Solitary hemangioma of the small intestine: an unusual cause of bleeding diagnosed at capsule endoscopy

Solitary small intestine hemangiomas are rare and usually present with overt bleeding or chronic anemia. Diagnosis is usually difficult because traditional imaging techniques often lack accuracy. Capsule endoscopy is a new diagnostic tool that has showed greater sensitivity than other methods to reveal causes of bleeding in the small intestine. A case of hemangioma of the ileum in a 13-year-old boy is presented. Capsule endoscopy allowed diagnosis and planning of surgical treatment.     

Diffuse microscopic angiodysplasia and nodular lymphoid hyperplasia in an infant with obscure massive lower gastrointestinal bleeding: a diagnostic challenge

The authors report a rare case of diffuse microscopic angiodysplasia and nodular lymphoid hyperplasia involving the distal ileum and total colon in a 13-month-old girl who had recurrent episodes of massive lower gastrointestinal bleeding of obscure origin. Colonoscopy showed multiple nodular hyperplasia and mucosal erosions, and all other diagnostic studies were negative. At laparotomy, intraoperative transluminal endoscopic transillumination was of benefit in identifying the bleeding foci but could not detect every angiodysplastic lesion.     

Role of intraoperative enteroscopy in the management of obscure gastointestinal bleeding at the time of video-capsule endoscopy

Background

This study aimed at evaluating the role of intraoperative enteroscopy (IOE) for the management of obscure gastrointestinal (GI) bleeding in patients who had been preoperatively explored by video-capsule endoscopy (VCE).

Methods

Eighteen patients who underwent IOE for obscure GI bleeding were prospectively recorded between November 2000 and January 2007. The bleeding site was preoperatively localized by VCE in the small bowel in 15 patients, but the origin of bleeding remained unknown in 3 patients.

Results

In the 3 patients with negative VCE, IOE was normal, but intraoperative conventional endoscopy identified gastric (n = 1) and colonic (n = 2) lesions. Among the 15 patients with VCE positive for small-bowel lesions, laparotomy and IOE yielded localization and treatment (surgical n = 11 and endoscopic n = 2) guidance for 13 of 15 (87%) lesions. At median 19-month follow-up, 3 bleeding recurrences (3 of 15 [20%]) were recorded, resulting in a 73% therapeutic efficacy of IOE.

Conclusions

IOE remains useful for the management of obscure GI bleeding when preoperative VCE is positive for small-bowel lesions that are not reachable by nonoperative enteroscopy. When VCE is negative, new conventional endoscopy should be proposed instead of IOE.     

自控镇痛技术在双气囊内镜检查中的可行性和安全性研究

目的评价患者自控镇痛（PCA）技术在双气囊内镜（DBE）检查过程中的安全性和可行性。方法根据麻醉方式的不同．前瞻性将2007年5月至2011年5月间云南省第一人民医院收治的120例疑似小肠疾病的患者按随机数字表法随机分为未行麻醉处理（A组）、TCI静脉泵输注丙泊酚（B组）和PCA泵静脉输注瑞芬太尼（c组）3组,每组40例。比较3种麻醉方法应用于DBE检查的可行性和安全性价。结果B组和C组患者耐受性较好,操作成功率均为100％。明显优于A组的80％（12／40,P〈0．01）。A组和B组患者血压、心率和血氧饱和度在操作过程中波动较大,而C组患者则较为平稳。B组和C组患者的病变检出率分别为67．5％（27／40）和72．5％（29／40）。明显高于A组的37．5％（15／40．均P〈0．01）。C组与B组比较,内镜到达深度更远,操作结束后离院时间更短（均P〈0．05）。结论PCA技术应用于DBE检查中．可满足患者在不同时刻的个体化镇痛需要,提高患者对检查的耐受性及依从性．能与操作者进行交流及配合变换体位．降低操作风险．提高双气囊内镜的操作成功率。     

Submucosal jejunal lymphangioma: an unusual case with obscure gastrointestinal bleeding in an adult, detected by video-capsule endoscopy and treated by laparoscopy

