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Onishi S, Iwashita T, Tezuka Y, Kojima K, Takada J, Kubota M, Ibuka T, Shimizu M. Recurrence rates and risk factors in obscure gastrointestinal bleeding. DEN OPEN 2025; 5:e70011. [PMID: 39253626 PMCID: PMC11382536 DOI: 10.1002/deo2.70011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/22/2024] [Accepted: 08/26/2024] [Indexed: 09/11/2024]
Abstract
Obscure gastrointestinal bleeding (OGIB), defined in 2010, involves bleeding from the GI tract that remains unexplained after standard diagnostic procedures. OGIB, which accounts for about 5% of all GI bleeds, poses diagnostic and management challenges, particularly due to the anatomical features of the small intestine. Advances in capsule endoscopy (CE) and balloon-assisted endoscopy have improved the diagnostic and therapeutic landscape for small intestinal lesions. Objective To determine the recurrence rate and identify risk factors for recurrence following diagnostic and therapeutic interventions using CE and balloon-assisted endoscopy in patients with OGIB. Methods A retrospective cohort study at Gifu University Hospital analyzed CE procedures for patients with OGIB from 2008 to 2022. Patients underwent CE with subsequent treatments based on the findings. Statistical analyses, including Kaplan-Meier and Cox proportional hazards models, were used to estimate cumulative recurrence rates and identify recurrence risk factors. Results Out of 417 patients, 65.2% had positive CE findings, leading to therapeutic interventions in 16.3% of cases. The cumulative recurrence rates at 12, 24, and 36 months were 4.3%, 9.0%, and 13.9%, respectively. Liver cirrhosis (hazard rate: 4.15, 95% confidence interval 1.88-9.18, p < 0.01) was identified as a significant risk factor for recurrence. Conclusions A significant recurrence rate in OGIB patients, with liver cirrhosis being a major risk factor. Despite diagnostic and therapeutic advances, a comprehensive approach including careful follow-up and consideration of risk factors is essential for management.
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Affiliation(s)
- Sachiyo Onishi
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Takuji Iwashita
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Yukari Tezuka
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Kentaro Kojima
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Jun Takada
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Masaya Kubota
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Takashi Ibuka
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Masahito Shimizu
- First Department of Internal MedicineGifu University HospitalGifuJapan
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Oka K, Hasegawa A, Mikuni H, Miyazaki R, Kumamoto T, Takeda Y, Ukai N, Kiyokawa T, Samura O, Okamoto A. Recurrent severe anemia associated with a jejunal arteriovenous malformation in pregnancy: A case report. Case Rep Womens Health 2023; 40:e00559. [PMID: 37954517 PMCID: PMC10632117 DOI: 10.1016/j.crwh.2023.e00559] [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: 09/02/2023] [Revised: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 11/14/2023] Open
Abstract
Background Small intestinal arteriovenous (AV) malformations may cause gastrointestinal hemorrhage, occasionally leading to anemia; however, they are rarely seen in pregnancy. This report presents a case of a pregnant woman who had recurrent severe anemia that was attributed to a small hemorrhagic intestinal arteriovenous malformation. Case Presentation A 24-year-old pregnant woman (gravida 2, para 1) presented with a low hemoglobin concentration (3.6 g/dL) in her first pregnancy and underwent an emergency cesarean section at 36 weeks due to non-reassuring fetal status. In her second pregnancy, she was hospitalized at 30 weeks with epigastric pain and nausea. A low hemoglobin level (6.6 g/dL) and scant fecal occult blood were revealed upon examination. She was referred to the hospital for further evaluation and pregnancy management. Recurrent blood transfusions were required; however, neither hematemesis nor obvious fecal hemorrhage was observed. At 31 weeks, a cesarean section was performed owing to persistent anemia. Postoperative small intestinal capsule endoscopy and flexible fiberoptic proximal small intestinal endoscopy revealed a suspected bleeding small intestinal arteriovenous malformation. The patient underwent partial resection of the small intestine on hospitalization day 16. Histopathological examination confirmed a small intestinal arteriovenous malformation. The patient had a good postoperative course and was discharged on hospitalization day 24. Conclusions Small intestinal arteriovenous malformations can bleed during pregnancy. They can go undetected if they spontaneously shrink postpartum. In severe anemia during pregnancy, hemorrhage from small intestinal arteriovenous malformations should be included in the differential diagnosis and promptly investigated even in the absence of gastrointestinal symptoms.
