Massive Lower Gastro-Intestinal Bleeding Due to Small Bowel Diverticula. A Report of Two Cases

Gastro-intestinal bleeding from the small bowel is a rare entity. It is difficult to determine the source of bleeding because of the unavailability of routine small bowel endoscopy. The most common reasons for bleeding from the small bowel are tumours, arteriovenous malformations and inflammatory bowel diseases. Diverticula of the small bowel are very uncommon. We present two cases of gastro-intestinal bleeding due to small bowel diverticula. Both of them were diagnosed on laparotomy. One had a short segment of small bowel, with six diverticula, which was resected. The second case had a long segment of small bowel with multiple diverticula. This patient was treated by isolating and excising the bleeding diverticulum. Haemodynamically unstable lower gastro-intestinal bleeding mandates exploratory laparotomy. Mesenteric angiography and Tc 99 labelled erythrocyte scintigraphy can detect the bleeding site. Intra-oper-ative endoscopy can be performed safely via an enterotomy and can localize the bleeding site.     

Meckel's diverticulum in the adult

Meckel's diverticula were removed from 49 adult patients during a 15 year period. In 24 (49 per cent) of the patients the diverticulum was the cause of symptoms while in the remaining 25 it was an incidental finding at laparotomy. Of the symptomatic patients, 10 had acute inflammation of their diverticula, 8 presented with small bowel obstruction (in 4 cases due to fibrous bands) and 4 attended because of gross rectal bleeding; of the 2 remaining patients one was found to have intussusception of Meckel's diverticulum into the terminal ileum whilst the other had a nodule of calcified material lying within a partly gangrenous vitellointestinal duct. There was no operative mortality in the series. Heterotopic tissue was noted histologically in six Meckel's diverticula, all of which produced symptoms. The importance of considering a diagnosis of Meckel's diverticulum in the young adult presenting with acute small bowel obstruction or rectal bleeding is emphasized.     

Angiodysplasia of the small bowel: a method of intraoperative identification.

Two cases of recurrent bleeding from the gastro-intestinal tract are described. The initial diagnosis and the identification of the lesions at laparotomy were difficult problems. In both cases the bleeding was due to a vascular lesion of the small bowel, referred to as angiodysplasia. The lesions were detected before operation by selective angiography and identified at laparotomy by a preoperative and an intraoperative injection of a vital stain through the catheter into the feeding vessels.     

Surgical resection for gastrointestinal metastatic melanoma

AIM: Metastases of melanoma are frequent. On the gastro-intestinal tract, commonest localizations are small bowel, stomach and colon. Surgical treatment of digestive metastases from melanoma is not well known and its value is still debated. PATIENTS AND METHODS: Medical records of 10 patients (six female and four male) operated for metastatic melanoma to gastro-intestinal tract were reviewed to determine results of surgery. RESULTS: Gastro-intestinal metastases were symptomatic in eight patients (abdominal pain in three, bowel obstruction in three, abdominal mass and obstructive jaundice in one each). Two patients had anemia. Diagnosis has been suggested by imaging in seven patients and endoscopy in three. All patients were operated on by laparotomy for resection of metastases located on small bowel in four patients, gallbladder in two, stomach in two and colon in two. Complete resection suppressed symptoms in nine cases. In one patient, resection was incomplete but provided satisfying symptomatic relief. One patient died at day 3; in other patients, median survival was 18 months (range: 3-120). CONCLUSION: In a patient with previous history of melanoma, digestive symptoms indicate morphological explorations due to suspicion of metastases to gastro-intestinal tract. Surgical treatment of these metastases is usually palliative but, in some cases, allows long-term survival.     

