement and early developed draining veins. One case involved a complication of intussusception of the small intestine that was discovered during surgery. No pseudoaneurysms, arteriovenous malformations or fistulae, or arterial rupture were observed. The completely excised size was approximately 1.20 to 5.50 cm (mean: 3.05 ± 1.25 cm) in maximum diameter based on measurements after the resection. There were ulcerations (n = 8), erosions (n = 10), hyperemia and edema (n = 10) on the intra-luminal side of the tumors. Eight tumors in patients with a large amount of blood loss were treated with transcatheter arterial embolization with gelfoam particles during interventional DSA.
CONCLUSION: Emergency interventional DSA is a useful imaging option for locating and diagnosing small bowel GISTs in patients with bleeding, and is an effective treatment modality.
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Martinez JC, Thomas JL, Lukaszczyk JJ. Single incision laparoscopic surgery approach for obscure small intestine bleeding localized by CT guided percutaneous injection of methylene blue. Int J Surg Case Rep 2014; 5:1082-5. [PMID: 25460480 PMCID: PMC4276324 DOI: 10.1016/j.ijscr.2014.06.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 05/18/2014] [Accepted: 06/21/2014] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Traditionally, localization of small intestine sources of obscure gastrointestinal bleeding has been a challenge. Advances in the field of endoscopy with the introduction of capsule endoscopy and radiographic imaging with computed tomography angiography and visceral angiography have facilitated more accurate visualization of the small intestine. If a bleeding lesion is identified on angiography and surgery is indicated, the use of methylene blue for enteric mapping is very effective to aid intraoperative localization of the culprit. However, when this is not an option, more invasive surgical techniques are required. PRESENTATION OF CASE We present a new technique used in a patient with angiodysplasia of the small intestine, in where preoperative localization was done using percutaneous computed tomography (CT) guided injection of methylene blue dye. This allowed us to perform a single incision laparoscopic small intestine resection of the culprit.
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Affiliation(s)
| | - Jamie L Thomas
- Department of Radiology, St Luke's University Hospital, Bethlehem, PA, USA
| | - John J Lukaszczyk
- Department of Surgery, St Luke's University Hospital, Bethlehem, PA 18015, USA.
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Frydman J, Bahouth H, Leiderman M, Ofer A, Kluger Y. Methylene Blue injection via superior mesenteric artery microcatheter for focused enterectomy in the treatment of a bleeding small intestinal arteriovenous malformation. World J Emerg Surg 2014; 9:17. [PMID: 24552355 PMCID: PMC3931282 DOI: 10.1186/1749-7922-9-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 02/09/2014] [Indexed: 12/27/2022] Open
Abstract
Introduction Obscure gastrointestinal bleeding from the small intestine may present the Acute Care Surgeon with a formidable diagnostic and therapeutic challenge. Despite the current array of diagnostic studies, localization of the causative pathology may be elusive, especially when the bleeding is intermittent. When a small intestinal arteriovenous malformation is the responsible lesion, a technique combining super-selective angiography with intra-operative methylene blue injection and focused enterectomy has been described in a number of case series. The current case report utilizes this same approach with emphasis on computed tomography angiography representing a key first step in the diagnostic algorithm. Case report In this case report, we describe the diagnosis and treatment of obscure gastrointestinal bleeding emanating from an arteriovenous malformation in the small intestine of a 52 year old male. After an extensive work-up including upper and lower endoscopy, double balloon enteroscopy and capsule endoscopy, he was referred for computed tomography angiography. Though he was not actively bleeding, a jejunal arteriovenous malformation was localized on imaging. This prompted directed transfemoral angiography, placement of a super-selective microcatheter in the 4th jejunal arterial branch, intra-operative methylene blue injection and focused enterectomy with pathological confirmation. The patient was found to be free of gastrointestinal bleeding on 6 month follow-up. Conclusions A step-wise, rational diagnostic approach should be utilized in the evaluation of obscure gastrointestinal bleeding. In the non-actively bleeding patient, computed tomography angiogram may facilitate the diagnosis of a small intestinal arteriovenous malformation. Methylene blue injection via a super-selective angiographic microcatheter may then allow for focused enterectomy.
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Affiliation(s)
- James Frydman
- Department of General Surgery, Rambam Health Care Campus, P,O, B 9602, 31096 Haifa, Israel.
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