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Affiliation(s)
- Kazuhiko Oka
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Akihiro Hasegawa
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hayato Mikuni
- Department of Gastroenterology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryosuke Miyazaki
- Department of Gastroenterology, The Jikei University School of Medicine, Tokyo, Japan
| | - Tomotaka Kumamoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yasuhiro Takeda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Natsuko Ukai
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takako Kiyokawa
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Osamu Samura
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Aikou Okamoto
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
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Yaginuma Y, Utano K, Utano Y, Nemoto D, Aizawa M, Matsuida H, Isohata N, Endo S, Togashi K. Diverticular hemorrhage of terminal ileum successfully treated by ultra-selective transcatheter arterial embolization using triaxial system: a case report. Clin J Gastroenterol 2021; 14:517-521. [PMID: 33403532 DOI: 10.1007/s12328-020-01328-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/13/2020] [Indexed: 12/22/2022]
Abstract
Small intestinal hemorrhage due to diverticulum is a relatively rare condition among gastrointestinal hemorrhages. We report a case of diverticular hemorrhage of the terminal ileum that was successfully treated by ultra-selective transcatheter arterial embolization using a triaxial system. A 25-year-old man was referred to our hospital due to melena. Abdominal contrast-enhanced computed tomography demonstrated marked extravasation of contrast medium in a diverticulum of the terminal ileum. We immediately attempted transcatheter arterial embolization after onset of hemorrhagic hypovolemic shock. Angiogram of the superior mesenteric artery revealed apparent hemorrhage at the end of the ileocolic artery. We performed embolization with 2 platinum coils using a triaxial system via the vasa recta of the terminal ileum. This procedure stopped extravasation of contrast medium. Postoperative course was uneventful, and he was discharged four days postoperatively. The triaxial system may facilitate high diagnostic ability to accurately identify target arteries of the ileal diverticular hemorrhage.
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Affiliation(s)
- Yuki Yaginuma
- Division of Radiology, Aizu Medical Center, Fukushima Medical University, 21-2 Maeda, Tanisawa, Kawahigashi, Aizuwakamatsu, Fukushima, 969-3492, Japan
| | - Kenichi Utano
- Division of Radiology, Aizu Medical Center, Fukushima Medical University, 21-2 Maeda, Tanisawa, Kawahigashi, Aizuwakamatsu, Fukushima, 969-3492, Japan. .,Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan.
| | - Yuka Utano
- Division of Radiology, Aizu Medical Center, Fukushima Medical University, 21-2 Maeda, Tanisawa, Kawahigashi, Aizuwakamatsu, Fukushima, 969-3492, Japan
| | - Daiki Nemoto
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Masato Aizawa
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Hajime Matsuida
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Noriyuki Isohata
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Shungo Endo
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Kazutomo Togashi
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
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4
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Kawachi J, Ogino H, Shimoyama R, Ichita C, Isogai N, Murata T, Miyake K, Nishida T, Fukai R, Kashiwagi H. Intraoperative angiography with indocyanine green injection for precise localization and resection of small bowel bleeding. Acute Med Surg 2020; 7:e549. [PMID: 32817800 PMCID: PMC7426192 DOI: 10.1002/ams2.549] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/20/2020] [Accepted: 06/30/2020] [Indexed: 12/22/2022] Open
Abstract
Aim Bleeding in the small bowel rarely occurs, and its treatment is challenging. Surgery is sometimes required in unstable patients; however, intraoperative identification of the bleeding site is extremely difficult. Many methods have been reported, but no standard strategy has been established yet. Here, we aimed to assess the safety and feasibility of intraoperative angiography with indocyanine green staining to accurately identify small bowel bleeding sites. Methods This retrospective study analyzed contrast‐enhanced computed tomography images of patients (n = 8) with small bowel extravasation who underwent surgery. If extravasation or other vessel abnormalities that were potential bleeding sites were detected on intraoperative angiography, a microcatheter was placed as close as possible to the extravasation site. Laparotomy was carried out, and 3–5 mL indocyanine green was injected through the microcatheter. The green‐stained segment of the small bowel was resected. Results Seven of the eight patients had positive angiographic findings and underwent bowel resection. The eighth patient had no abnormalities and hence did not undergo laparotomy. The rate of hemostatic success among the resected cases was 85.7% (six of seven cases). The resected specimens showed pathologic features in six of the seven patients (85.7%), all of whom achieved hemostasis. One patient had pneumonia and congestive heart failure that required longer hospital stay, but no mortality occurred. Conclusions Intraoperative angiography with indocyanine green injection, followed by resection for massive small bowel bleeding is effective. This can be a therapeutic option for hemodynamically unstable patients.
