A 77-year-old woman was admitted because she had been passing tarry stools for 1 week.
She had a past medical history of hypertension, coronary artery disease, and uremia
requiring dialysis. Following negative upper endoscopy and colonoscopy examinations,
she underwent double-balloon enteroscopy. Several blood clots were found in the jejunum
and a source of active bleeding was found after 2 hours’ examination (Figure [1]). Injection therapy with a total of 3 ml of 1 in 10 000 epinephrine in hypertonic
saline resulted in initial hemostasis, but the bleeding recurred 2 days later. The
patient required surgical intervention, when segmental ecchymosis of the intestine
was observed, 280 cm from the ileocecal valve (Figure [2]). The remaining small intestine was unremarkable. Subsequent histological examination
revealed ischemic necrosis, involving only 1.5 cm of the resected intestine, which
we believed corresponded with the injection site. The patient experienced no further
bleeding over a 6-month period after the operation.
Figure 1 Endoscopic view showing active bleeding from a mucosal fold (arrow). The adjacent
intestinal mucosa was intact. It was difficult to visualize the source of bleeding,
but it was presumed to be a bleeding angiodysplastic lesion.
Figure 2 Macroscopic view of the resected small intestine. Note the band-like ischemic change
(arrows).
Since the introduction of double-balloon enteroscopy [1], endoscopists have been expected to perform an increasing number of diagnostic and
therapeutic procedures involving the small intestine using this technique [2]
[3]. However, experience of therapeutic endoscopy in the small intestine is limited
and we experienced two problems related to the procedure in this patient. Firstly,
endoscopic examination for the investigation of active small-bowel bleeding is particularly
difficult: prolonged procedure times and large volumes of irrigation fluids may be
required, and patient intolerance and fluid overload are potential problems. Secondly,
injection therapy, using a variety of solutions, has been deployed in order to control
peptic ulcer bleeding [4]. In this patient, the finding of intestinal necrosis at the injection site highlighted
the problems of the optimal volume and the safety of solutions used for injection
therapy in the small intestine. Advanced age, atherosclerotic vascular disease, anemia,
hypoxemia, and shock are all associated with intestinal necrosis following injection
thearpy [5]. In addition, the thinner wall of the small intestine may make this complication
more likely during double-balloon enteroscopy. Therapeutic endoscopists should be
aware of this complication. Further studies are necessary to evaluate the safety of
endoscopic procedures when applied to the small intestine.
Competing Interests: None
Endoscopy_UCTN_Code_CPL_1AI_2AD