Bleeding from duodenal ulcer in a patient with bilio-pancreatic diversion

Scopinaro’s bilio-pancreatic diversion is considered as an acceptable malabsorptive surgical approach for the treatment of morbid obesity. We describe a case of acute recurrent gastro-intestinal bleeding in a patient with a previous Scopinaro’s bilio-pancreatic diversion. At the first admission in our department, gastroscopy, colonoscopy, contrast-enhanced computerized tomography and angiography resulted negative for active bleeding. Hypovolemic shock indicated laparotomy and an intraoperative enteroscopy performed through a small enterotomy showed an ulcerative perforation sourced in an ischemic portion of a distended duodenal stump, with a bleeding branch of gastro-duodenal artery at the bottom. Hemorrhage was stopped with stitches. Two years later a new episode of duodenal bleeding associated with severe malnutrition occurred. A covered chronic ischemic perforation sustained by duodenal distension due to biliopancreatic limb sub-obstruction appeared to be the most probable etiology of the recurrent duodenal bleeding. The patient underwent again to laparotomy and adhesiolysis; hemorrhage was stopped by means of ligation of gastroduodenal artery and bilio-pancreatic diversion was converted into a standard Roux-en-Y gastroenterostomy with an entero-entero anastomosis 40 cm from the Treitz ligament in order to restore an anatomo-functional condition guaranteeing normal absorption and intestinal transit. After Scopinaro’s bilio-pancreatic diversion duodenal bleeding can represent a rare serious presentation of biliopancreatic limb obstruction; because of the complex anatomical reconstruction performed during this intervention, the duodenum results unavailable during upper gastro-intestinal endoscopy, and if a duodenal bleeding is suspected laparotomy followed by enteroscopy represents an effective diagnostic approach.     

Laparoscopic drainage of an intramural duodenal haematoma: a novel technique and review of the literature

Small bowel diverticulosis is an uncommon and often asymptomatic condition that is sporadically observed during radiographic examination or laparotomy. Although it is frequently seen in duodenum, jejunal and ileal locations are very rare. The majority of patients with jejunal diverticula have no symptoms. However, they can present with a number of acute and emergent complications with a high rate of mortality. Bleeding from jejunal diverticula occurs in less than 3% - 8% of patients and often present as fresh rectal haemorrhage. This can confuse the clinician since a bleeding source in colon is far more common. We report a patient with acute massive rectal bleeding. Abdominal CT angiography demonstrated a jejunal diverticulum as the bleeding source and the patient underwent resection of the affected segment. She has since remained free of gastrointestinal bleeding. Although jejunal diverticulosis is rare, it is an important differential diagnosis for patients with gastrointestinal haemorrhage of unknown origin as it may cause extensive rectal bleeding. Abdominal CT angiography can localize the bleeding source and resection of the affected bowel and primary anastomosis is the treatment of choice.     

The role of capsule endoscopy in the study of intestinal diseases. Critical analysis and observation of the first 50 cases

The total visualization of the intestinal surface through wireless capsule endoscopy has furnished new insights for the diagnosis of intestinal diseases. The length, difficulty of access and particular morphology of this region makes a correct diagnosis of gastrointestinal diseases associated with bleeding possible only in 5% of cases. Our study was aimed at assessing the clinical impact and diagnostic outcomes of wireless capsule endoscopy through analysis of the first 50 cases observed in our Endoscopy and Coloproctology Unit. Fifty patients aged 23-85 years (mean age: 43.5) were selected for wireless endoscopy. The main indications were patients with a suspected or established diagnosis of inflammatory bowel disease or malabsorption, abdominal pain, chronic diarrhoea and obscure bleeding. Patients with a clinical or radiological diagnosis of gastrointestinal stenosis, Zencker's diverticula, or colonic diverticulosis were excluded from the study. In 2 out of 8 patients with abdominal pain, erosions of the intestinal wall were detected, while in the only patient with gastrointestinal bleeding a neoplastic lesion of the right colon was accidentally diagnosed. As far as inflammatory bowel disease is concerned, in all the cases of established diagnosis of ulcerative colitis no small bowel lesions were visible at wireless endoscopy, while all the cases with silent Crohn's disease of the terminal ileum were confirmed. No cases of neoplastic lesions of the small bowel were recorded in our series either in celiac-disease patients or in patients with familial intestinal polyposis. In celiac-disease patients (N = 24) wireless capsule endoscopy allowed accurate definition of the extent of the mucosal damage. On the basis of our preliminary experience wireless capsule endoscopy would appear to warrant an important role in the management of patients with small bowel diseases, supplementing information obtained with other diagnostic techniques.     