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Affiliation(s)
- Jun Kawachi
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Hidemitsu Ogino
- Department of Surgery Narita Tomisato Tokushukai Hospital Tomisato Japan
| | - Rai Shimoyama
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Chikamasa Ichita
- Gastroenterology Center Shonan Kamakura General Hospital Kamakura Japan
| | - Naoko Isogai
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Takaaki Murata
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Katsunori Miyake
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Tomoki Nishida
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Ryuta Fukai
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
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Ikeoka S, Yoshizaki T, Matsuda T, Katayama N, Matsumoto M, Takagi M, Momose K, Eguchi T, Morisawa T, Okada A. A rare case of pyogenic granuloma of the jejunum causing gastrointestinal bleeding. Clin J Gastroenterol 2020; 13:1125-1128. [PMID: 32734317 DOI: 10.1007/s12328-020-01187-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022]
Abstract
Pyogenic granulomas (PG) are lobular capillary hemangiomas mostly found in the mucous membranes of the skin and oral cavity, and rarely occur in the gastrointestinal tract. Here we describe a case of an 84-year-old patient with alcoholic cirrhosis who presented with persistent melena and progressive anemia. Endoscopy showed esophageal varices and he underwent endoscopic variceal ligation (EVL) with transient resolution of anemia. However, due to worsening anemia, he underwent capsule endoscopy that revealed a bleeding tumor in the small intestine. We performed double-balloon endoscopy and found a 7-mm polyp with a white coat located in the jejunum and resected it at a later date. Histological characteristics led to the diagnosis of PG, and the patient's melena and anemia subsequently improved.
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Affiliation(s)
- Seitaro Ikeoka
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Tetsuya Yoshizaki
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan.
| | - Tatsuya Matsuda
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Norio Katayama
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Masanori Matsumoto
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Megumi Takagi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Kenji Momose
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Takaaki Eguchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Toshiyuki Morisawa
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Akihiko Okada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
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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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7
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Takase N, Fukui K, Tani T, Nishimura T, Tanaka T, Harada N, Ueno K, Takamatsu M, Nishizawa A, Okamura A, Kaneda K. Preoperative detection and localization of small bowel hemangioma: Two case reports. World J Gastroenterol 2017; 23:3752-3757. [PMID: 28611528 PMCID: PMC5449432 DOI: 10.3748/wjg.v23.i20.3752] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/17/2017] [Accepted: 04/12/2017] [Indexed: 02/06/2023] Open
Abstract
Among the various diagnostic modalities for small bowel hemangioma, video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) can be recommended as part of the work-up in patients with obscure gastrointestinal bleeding (OGIB). DBE is superior to VCE in the accuracy of diagnosis and therapeutic potential, while in most cases total enteroscopy cannot be achieved through only the antegrade or retrograde DBE procedures. As treatment for small bowel bleeding, especially spout bleeding, localization of the lesion for the decision of DBE insertion facilitates early treatment, such as endoscopic hemostatic clipping, allowing patients to avoid useless transfusion and the worsening of their disease into life-threatening status. Applying endoscopic India ink marking prior to laparoscopic surgical resection is a particularly useful technique for more minimally invasive treatment. We report two cases of small bowel hemangioma found in examinations for OGIB that were treated with combination of laparoscopic and endoscopic modalities.
