Laparoendoscopic techniques for occult gastrointestinal bleeding

Up to 5% of gastrointestinal bleeds occur between the ligament of Treitz and the ileocecal valve. These patients present with occult bleeding and pose diagnostic and therapeutic challenges. Currently, an array of technology exists for diagnostic purposes, including upper and lower endoscopies, capsule endoscopy, nuclear scans, angiography, and intraoperative endoscopy. All of these modalities have advantages and disadvantages. However, the diagnostic gold standard for occult gastrointestinal bleeding does not exist. We present a case of an 18-year-old male with occult gastrointestinal bleeding to illustrate the variety of available modalities. Initially, the patient underwent upper, lower, and push endoscopies. Subsequently, he had a nuclear bleeding scan, video capsule endoscopy, and an angiogram. Ultimately, the patient had a diagnostic laparoscopy with mobilization of the terminal ileum and right colon. The bowel was exteriorized and an intraoperative endoscopy was performed through a small bowel enterotomy. Multiple arteriovenous malformations (AVMs) were ascertained and resected. This case is presented in detail and the technique of intraoperative endscopy is reviewed. The diagnostic literature regarding AVMs is also reviewed.