- Email: [email protected]
An Unusual Case of Acute Intestinal Hemorrhage
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI An Unusual Case of Acute Intestinal Hemorrhage Jeroen De Groote,1,3 Christophe Snauwaert,2 and Luc Defreyne3 Departments of 1Radiology, 2Gastroenterology, and 3Vascular and interventional Radiology, Universitair Ziekenhuis, Gent, Belgium
Question: A 67-year-old man was transferred to the emergency department with acute abdominal pain and hematochezia. On clinical examination, the patient presented with pallid skin, a tender abdomen, tachycardia, and hypotension, suggesting hypovolemia. Hematologic investigations revealed a significant anemia, transfusion-related dilutional thrombocytopenia, and coagulopathy as a consequence of initial fluid resuscitation. The patient has a known medical history of peptic ulcer bleeding and laparoscopic bilateral inguinal hernia repair. He was currently not on any active medical treatment. Urgent upper and lower endoscopy revealed a small hiatal hernia and colonic diverticulosis but no active bleeding sites could be detected. CT angiography (CT-A) of the abdomen confirmed an active arterial bleeding located at the mesenteric site of the proximal jejunal bowel wall (Figure A, arrow) with contrast pooling in venous scan phase (Figure B). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
© 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.07.047
Gastroenterology 2015;148:e10–e11
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 5: Arterial Bleeding From a Jejunal Diverticulum The patient was transferred to the interventional radiology department for mesenteric angiography. Severe mesenteric vasoconstriction was observed due to hypovolemic shock (Figure C). Angiography revealed extravasation from a straight jejunal artery (Figure C). Selective microcatheterization of the involved vas rectum was performed (Figure D). Embolization with microcoils resulted in occlusion of the ruptured vas rectum and hemostasis (Figure E). Postprocedural transfer to the intensive care unit was followed by an uneventful recovery. Postoperative cap-assisted push enteroscopy located the former bleeding site in a jejunal diverticulum (Figure F, arrowheads). A small loop of the placed microcoil was visible through the rupture site at the luminal wall (Figure F, G, arrows). Retrospectively, multiple diverticula could be visualized on the initial CT, located at the mesenteric site of the jejunal wall in close proximity to the bleeding site (Figure A, B). In contrast with colonic diverticulosis, small bowel diverticula are relatively rare. Jejunal diverticula are the rarest of all small bowel diverticula (incidence of 0.5%–2, 3%) and are mostly asymptomatic.1 Chronic abdominal symptoms, including pain, nausea, steatorrhea, and malabsorption might be related to small bowel diverticula. However, jejunal diverticula present more often with acute symptomatology such as diverticulitis, intestinal perforation, small bowel obstruction, and haemorrhage.1 In patients with acute gastrointestinal hemorrhage, primary management consists of conservative medical therapy followed by enteroscopic evaluation for diagnosis and eventually intervention. However, even after appropriate bowel cleansing, enteroscopy fails to determine the bleeding source in 10%–20% of the cases. CT-A has a sensitivity of detecting active acute intestinal bleeding in 85.2%, with an overall specificity of 92.1%.2 At our institution, enteroscopic failure is followed by CT-A. Scan protocol should include a precontrast, arterial, and venous scan phase. Arterial bleeding is associated with extravasation of contrast medium into the bowel lumen in the arterial phase. This contrast extravasation increases and diffuses in the bowel lumen in the venous phase. The precontrast scan is used to differentiate spontaneous intraluminal hyperdensities with active contrast extravasations. Confirmation of an active bleeding location on CT-A is followed by mesenteric angiography. If positive, superselective embolization using various techniques including microcoils, gelfoam pledgets, and polyvinyl alcohol particles is the choice. Microcoil embolization in lower gastrointestinal bleeding is associated with a technical success rate of 88.6% with a 30-day clinical success rate of 56.8%.3 Morbidity and mortality rates are lower compared with surgery.3
References 1. 2. 3.