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8
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Koganemaru M, Nonoshita M, Iwamoto R, Kuhara A, Nabeta M, Kusumoto M, Kugiyama T, Nagata S, Abe T. Ultraselective embolization using a 1.7-Fr catheter and soft bare coil for small intestinal bleeding. MINIM INVASIV THER 2016; 25:345-350. [PMID: 27309942 DOI: 10.1080/13645706.2016.1192553] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We aimed to evaluate the safety and efficacy of embolization using a 1.7-Fr catheter and soft bare coil to treat acute small intestinal bleeding. MATERIAL AND METHODS Subjects were five consecutive patients who experienced onset of melena with small intestinal bleeding and underwent transcatheter arterial embolization with 1.7-Fr catheters and 0.010-inch detachable bare coils (five procedures in total). Technical success, clinical success, relative post-procedural complications, arterial bleeding source and cause, and relationship between coagulopathy and embolization efficacy were examined by capsule endoscopy. RESULTS We achieved 100% technical and clinical success for the five transcatheter arterial embolizations. All catheterizations of the vasa recta of the bleeding artery (jejunal artery, n = 2; ileal artery, n = 3) were possible with a 1.7-Fr catheter. We achieved high embolization efficacy in two patients with coagulopathy. No rebleeding, intestinal ischemia, or necrosis was observed on follow-up capsule endoscopy. We confirmed that peptic ulcers/ulcer scars were the cause of bleeding for all patients. CONCLUSION Embolization with 0.010-inch coils using a 1.7-Fr catheter and catheterization of the vasa recta of bleeding vessels was effective and safe for treating small intestinal bleeding.
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Affiliation(s)
- Masamichi Koganemaru
- a Department of Radiology , Kurume University School of Medicine , Kurume , Fukuoka , Japan
| | - Masaaki Nonoshita
- a Department of Radiology , Kurume University School of Medicine , Kurume , Fukuoka , Japan
| | - Ryoji Iwamoto
- a Department of Radiology , Kurume University School of Medicine , Kurume , Fukuoka , Japan
| | - Asako Kuhara
- a Department of Radiology , Kurume University School of Medicine , Kurume , Fukuoka , Japan
| | - Masakazu Nabeta
- a Department of Radiology , Kurume University School of Medicine , Kurume , Fukuoka , Japan
| | - Masashi Kusumoto
- a Department of Radiology , Kurume University School of Medicine , Kurume , Fukuoka , Japan
| | - Tomoko Kugiyama
- a Department of Radiology , Kurume University School of Medicine , Kurume , Fukuoka , Japan
| | - Shuji Nagata
- a Department of Radiology , Kurume University School of Medicine , Kurume , Fukuoka , Japan
| | - Toshi Abe
- a Department of Radiology , Kurume University School of Medicine , Kurume , Fukuoka , Japan
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9
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Abstract
Sarcoidosis is an inflammatory disease characterized by non-caseating granulomas in the absence of other autoimmune processes, infectious diseases, or foreign agents. The etiology of sarcoidosis is not completely understood. Several organ systems can be affected, of which the most frequently involved include the lungs and lymph nodes. Intra-abdominal sarcoidosis is less common, but can be found in the absence of pulmonary or lymphatic disease. Intra-abdominal sarcoidosis is most often asymptomatic. However, long-standing unrecognized disease can result in life-threatening complications. The identification, monitoring and prevention of these complications will be discussed, with emphasis on both clinical and histological presentations of intra-abdominal sarcoidosis.
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10
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Yamazaki O, Hanafusa N, Yamada A, Noiri E, Fujita T. Recurrent intestinal bleeding treated by double-balloon endoscopy in haemodialysis patients. NDT Plus 2009; 2:469-72. [PMID: 25949382 PMCID: PMC4421314 DOI: 10.1093/ndtplus/sfp111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 07/27/2009] [Indexed: 12/22/2022] Open
Abstract
Gastrointestinal (GI) bleeding is a common and troublesome complication of end-stage renal disease (ESRD). Patients often have various lesions in the small bowel and in either upper or lower GI tracts. Recently developed double-balloon endoscopy (DBE) enables observation of the entire small intestine through a combination of anterograde and retrograde approaches. Moreover, DBE is useful not only for diagnosis of small intestinal lesions; it provides a mode of treating the disease. This article presents patients with several small intestinal diseases from our facility. Their bleeding sources were identified using DBE. We also report two representative cases of angiodysplasia that had been diagnosed and treated successfully using DBE. One case particularly underscored the usefulness of the combination of capsule endoscopy (CE) and DBE as an electively diagnostic approach for patients with GI bleeding. Small intestinal bleeding is often observable repeatedly in a single patient, as described for case 1. In such circumstances, DBE can treat the lesions successfully without surgical procedures. In this report, ESRD patients, in whom comorbid conditions made it difficult to perform surgical procedures, receive great benefit from DBE.