A 54 year-old man, without any remarkable medical history, was examined for recurrent episodes of colicky abdominal pain, over a period of nine months, with positive faecal occult blood test. Three months earlier he had undergone an extensive evaluation for a single episode of melaena, including upper gastrointestinal endoscopy, colonoscopy to the caecum, enteroscopy and an abdominal ultrasound scan, that were negative. He was then submitted to the video capsule endoscopy (Given Imaging Ltd, Yoqneam, Israel) that revealed a polypoid white-yellowish lesion in the mid portion of the jejunum. The patient was admitted to our Department of Surgery in January 2005. During the operation, performed by laparoscopic video-assisted approach, the lesion, measuring 1.5x2 cm, was found at about 100 cm from the ligament of Treitz and was successfully excised. At histology, the final diagnosis was submucosal lymphangioma. The lymphangioma is a benign neoplastic lesion of the lymphatic system that usually is present in infancy and is found, in the majority of the patients, in the subcutaneous tissue outside the abdomen. The intrabdominal site accounts for less than 1% of the cases, and often occurs in the mesentery of the small bowel. Finding the lesion in the submucosa of the jejunum in an adult is very rare. The case here reported seems unusual to the Authors and worthy of publication because of the chronic, ambiguous clinical symptomatology, the occult digestive blood loss, and all the diagnostic examinations resulting negative, except for the video-capsule endoscopy. Moreover, the choice of the laparoscopic video-assisted technique, confirming the expected site of the lesion, with a 'minimal' small bowel resection, made the postoperative course of the patient very short and uneventful. He is well and free of disease one year after the intervention. From a brief review of surgical literature, the case reported is the second one detected by the video capsule endoscopy and the fifth operated on by laparoscopy.     

Incidence of tumoral pathology according to study using capsule endoscopy for patients with obscure gastrointestinal bleeding

Background Capsule endoscopy has involved a significant advance in techniques for imaging of the small bowel. Its most frequent indication is for studying patients with obscure gastrointestinal bleeding (OGIB). Small bowel tumors are infrequent, representing only 1% to 3% of all malignant gastrointestinal tumors. This study aimed to assess retrospectively the occurrence and characteristics of tumoral pathology diagnosed by means of capsule endoscopy in patients with OGIB. Methods A retrospective review analyzed the first 320 patients submitted to capsule endoscopy because of OGIB (166 with obscure overt bleeding and 154 with obscure occult bleeding) at a single center. The patients with a tumor diagnosis were analyzed in terms of incidence, characteristics, and treatment of OGIB pathology. Results Tumor incidence was of 7.18% (23/320), with 65.2% of the cases supported with histologic confirmation (15/23). Obscure overt bleeding was the most frequent form of presentation, with the jejunum as the most frequent location (65.2%). For 16 patients, an intervention was conducted with a healing intent. Capsule endoscopy allowed the diagnosis of two cecal adenocarcinomas missed by colonoscopy. Conclusions Small bowel tumors are not an infrequent cause of OGIB. Capsule endoscopy, even if it does not allow determination of the benign or malignant nature or the histologic type of the tumor, is a useful tool for the diagnosis and early management of these tumors.     

An unusual cause of paraphimosis: hemangioma of the glans penis

Paraphimosis is a urologic emergency that occurs in uncircumcised boys. In untreated paraphimosis, increasing edema caused by vascular and lymphatic obstruction results in ominous sequelae such as penile gangrene, which leads to autoamputation in days or weeks. Most cases of paraphimosis are iatrogenic, but that condition has unusual causes as well. We present a very rare case of paraphimosis that occurred in a patient with a hemangioma of the glans penis. We suggest that the swelling of the hemangioma pushed the penile skin backward and caused paraphimosis. To our knowledge, such a presentation has not been previously reported in the English literature.     