Diverticular disease of the small bowel: report of 27 cases

Diverticula of the small bowel are usually asymptomatic but occasionally can present with serious complications. Because of the rarity of small bowel diverticulosis and the limited case number in most published reports, we analyzed one of the largest series with symptomatic small bowel diverticular disease. In this retrospective review, we studied 27 symptomatic patients with diverticula of the small bowel that was treated surgically. The study included 13 male and 14 female patients (age range, 30-87 years; mean age, 69.3 years). Fourteen patients underwent an elective operation for chronic refractory symptoms. Thirteen patients underwent emergency surgery because of rupture of the diverticula and associated peritonitis, diverticulitis and small bowel obstruction, or lower gastrointestinal bleeding. Surgical treatment consisted of resection of the intestinal segment containing the diverticula. All patients were symptom-free postoperatively and no "short bowel" problems developed. Abdominal pain, gastrointestinal bleeding, and bowel obstruction were the most common clinical symptoms. Small bowel diverticulosis should be treated surgically only when refractory symptoms or severe complications are present.     

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     

Surgical approach to occult gastrointestinal bleeding.

In 5% of patients with gastrointestinal bleeding, standard evaluation fails to reveal the source of the bleeding. We describe the management of 71 patients treated for obscure gastrointestinal bleeding at the Mount Sinai Medical Center, New York, New York, from 1985 to 1991. There were 38 men (54%) and 33 women (46%). The mean age was 60 years. The patients had bleeding episodes for a mean period of 26 months and required an average of 20 units of blood prior to surgical treatment. All had undergone an extensive diagnostic workup including barium contrast studies, endoscopies, and angiographies. Some had multiple bleeding scans, Meckel scans, and surgical explorations. Three patients were found to have "watermelon stomach" on endoscopy and had an antrectomy. Sixty-eight (96%) patients underwent a preoperative small bowel enteroscopy, which revealed the precise diagnosis in 50 (70%) of the patients. All patients underwent surgery. In 30 (42%) patients in whom the bleeding site was not apparent at exploration, intraoperative enteroscopy was performed. Two actively bleeding patients had intraoperative enteroscopy, which failed to localize the bleeding site, and intraoperative scintigraphy was utilized. The bleeding was found to originate in small bowel arteriovenous malformation (AVM) (28 patients), leiomyoma (8 patients), primary small bowel malignancies (11 patients), and other causes (24 patients). Fifty-six patients (80%) had no further bleeding; 9 with multiple small bowel AVM have experienced rebleeding and are alive. Six patients died of recurrent bleeding, and six died of metastatic cancer. An aggressive approach should be applied in patients in whom standard evaluation fails to localize the source of gastrointestinal bleeding. Enteroscopy, surgical exploration with additional intraoperative enteroscopy, and occasional intraoperative scintigraphy can achieve an excellent yield and allow resection and potential cure.     

Diagnosis and control of diverticular bleeding by arteriography and vasopressin infusion. A report of 2 cases.

Large-bowel bleeding usually arises from either angiodysplasia or colonic diverticula. Diverticular bleeding is more common in the right or the transverse colon, even though diverticula are more common on the left. Arteriography in these patients may identify the bleeding site, and in some cases vasopressin infusion controls the bleeding. Embolization of the large bowel is not recommended because of the danger of necrosis.     

Minimally invasive surgery using intraoperative real-time capsule endoscopy for small bowel lesions

Background

The small bowel has been considered the “black box” of gastroenterology. Identifying the exact site of small bowel hemorrhage is often difficult, thus complicating surgical treatment. We report two cases of small bowel bleeding lesions that were successfully managed by intraoperative real-time capsule endoscopy and minimally invasive surgery.