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Affiliation(s)
| | | | - Atsuo Yamada
- Department of Gastroenterology , The University of Tokyo Hospital , Japan
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11
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Abstract
OBJECTIVE Reports suggest that the rates of tuberculosis (TB) continue to rise in the UK and throughout the world. The spread of the disease is aided by poverty, overcrowding, co-infection with human immunodeficiency virus and drug resistance. Consistent with the overall trend, intra-abdominal and gastrointestinal (GI) TB rates are rising. Tuberculosis is a treatable disease, whether occurring in the lungs or at extra-pulmonary sites but the nonspecific features of the disease result in difficulty in establishing a diagnosis. In this report, we have concentrated on the benefits and potential pitfalls of diagnostic methods. METHOD A literature review was performed using the National Library of Medicine's Pubmed Database using the keywords diagnosis, management, abdominal and GI TB. RESULTS Abdominal TB presents a particular challenge, as the diverse features of the disease do not readily suggest a particular diagnosis and diagnostic delays lead to significant morbidity and mortality. A number of investigative methods have been used to aid in the diagnosis of abdominal and GI TB. CONCLUSION The nonspecific presentation of abdominal and GI TB present challenges in the diagnosis of this increasingly common disease. A high index of suspicion is an important factor in early diagnosis. After a diagnosis has been established, prompt initiation of treatment helps prevent morbidity and mortality.
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Affiliation(s)
- S Rasheed
- St Mark's Hospital, Harrow, Middlesex, UK
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12
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Affiliation(s)
- Michael F McGee
- Department of Surgery, Case Western Reserve University School of Medicine, Case Medical Center, Cleveland, OH 44106, USA
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13
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Iwata Y, Shiomi S, Otso R, Sasaki N, Hara J, Nakamura S, Nishiguchi S, Ochi H. A case of cavernous hemangioma of the small intestine diagnosed by scintigraphy with Tc-99m-labeled red blood cells. Ann Nucl Med 2000; 14:373-6. [PMID: 11108167 DOI: 10.1007/bf02988698] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hemangioma of the small intestine is rare, and the preoperative diagnosis of it is difficult. We report a patient with gastrointestinal bleeding for whom Tc-99m-labeled red blood cell scintigraphy was useful in diagnosing cavernous hemangioma of the small intestine. A 25-year-old man was referred to our hospital for recurrent iron deficiency anemia. Because of the patient's severe anemia, imaging was performed to locate the bleeding lesion in the gastrointestinal tract. Scintigraphy with Tc-99m-labeled red blood cells revealed pooling indicating a tumor and extravasation of blood from the tumor. Scintigraphy with Tc-99m pertechnetate revealed no abnormal accumulation. Partial resection of the small intestine was done, and cavernous hemangioma of the small intestine was diagnosed by using the specimen of resected tissue.
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Affiliation(s)
- Y Iwata
- Third Department of Internal Medicine, Osaka City University Medical School, Japan
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14
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Affiliation(s)
- G S Hastings
- Department of Diagnostic Imaging, Division of Interventional Radiology, University of Maryland School of Medicine, Baltimore 21201-1595, USA.
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15
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Grassi R, di Mizio R, Romano S, Cappabianca S, del Vecchio W, Severini S. Multiple jejunal angiodysplasia detected by enema-helical CT. Clin Imaging 2000; 24:61-3. [PMID: 11124471 DOI: 10.1016/s0899-7071(00)00162-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The small bowel angiodysplasia is a rare entity that causes lower intestinal bleeding; the diagnosis is difficult and based on selective angiogram. In our case, an 85-year-old woman was hospitalized after frequent episodes of melena. We performed an enema-helical CT abdominal examination before and after contrast medium administration per venam, detecting some increased intensity areas that surgery confirmed to be a vascular dysplasia on the jejunal first loop. We found the source of hemorrhage without performing an angiographic examination.
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Affiliation(s)
- R Grassi
- Institute of Radiology, Second University of Naples, Naples, Italy
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16
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Affiliation(s)
- G R Zuckerman
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
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17
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Chen CY, Lu CL, Lo SS, Yu IT, Chang FY, Lee SD. Case report: life-threatening haematochezia from a jejunal leiomyoma. J Gastroenterol Hepatol 1997; 12:382-4. [PMID: 9195385 DOI: 10.1111/j.1440-1746.1997.tb00447.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Leiomyoma is a common benign intestinal tumour. Melaena is not rare in this tumour. Recently, rectal haematochezia has been considered as one of the very rare manifestations of leiomyoma. We report a case of jejunal leiomyoma showing life-threatening rectal bleeding. This 76-year-old man was admitted to hospital because of continuous rectal bleeding for 2 days. Haemorrhagic shock occurred and transfusion of 27 units of packed red blood cells failed to correct the shock. Emergent superior mesenteric angiography revealed a distal jejunal tumour showing evidence of active oozing. Segmental intestinal resection was performed to remove this jejunal tumour. Final pathological examination disclosed a jejunal leiomyoma with a ruptured artery responsible for the life-threatening bleeding. The patient recovered after tumour resection. Our presenting case was probably the second case of jejunal leiomyoma showing haematochezia. The diagnostic priority is discussed.
