Bringing light into darkness: peroral double-balloon enteroscopy-guided endoscopic injection sclerotherapy for a jejunal hemangioma

Small bowel bleeding accounts for 5–10% of all gastrointestinal bleeding cases, with small bowel hemangioma being one of the most common causes. It is characterized by an insidious onset and a high recurrence rate [1]. The standard treatment for small bowel hemangioma is surgical resection, which is both invasive and costly [2]. Recently, endoscopic injection sclerotherapy, typically used for esophageal varices, has been increasingly applied to treat gastrointestinal vascular lesions, including small bowel hemangioma [3].

We report the case of a 52-year-old woman with no underlying systemic disease, who presented to our hospital with a 6-month history of recurrent melena and anemia. Laboratory tests revealed iron deficiency anemia, with a hemoglobin level at 6.9 g/dL. Contrast-enhanced abdominal computed tomography, esophagogastroduodenoscopy, and colonoscopy did not identify a bleeding source. Subsequently, peroral double-balloon enteroscopy revealed a 2.0-cm irregular, elevated lesion in the middle of the jejunum. The lesion was soft and non-pulsatile, consistent with the appearance of a hemangioma ([Fig. 1] a, [Video 1]). Bleeding points were identified in the central depression of the lesion, indicating the bleeding source ([Fig. 1] b). Methylene blue dye was applied to delineate the margins of the lesion ([Fig. 1] c). After confirming positive blood reflux, we performed endoscopic injection sclerotherapy using an 8-ml polidocanol-methylene blue mixture ([Fig. 1] d). After the injection, the hemangioma was notably reduced in size ([Fig. 1] e). For future radiological or surgical reference, a metal clip was anchored to the proximal part of the jejunum, 5 cm away from the lesion ([Fig. 1] f). The patient remained free of recurrence during the 1-year follow-up.

Endoscopic injection sclerotherapy for a hemangioma located in the middle part of the jejunum using peroral double-balloon enteroscopy in a 52-year-old woman with recurrent melena and anemia.Video 1

Fig. 1 Peroral double-balloon enteroscopy-guided endoscopic injection sclerotherapy for a hemangioma located in the middle part of the jejunum. a Double-balloon enteroscopy showing an irregular elevated lesion in the middle part of the jejunum. b Bleeding spots located in the central depressed part of the lesion, indicating the bleeding source. c Methylene blue was applied to the lesion to delineate its margins. d Positive blood reflux was seen within the puncture needle. e After the injection, the hemangioma was reduced in size. f For future radiological or surgical reference, a metal clip was anchored to the jejunal wall in the proximal part of the jejunum, 5 cm away from the lesion.

Endoscopic intervention for small bowel hemangioma poses significant challenges due to anatomical and technical limitations. Although various endoscopic treatments, such as double-balloon enteroscopy-guided argon plasma coagulation, polypectomy, and endoscopic mucosal resection, have been proposed for small bowel hemangioma, a definitive consensus on the optimal approach is lacking [2] [4]. Based on our experience, double-balloon enteroscopy-guided endoscopic injection sclerotherapy is a simple, effective, convenient, and minimally invasive procedure that requires only a standard injection needle. It should be considered a preferred treatment option for small bowel hemangioma, particularly in patients with recurrent episodes or those who are unsuitable for surgery.

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Artikel online veröffentlicht:
22. November 2024

• References

• 1 Gerson LB, Fidler JL, Cave DR. et al. ACG clinical guideline: diagnosis and management of small bowel bleeding. Am J Gastroenterol 2015; 110: 1265-1288
• 2 Igawa A, Oka S, Tanaka S. et al. Polidocanol injection therapy for small-bowel hemangioma by using double-balloon endoscopy. Gastrointest Endosc 2016; 84: 163-167
• 3 Yang J, Zhou L, Xu D. et al. Endoscopic injection sclerotherapy for treating recurrent bleeding of small bowel angioectasias. BMC Gastroenterol 2023; 23: 233
• 4 Gualandi N, Cortegoso VP, Bonura GF. et al. Endotherapy for small-bowel recurrent bleeding from a jejunal cavernous hemangioma in an elderly patient. Endoscopy 2024; 56: E589-E590