Methods

We developed a double-lumen tube similar to, but thinner and longer than, the Miller–Abbott tube. We insert the tube nasally, 3 or 4 days preoperatively, such that its balloon tip reaches the anus by the operative day. During surgery, the endoscopic capsule is connected to the balloon tip of the tube that protrudes from the anus. An assistant pulls on the nasal end of the tube, bringing the balloon tip and capsule back into the bowel. Capsule endoscopic images are displayed in a real-time video format.

Results

We employed this procedure in two patients with repeated melena. Various examinations including gastroendoscopy and total colonoscopy showed bleeding confined to the small bowel, but the exact lesion site was unknown. Minimally invasive surgery was successfully performed in both patients: open minilaparotomy in one and laparoscopy in the other. The small bowel and capsule endoscope were easily controlled during minilaparotomy, and real-time capsule endoscopic images clearly identified the bleeding lesion. Control of the small bowel was more difficult in the laparoscopic case; however, real-time capsule endoscopic images identified a small tumor that was successfully resected.

Conclusions

Intraoperative capsule endoscopy combined with the tube provides surgeons real-time images indicating the exact site of lesions. The tube also helps surgeons control the position of the capsule endoscope and enables suction of intraluminal fluid or inflation of the lumen to allow clearer views during the operation. We conclude that combined use of capsule endoscopy and the tube facilitates management of bleeding lesions in the small bowel.     

空肠回肠间质瘤的诊断和治疗

目的 探讨空肠回肠间质瘤诊断和治疗经验。方法 对我院1993～2003年收治的有完整资料经术后病理和免疫组化证实的15例空肠回肠间质瘤病例进行回顾性分析。结果 本组病人主要临床表现为黑便、腹痛、头晕、乏力。术前选择性血管造影发现小肠出血2例、核素扫描发现小肠出血1例。剖腹探查确诊7例,腹腔镜腹腔探查确诊4例,术前明确诊断的仅1例。发病至确诊时间2月～7年。14例病人行间质瘤切除、小肠吻合术,1例肿瘤无法切除的病人行口服Gleevec保守治疗。随访2月～9年,除1例病人死于其它疾患,1例在继续服用格列卫治疗外,余13例病人均健在,空肠回肠问质瘤无复发。结论 空肠回肠间质瘤缺乏特征性临床表现及有效诊断手段,易致长期延误诊治。对长期不明原因的消化道出血病人及早行剖腹探查或腹腔镜腹腔探查是避免空肠回肠间质瘤长期延误诊治、改善病人预后的关键。     

下消化道出血11例诊治体会

目的探讨不明原因下消化道出血的手术诊治体会。方法回顾性分析10年间经内镜、血管造影、增强CT扫描及核素扫描均不能明确下消化道出血部位及原因、由于反复出血或出血凶猛而采用剖腹探查诊治者11例的临床资料。结果最常见的出血原因是血管发育不良或畸形(5例),其次,小肠憩室2例,小肠平滑肌瘤1例,3例原因不明。最终的手术方式主要是右半结肠切除(7例),其他有病变小肠段切除3例及结肠次全切除1例。死亡率27.3%,再出血率18.2%。结论原因不明的下消化道出血,多数病人可以通过剖腹探查明确诊断及治疗,应及时手术。     

Acute hemorrhage from Meckel's diverticulum--Laparotomy or laparoscopy?

Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract with a potential risk to develop complications such as obstruction, diverticulitis or intussusception. Lower gastrointestinal bleeding due to ulceration of heterotopic gastric tissue of the diverticulum is a known phenomenon in children and young adults. We present two cases of a 15-year-old girl and a 20-year-old man that revealed a massive lower gastrointestinal hemorrhage of unknown origin. In this emergency situation laparotomy was performed in combination with lower endoscopy as rendezvous manouver. In both cases a Meckel's diverticulum with peptic ulceration was the source of hemorrhage, in one case the bleeding was active and visible. After resection of a short small bowel segment and end-to-end anastomosis the postoperative course was uneventful. We prefer in the case of lower gastrointestinal hemorrhage with hemodynamic instability laparotomy with intraoperative endoscopy instead of laparoscopy.     