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Affiliation(s)
- C Y Chen
- Department of Medicine, Veterans General Hospital-Taipei, Taiwan, Republic of China
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Fujikawa T, Kurata M, Takaori K, Matsusue S, Takeda H, Sakai S. Solitary cavernous hemangioma of the duodenum: report of a case. Surg Today 1996; 26:807-9. [PMID: 8897680 DOI: 10.1007/bf00311641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Vascular lesions of the duodenum, including hemangioma, are rare causes of gastrointestinal bleeding. We herein describe a 52-year-old woman with a solitary cavernous hemangioma of the duodenum that caused chronic gastrointestinal bleeding. Repeated upper gastrointestinal endoscopy and a barium meal study revealed a solitary vascular tumor in the fourth portion of the duodenum, although the initial investigations including selective angiography were unsuccessful. A wedge resection of the duodenum was performed and microscopical examination showed a cavernous hemangioma. Vascular lesions should therefore also be considered in the differential diagnosis of patients with gastrointestinal bleeding of unknown origin.
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Affiliation(s)
- T Fujikawa
- Department of Abdominal Surgery, Tenri Hospital, Nara, Japan
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19
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Krüger K, Heindel W, Dölken W, Landwehr P, Lackner K. Angiographic detection of gastrointestinal bleeding. An experimental comparison of conventional screen-film angiography and digital subtraction angiography. Invest Radiol 1996; 31:451-7. [PMID: 8818785 DOI: 10.1097/00004424-199607000-00008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
RATIONALE AND OBJECTIVES The authors experimentally assess and compare the detection limit of gastrointestinal bleeding in digital subtraction angiography (DSA) and conventional screen-film angiography. MATERIALS AND METHODS Arterial blood flow was simulated using a tube model in which bleeding was imitated by exudation of liquid containing contrast material. Gut peristalsis was imitated using silicone tubes filled with air and liquid. Images were acquired by DSA and conventional screen-film angiography. The iodine concentration was increased in increments from 1 mg I/mL, with and without simulated peristalsis, and with both free and circumscribed extravasation of contrast material. RESULTS The detection limit for free extravasation in DSA was 1 mg I/mL without peristalsis and 60 mg I/mL with peristalsis. The corresponding figures for circumscribed extravasation were 1 mg I/mL and 34 mg I/mL. The detection limit for free extravasation in screen-film angiography was 172 mg I/mL both with and without simulated peristalsis. Circumscribed extravasation was detected at 9 mg I/mL without peristalsis and 7 mg I/mL with peristalsis. CONCLUSION Digital subtraction angiography is the more sensitive angiographic technique for detection of gastrointestinal bleeding and is superior to conventional screen-film angiography, provided that it is performed with adequate parasym-pathicolysis and suspended respiration. Only when these requirements cannot be achieved is screen-film angiography advantageous.
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Affiliation(s)
- K Krüger
- Department of Diagnostic Radiology, University of Cologne Medical School, Germany
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Shapiro MJ. THE ROLE OF THE RADIOLOGIST IN THE MANAGEMENT OF GASTROINTESTINAL BLEEDING. Gastroenterol Clin North Am 1994. [DOI: 10.1016/s0889-8553(21)00121-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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21
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Okazaki M, Furui S, Higashihara H, Koganemaru F, Sato S, Fujimitsu R. Emergent embolotherapy of small intestine hemorrhage. GASTROINTESTINAL RADIOLOGY 1992; 17:223-8. [PMID: 1612307 DOI: 10.1007/bf01888554] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The efficacy of emergent embolotherapy was evaluated in six patients suffering hemorrhage from the small intestine. Hemorrhage was from the jejunum in four patients, from the ileum in one, and from Meckel's diverticulum in one. Superselective embolization of the arcade of the small intestine artery branch was performed in all patients with a coaxial catheter. Embolic materials used were Gelfoam particles alone or Gelfoam particles plus coils in earlier cases and microcoils in recent cases. Complete hemostasis was immediately achieved in all patients, but one patient died of disseminated intravascular coagulation. After stabilization of the patient's condition by hemostasis, elective surgery was performed on three patients suffering small intestine ulcer. Histopathologically, no bowel infarction was noted but mild mucosal inflammation with submucosal edema was found in the jejunum of two patients. We recommend embolization for life-threatening small intestine hemorrhage, preferentially in situations where the blood vessel involved can be super-selectively occluded at the nearest level of the arcade of the vasa recta, lest the vasa recta should be occluded.
