Successful treatment of obscure gastrointestinal bleeding with intraoperative enteroscopy

A 51-year-old man was referred to our institution with persistent iron deficiency anemia. Initial gastroduodenoscopy and colonoscopy at his local hospital were unremarkable. A subsequent small bowel capsule endoscopy revealed a distal small bowel polyp with evidence of fresh bleeding ([Fig. 1]). A triple-phase abdominal computed tomography scan confirmed a 13-mm vascular polypoid lesion within the distal small bowel, with hyperenhancement on the arterial phase ([Fig. 2]). After a discussion in a multidisciplinary team meeting, it was decided that surgical resection guided by intraoperative enteroscopy to localize the lesion would be the most appropriate course of action.

Fig. 1 Small bowel capsule endoscopy images. a Fresh bleeding. b Polypoid lesion in the distal small bowel.

Fig. 2 Abdominal computed tomography scan showing a polypoid lesion within the distal small bowel with hyperenhancement on the arterial phase.

During intraoperative enteroscopy, an actively bleeding polyp was detected in the distal ileum ([Video 1]), and a limited small bowel resection was performed without complications ([Fig. 3]). The patient was discharged 2 days after the surgery. Histological examination of the resected specimen showed a nodular area of ulceration lined with prominent granulation tissue. However, the cause for this ulceration was not histologically identified.

Video 1 The intraoperative enteroscopy procedure.

Fig. 3 The small bowel surgical resection specimen showing the lesion within the ileum.

Obscure gastrointestinal bleeding (OGIB) is a challenging condition that accounts for nearly 5 % of all gastrointestinal bleeding cases [1]. Small bowel vascular lesions are the most common cause of OGIB [2]. Advances in small bowel capsule endoscopy and device-assisted enteroscopy revolutionized the diagnosis and management of small bowel bleeding [3]. Although the majority of cases can be managed endoscopically, this case highlights the value of intraoperative enteroscopy for the localization and treatment of small bowel lesions when endoscopic treatment is not feasible [4].

Endoscopy_UCTN_Code_CCL_1AC_2AC

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Sey MSL, Yan BM. Optimal management of the patient presenting with small bowel bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43
• 2 Rockey DC. Occult and obscure gastrointestinal bleeding: Causes and clinical management. Nat Rev Gastroenterol Hepatol 2010; 7: 265-279
• 3 Pennazio M, Rondonotti E, Despott EJ. et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022. Endoscopy 2023; 55: 58-95
• 4 Voron T, Rahmi G, Bonnet S. et al. Intraoperative enteroscopy: Is there still a role?. Gastrointest Endosc Clin N Am 2017; 27: 153-170

Publikationsverlauf

Artikel online veröffentlicht:
27. Juni 2023