Massive bleeding from multiple jejunal diverticula associated with an angiodysplasia: Report of a case

We report herein the case of a 70-year-old woman who presented with massive bleeding from multiple jejunal diverticula. She was initially admitted to our hospital with massive melena. An upper gastrointestinal endoscopic examination revealed no bleeding site. Colonoscopy revealed clotted and red blood throughout the colon, and a small diverticulum in the ascending colon which was thought to be the source of bleeding. Following admission, she was treated conservatively at first, but melena continued and the anemia did not improve despite blood transfusions. A laparotomy was performed and multiple jejunal diverticula, distributed from 10 to 40 cm distal to the ligament of Treitz, were found. A segment of the jejunum containing all diverticula was resected. The most distal diverticulum contained a clot of blood, but no ulceration was observed. A histological examination revealed many dilated blood vessels in the mucosa and submucosa of this diverticulum, which were compatible with the findings of angiodysplasia. Based on these findings, we believe that angiodysplasia was the cause of bleeding from the jejunal diverticula in this case. Received: May 24, 1999 / Accepted: March 24, 2000     

Papillary lymphoid hyperplasia of the terminal ileum: an unusual cause of intussusception and gastrointestinal bleeding in childhood.

Papillary lymphoid hyperplasia of the terminal ileum is a benign condition associated with abdominal pain, intussusception, and gastrointestinal hemorrhage. It appears to represent a distinct clinicopathologic entity, separate from the usual idiopathic intussusception of infancy and childhood. The lesions are reasonably well circumscribed, localized in the submucosa of the terminal ileum, and composed of lymphoid tissue with prominent germinal follicles. Management by ileocolectomy resulted in complete cure with no postoperative complications in our six cases. However, many authors recommend conservative therapy. The cause is not known but there may be some relationship between these cases and intestinal adenovirus infection.     

Hemosuccus pancreaticus complicating chronic pancreatitis: an obscure cause of upper gastrointestinal bleeding

Background: Hemosuccus pancreaticus, a rare form of upper gastrointestinal bleeding, may complicate chronic pancreatitis and pose a significant diagnostic and therapeutic dilemma. Aim: To present our experience with this potentially life-threatening complication of chronic pancreatitis. Methods: We reviewed our experience with management (both operative as well as angiographic embolization) of patients with hemosuccus pancreaticus complicating histologically documented chronic pancreatitis between 1976 and 1997. Diagnosis of hemosuccus pancreaticus was based on clinical presentation, preoperative endoscopic and radiographic imaging, operative findings, and pathologic evaluation. Results: During the period, we managed eight patients with hemosuccus pancreaticus (1.5% of all patients with chronic pancreatitis treated surgically). Gastrointestinal bleeding presented as hematemesis in three and hematochezia in three, but all had recent melena and were anemic; three of these patients were hemodynamically unstable. Abdominal pain was present in six. When performed, angiography (n=6) was diagnostic of a pseudoaneurysm; computed tomography (n=7) showed a pseudoaneurysm in two and a pseudocyst in five. Endoscopy (n=8) revealed blood issuing from the ampullary papilla in two patients. Operative management (n=6) involved distal pancreatectomy, pancreatoduodenectomy, or total pancreatectomy in two patients each. Angiographic embolization was successful in one patient, but the other died from uncontrollable hemorrhage. Conclusions: Hemosuccus pancreaticus is rare, but should be considered in patients with chronic pancreatitis and gastrointestinal bleeding. In the absence of pancreatitis-related indications for surgery, angiographic embolization can be definitive treatment. If there are pancreatitis-related indications for operation, angiographic embolization may allow an elective operative procedure based on structural changes of the pancreas. If embolization fails, pancreatic resection is usually required, often on an emergent basis. Received: 23 August 1999 Accepted: 27 December 1999     

Contribution of intraoperative enteroscopy in the management of obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding remains a significant diagnostic challenge. Our aims were (1) to determine the efficacy of intraoperative enteroscopy (IOE) in identifying lesions responsible for obscure gastrointestinal bleeding and (2) to determine the outcome of patients after treatment of these lesions. We retrospectively reviewed all patients who underwent IOE for obscure gastrointestinal bleeding from 1992 to 1998. Patients were divided into those with overt and those with occult gastrointestinal bleeding. Follow-up was complete in 67 patients (96%), with a median of 32 months (range 1 to 91 months). Seventy patients (52 overt and 18 occult) underwent IOE after extensive preoperative evaluation. Median duration of bleeding was 12 months, requiring a median of 14 blood transfusions. Risk factors for bleeding were identified in 46 patients (61 %). A lesion was identified and treated in 52 patients (74%)—39 in the overt group and 13 in the occult group. Lesions identified were vascular (54%), ulcerations (31%), tumors (11%), and small bowel diverticula (4%). Overall, 35 patients (52%) were found to have one or more lesions at IOE that were treated surgically and had no further bleeding. IOE, through a mid-small bowel enterotomy, has low morbidity and is effective in that it identified a treatable lesion in 74% of patients, which led to cure of bleeding in 52%. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000, and published as an abstract in Gastroenterology 118(Suppl l):A1057, 2000.     

