Preoperative "two-way" enteroscopy,followed by intraoperative enteroscopy in a patient with obscure-overt gastrointestinal bleeding and severe iron-deficiency anemia

We present the case of a 69-year-old woman admitted to hospital because of chronic gastrointestinal bleeding of an unknown source with a consequent severe iron deficiency anemia (IDA), undiagnosed for the past 25 years. In the last three years the episodes of severe bleeding became frequent, usually followed by melena. The patient was admitted 11 times in different departments without the identification of the bleeding source. During the evolution of the disease, the biological exams showed a severe IDA with low values of hemoglobin, low serum iron, mixed deficiency depicted by bone-marrow examination, and a reticulocyte crisis after parenterally administered iron. Repeated upper (6) and lower (2) gastrointestinal endoscopies failed to find a source of bleeding. Push enteroscopy allowed the visualization of approximately 40 cm of the proximal jejunum, after the Treitz angle, and demonstrated multiple punctiform jejunal angiodysplasias, which bled excessively after bipolar coagulation. We also performed a total colonoscopy with intubation of the ileo-cecal valve and visualization of the terminal ileum on approximately 30 cm, without any pathological findings. Because endoscopic treatment was ineffective, we decided to perform a segmentary enterectomy, with the length of small bowel resection tailored by intraoperative enteroscopy. A favourable evolution after limited resection of the small bowel indicated the importance of both preoperative "two-way" enteroscopy associated with intraoperative enteroscopy for diagnosing and treating the source of obscure gastrointestinal bleeding