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Affiliation(s)
- M Okazaki
- Department of Diagnostic Radiology, Fukuoka University Hospital, Japan
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Chen MY, Ott DJ, Kelley TF, Gelfand DW. Impact of the small bowel study on patient management. GASTROINTESTINAL RADIOLOGY 1991; 16:189-92. [PMID: 1879631 DOI: 10.1007/bf01887343] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Medical records of 528 consecutive patients who had a peroral small bowel examination or enteroclysis were reviewed. Clinical indications, efficacy of the small bowel examinations, and patient outcome were correlated to determine the impact of the small bowel examination on patient management. The most frequent indications were abdominal pain (19%), diarrhea (15%), obstruction (12%), bleeding (11%), postsurgical evaluation (10%), and assessment of Crohn's disease (8%). Two thirds of the studies (67%) were normal, and 33% of the examinations were abnormal, with similar results in all age groups. Small bowel obstruction (13%), miscellaneous results primarily including diffuse small bowel diseases (7%), adhesions (6%), and Crohn's disease (5%) were the most common abnormalities detected. The effects of small bowel studies on patient management were exclusion of serious pathology (67%), diagnosis that changed therapy (32%), and incidental findings (1%). Small bowel enteroclysis had a higher yield of positive examinations than the peroral small bowel examination, most likely due to patient selection.
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Affiliation(s)
- M Y Chen
- Department of Radiology, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, NC 27103
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Kurosawa S, Kuwata H, Kushibiki K, Akimoto K, Hashimoto T, Kojima T. The value of RI scintigraphy and angiography in small intestinal bleeding--report of eight cases. GASTROENTEROLOGIA JAPONICA 1991; 26 Suppl 3:129-32. [PMID: 1884945 DOI: 10.1007/bf02779281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We retrospectively reviewed eight cases of small intestinal bleeding and assessed the value of RI scintigraphy and angiography in diagnosing the bleeding site. The patients' average age was 56.2 years. Chief complaints was melena of variable degree. In most cases neither upper endoscopy nor colonoscopy was diagnostic. RI scintigraphy (Tc-99 labeled HSA) showed 75% of positive rate whereas angiography showed 66.7% (4/6) of positive rate. All four cases of leiomyosarcoma and leiomyoma demonstrated hypervascular stain and/or extra-vasation in angiography whereas RI scintigraphy failed to detect active GI bleeding in 2 of the 4 cases. Therefore angiography was considered useful for the detection of bleeding from leiomyoma and leiomyosarcoma which are often hypervascular. Scintigraphy is thought of most value in the demonstration of small amount of bleeding with minimum vascular abnormality.
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Affiliation(s)
- S Kurosawa
- Department of Gastroenterology, Showa General Hospital, Tokyo, Japan
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24
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Stampfl DA, Grimm IS, Barbot DJ, Rosato FE, Gordon SJ. Sarcoidosis causing duodenal obstruction. Case report and review of gastrointestinal manifestations. Dig Dis Sci 1990; 35:526-32. [PMID: 2180656 DOI: 10.1007/bf01536930] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- D A Stampfl
- Department of Medicine, Jefferson Medical College, Philadelphia, Pennsylvania 19107
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Tillotson CL, Geller SC, Kantrowitz L, Eckstein MR, Waltman AC, Athanasoulis CA. Small bowel hemorrhage: angiographic localization and intervention. GASTROINTESTINAL RADIOLOGY 1988; 13:207-11. [PMID: 3260203 DOI: 10.1007/bf01889061] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Occult bleeding in the small bowel was localized with mesenteric angiography in 64 patients. Two groups of patients were identified. In the first group comprising 38 patients, bleeding sites were localized by the demonstration of contrast extravasation. In the second group of 26 patients, there was no extravasation. However, other angiographic findings suggested the source of bleeding. No active bleeding was necessary for a positive study in the second group. We conclude that in patients with suspected occult small bowel hemorrhage, mesenteric angiography helps localize the bleeding site. Clinically active bleeding is not always necessary, as angiographic findings other than extravasation may localize the source of hemorrhage.