Laparoscopy-assisted exploration of obscure gastrointestinal bleeding after capsule endoscopy: the Korean experience

BACKGROUND: Obscure gastrointestinal bleeding (OGB) is generally defined as recurrent acute or chronic bleeding for which no source has been identified by routine radiologic and endoscopic examination. The aim of this study was to report our early experiences detecting small bowel bleeding by capsule endoscopy (CE) and the results of laparoscopy assisted surgery for OGB. MATERIALS AND METHODS: Seventy-five patients with OGB were examined by CE. Twelve of 24 patients in the active bleeding group underwent laparoscopic or laparoscopy assisted surgery and we carried out intraoperative enteroscopy to find the focus of the bleeding. RESULTS: Laparoscopic localization of the lesion was successful for 4 patients-those with Meckel's diverticulum, gastrointestinal stromal tumor, lymphoma, and ischemic necrosis. In 3 cases in which there was no natural passage of the capsule endoscope, lesions were identified by small bowel exploration through simple palpation by hand. Intraoperative enteroscopy was performed extracorporeally in 5 cases through a minilaparotomy window using an extended incision of a port site less than 7 cm in length. The lesions that were identified by CE preoperatively were resected successfully, via laparoscopic or laparoscopy-assisted surgery. The gastrointestinal bleeding has not recurred during the postoperative follow-up period (mean, 10.6 months). CONCLUSION: The laparoscopic approach can be chosen for surgical management of OGB patients with active bleeding whose lesions have been identified by CE. This approach allows minimally invasive surgical treatment for ongoing OGB.     

The capillary hemangioma of the stomach: an unusual cause of haemorrhage. Case report

Gastric haemorrhages are common clinical emergencies which often directly involve the surgeon in diagnosis and treatment; among these, rare vascular neoplasms deserve particular attention. The Authors report a rare case of benign vascular tumour of the stomach, a capillary angioma. After a literature review they highlight the importance of specific exams to reveal these small neoformations which, generally, show up clinically with acute bleeding, which may be severe, and which may not be discovered if the clinical evaluation is not very detailed. The surgical excision supported by a frozen sections is the most effective treatment.     

Laparotomy and intraoperative enteroscopy for obscure gastrointestinal bleeding before and after the era of video capsule endoscopy and deep enteroscopy: A tertiary center experience

Background

To evaluate roles of intraoperative endoscopy (IOE) in management of severe obscure GI bleeding (OGIB) before vs. after introduction of video capsule endoscopy (VCE) and deep enteroscopy (DE).

Extraluminal colonic arteriovenous haemangioma: an unusual cause of chronic lower gastrointestinal bleeding

Lower gastrointestinal bleeding is a common general surgical presentation in acute and chronic settings. Vascular anomalies account for 2% of such cases and can therefore be missed. We discuss a rare vascular anomaly in one of our patients where the diagnosis was not established for a ten-year period. We describe the subsequent management and a brief review of the literature of this uncommon condition.     

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目的 探讨急性疑难下消化道出血部位的术中定位方法。方法 对12例 术前检查、术中探查不能确定出血部位的下消化道出血病人，行分段肠道灌洗后内镜检查。结果 9例发现出血部位，3例未明。结论 术中灌洗内镜检查有助于术中出血部位的准确定位，操作简便，直观有效。     

Radiographic techniques for the localization and treatment of gastrointestinal bleeding of obscure origin

Purpose/background  

Acute gastrointestinal bleeding (GIB) is an emergency with high mortality rates, which requires a quick localization and treatment of the bleeding site. In this article, we give a summary of the diagnostic and interventional treatment of acute GIB with an emphasis on radiological methods.