胶囊内镜在小肠疾病诊断中的价值

目的探讨胶囊内镜对小肠疾病的诊断价值。方法2002年9月至2007年3月间对155例患者所进行的159例次胶囊内镜检查进行回顾性研究。记录胶囊内镜在胃和小肠的平均运行时间,评价患者的耐受性、胶囊内镜完成检查情况及胶囊内镜下病变的检出情况等。结果155例患者中,不明原因的消化道出血97例,腹痛42例,腹部不适6例,腹泻4例,体检6例。93．1％的患者（148／159）完成了全小肠摄影。所有患者在检查过程中未诉特殊不适。胶囊内镜胃内平均停留时间为65．5（1～335）min,小肠平均停留时间为282．2（45～524）min。胶囊内镜病变检出率为78．6％（125／159）。胶囊内镜发现血管病变43．4％（69／159）,小肠炎性病变28．3％（45／159）,黏膜下结节10．1％（16／159）,小肠憩室8．2％（13／159）,小肠肿物5．7％（9／159）以及小肠息肉、小肠异物、小肠寄生虫等。不明原因消化道出血病变检出率为89．7％（87／97）,腹痛查因病变检出率为73．8％（31／42）。结论胶囊内镜检查安全性较高,患者容易接受。胶囊内镜对小肠疾病、尤其消化道不明原因出血者具有重要的诊断价值。     

Small bowel metastases from primary lung carcinoma: a rarity waiting to be found?

Isolated, small bowel metastases from lung carcinoma are extremely rare; only 34 cases have been previously reported. Rarer still is the presentation of lung carcinoma with a lesion metastatic to the small bowel. These 34 cases and 3 recent ones from Easton Hospital (Easton, PA) were analyzed to clarify the clinical and pathologic features of the disease. The majority of patients had a history of abdominal pain (86%), melena (23%), or nausea and vomiting (26%). Few had weight loss (16%). Twenty-one patients (57%) came to the hospital with perforation and peritonitis, including 9 in whom lung carcinoma was undiagnosed before laparotomy. Thirteen patients (34%) underwent laparotomy because of small bowel obstruction, 2 (6%) for bleeding and 1 (3%) for a mass found during work-up. Squamous cell (49%) and large cell (22%) were the most common cell types, and the jejunum was the most common site of the metastases (79%). Survival time was dismal (mean 51 days) and was unaffected by therapy to the primary site of the cancer or its metastases. The authors conclude that small bowel metastases from lung carcinoma are not uncommon and may be seen more frequently as patients live longer after their diagnosis of cancer. Small bowel metastases must be considered in any patient with both lung carcinoma and abdominal pain, and should be expected in patients with both lung carcinoma and an acute abdomen.     

Principles for use of intraoperative enteroscopy for hemorrhage from the small bowel

Most patients with bleeding from the small bowel are frequently difficult to diagnose and treat because the rate of bleeding is slow and because this is the "blind area" of gastrointestinal endoscopy. We used a colonoscope passed by mouth intraoperatively in order to determine the site of bleeding in four patients. All patients required resection with one requiring laser therapy as well. We found that the following principles were important in maximizing the value of this technique: (1) Good communication between the endoscopist and operating surgeon during the procedure, (2) clamping the distal small bowel to prevent air accumulation in the colon (3) examining the bowel on the way in and avoiding the use of suction to minimize scope trauma artifact, (4) turning off the room lights in order to examine the transilluminated bowel externally, (5) examining the entire small bowel if possible, and (6) marking each site externally with a suture as it is identified.