Patel VA, Jefferis H, Spiegelberg B, et al. Jejunal diverticulosis is not always a silent spectator: a report of 4 cases and review of the literature. World J Gastroenterol 2008;14:5916–5919. García-Blázquez V, Vicente-Bártulos A, Olavarria-Delgado A, et al. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. Eur Radiol 2013;23:1181–1190. Mensel B, Kühn J, Kraft M, et al. Selective microcoil embolization of arterial gastrointestinal bleeding in the acute situation: outcome, complications, and factors affecting treatment success. Eur J Gastroenterol Hepatol 2012;24:155–163.
e11
Question: A 67-year-old man was transferred to the emergency department with acute abdominal pain and hematochezia. On clinical examination, the patient presented with pallid skin, a tender abdomen, tachycardia, and hypotension, suggesting hypovolemia. Hematologic investigations revealed a significant anemia, transfusion-related dilutional thrombocytopenia, and coagulopathy as a consequence of initial fluid resuscitation. The patient has a known medical history of peptic ulcer bleeding and laparoscopic bilateral inguinal hernia repair. He was currently not on any active medical treatment. Urgent upper and lower endoscopy revealed a small hiatal hernia and colonic diverticulosis but no active bleeding sites could be detected. CT angiography (CT-A) of the abdomen confirmed an active arterial bleeding located at the mesenteric site of the proximal jejunal bowel wall (Figure A, arrow) with contrast pooling in venous scan phase (Figure B). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
© 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.07.047
Gastroenterology 2015;148:e10–e11
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 5: Arterial Bleeding From a Jejunal Diverticulum The patient was transferred to the interventional radiology department for mesenteric angiography. Severe mesenteric vasoconstriction was observed due to hypovolemic shock (Figure C). Angiography revealed extravasation from a straight jejunal artery (Figure C). Selective microcatheterization of the involved vas rectum was performed (Figure D). Embolization with microcoils resulted in occlusion of the ruptured vas rectum and hemostasis (Figure E). Postprocedural transfer to the intensive care unit was followed by an uneventful recovery. Postoperative cap-assisted push enteroscopy located the former bleeding site in a jejunal diverticulum (Figure F, arrowheads). A small loop of the placed microcoil was visible through the rupture site at the luminal wall (Figure F, G, arrows). Retrospectively, multiple diverticula could be visualized on the initial CT, located at the mesenteric site of the jejunal wall in close proximity to the bleeding site (Figure A, B). In contrast with colonic diverticulosis, small bowel diverticula are relatively rare. Jejunal diverticula are the rarest of all small bowel diverticula (incidence of 0.5%–2, 3%) and are mostly asymptomatic.1 Chronic abdominal symptoms, including pain, nausea, steatorrhea, and malabsorption might be related to small bowel diverticula. However, jejunal diverticula present more often with acute symptomatology such as diverticulitis, intestinal perforation, small bowel obstruction, and haemorrhage.1 In patients with acute gastrointestinal hemorrhage, primary management consists of conservative medical therapy followed by enteroscopic evaluation for diagnosis and eventually intervention. However, even after appropriate bowel cleansing, enteroscopy fails to determine the bleeding source in 10%–20% of the cases. CT-A has a sensitivity of detecting active acute intestinal bleeding in 85.2%, with an overall specificity of 92.1%.2 At our institution, enteroscopic failure is followed by CT-A. Scan protocol should include a precontrast, arterial, and venous scan phase. Arterial bleeding is associated with extravasation of contrast medium into the bowel lumen in the arterial phase. This contrast extravasation increases and diffuses in the bowel lumen in the venous phase. The precontrast scan is used to differentiate spontaneous intraluminal hyperdensities with active contrast extravasations. Confirmation of an active bleeding location on CT-A is followed by mesenteric angiography. If positive, superselective embolization using various techniques including microcoils, gelfoam pledgets, and polyvinyl alcohol particles is the choice. Microcoil embolization in lower gastrointestinal bleeding is associated with a technical success rate of 88.6% with a 30-day clinical success rate of 56.8%.3 Morbidity and mortality rates are lower compared with surgery.3
References 1. 2. 3.
Patel VA, Jefferis H, Spiegelberg B, et al. Jejunal diverticulosis is not always a silent spectator: a report of 4 cases and review of the literature. World J Gastroenterol 2008;14:5916–5919. García-Blázquez V, Vicente-Bártulos A, Olavarria-Delgado A, et al. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. Eur Radiol 2013;23:1181–1190. Mensel B, Kühn J, Kraft M, et al. Selective microcoil embolization of arterial gastrointestinal bleeding in the acute situation: outcome, complications, and factors affecting treatment success. Eur J Gastroenterol Hepatol 2012;24:155–163.
e11