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Affiliation(s)
- C L Tillotson
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston 02114
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Abstract
As embolism of small bowel arteries carries the risk of bowel infarction, the technique is usually reserved for situations where a vasopressin infusion has failed to control bleeding. We report three cases in which embolisation was used as the primary treatment to control small bowel haemorrhage without the complication of bowel infarction.
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Hannig C, Allgayer B, Risch M, Holzmann T, Dörrler J, Strässle M. Duodenal fistula--a rare complication following the removal of an infected aortic graft: case report. Cardiovasc Intervent Radiol 1986; 9:33-6. [PMID: 3085939 DOI: 10.1007/bf02576982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
We present a rare case of fistulation from the duodenum into the prosthesis site of an aortic Y graft removed 8 months previously owing to infection. We have verified the topographical and anatomical location of the fistulation by fistula filling and CT and MR examination. To our knowledge such a postoperative complication has not been previously documented. In evaluating and comparing our observation we discuss their significance for topographical associations and prognosis and as an indication for surgical intervention.
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28
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Becker GJ, Park HM, O'Connor KW, Tarver RD, Scott JA, Jackson VP, Lappas JC, Broadie TA, Holden RW. Portal hypertension due to jejunal vascular malformation. GASTROINTESTINAL RADIOLOGY 1985; 10:349-51. [PMID: 4054502 DOI: 10.1007/bf01893129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We report a case of hepatic portal venous hypertension secondary to a small-bowel vascular malformation in a 24-year-old man with anemia. Preoperative diagnostic evaluation included gastrointestinal barium studies and endoscopy (showing esophageal varices), hepatic panangiography, peroral small-bowel biopsy, percutaneous transhepatic portal venography, and manometry. Preoperative injection of methylene blue dye into the jejunal arteries supplying the malformation resulted in easy localization of the lesion at surgery. Direct manometry at the time of segmental jejunal resection yielded a portal pressure of 35 mmHg, with subsequent reduction to 21 mmHg.
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Maglinte DD, Elmore MF, Chernish SM, Miller RE, Lehman G, Bishop R, Blitz G, Kohne J, Isenberg MT. Enteroclysis in the diagnosis of chronic unexplained gastrointestinal bleeding. Dis Colon Rectum 1985; 28:403-5. [PMID: 3874048 DOI: 10.1007/bf02560223] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In a six-year period (1977-83), lesions were identified by enteroclysis in 26 patients with melena or recurrent gastrointestinal bleeding undiagnosed by other modalities. These included nine Meckel's diverticula, three metastatic lesions, three primary carcinomas, one lipoma, four leiomyomas, five surgically created blind pouches, one carcinoid, and one idiopathic dilatation of the ileum. Our experience suggests that, when the standard diagnostic procedures used to investigate chronic gastrointestinal blood loss are unrevealing, enteroclysis should be performed. The method is fast, accurate, is done in one sitting, and can be productive in the diagnostically difficult patient.
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Kadir S, Ernst CB. Current concepts in angiographic management of gastrointestinal bleeding. Curr Probl Surg 1983; 20:281-343. [PMID: 6601567 DOI: 10.1016/s0011-3840(83)80011-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Clark RA, Colley DP, Eggers FM. Acute arterial gastrointestinal hemorrhage: efficacy of transcatheter control. AJR Am J Roentgenol 1981; 136:1185-9. [PMID: 6786033 DOI: 10.2214/ajr.136.6.1185] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Sixty-five sites of arterial gastrointestinal hemorrhage in 63 patients were managed with transcatheter therapy. Arterial vasopressin infusion was attempted primarily for all but three sites; embolization was used in these cases and in those for whom vasopressin infusion failed to control bleeding. The results obtained suggest that this regimen, that is, primary vasopressin infusion with embolization reserved for infusion failures or contraindications, is more effective for control of arterial gastrointestinal hemorrhage than the use of either method alone. The role of primary embolization for control of this type of bleeding may need reassessment.
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