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Intraoperative Endoscopy of the Small Bowel
AORN JOURNAL
MARCH 1990, VOL. 51, NO 3
Intraoperative Endoscopy of the Small Bowel TREATMENT FOR OCCULT HEMORRHAGE Becky A. Shoaf, RN; Keith N. Apelgren, MD
A
rteriovenous malformation (AVM) of the bowel is one of the most common causes of lower gastrointestinal (GI) hemorrhage.' Identification of the AVM in the small intestine is difficult using conventional endoscopy and angiography. The latest in fiberoptic transoral endoscopic technology combined with transillumination of the small bowel, however, allows the surgical team to localize the AVM (Fig 1). This technique provides for accurate resection of the area of small intestine responsible for occult bleeding. There are three types of AVMs.* Type I AVMs are solitary lesions found frequently in the older population. These are thought to be an acquired dysplasia. Type I1 lesions are found in younger patients and are characterized by abnormal vessels in the submucosa. The third type of lesion is associated with Rendu-Osler-Weber syndrome. These are characterized by unique punctuate angiomas in the lip and cheek mucosa, as well
as angiomas of the face, fingers, and small bowel. The condition is familial, and spontaneous epistaxis is the primary manifestation. The etiology of AVMs is unknown. The major controversy on the etiology is whether AVMs are congenital or acq~ired.~ The occurrence of AVMs in younger patients as well as the association of AVMs with valvular stenosis support the congenital theory! Other authors suggest that the lesions result from the acquired degenerative changes of aging.5
Diagnosis
A
complete history and physical examination must be performed on patients suspected of having AVMs of the small bowel. The physician must pay particular attention to the condition of the skin because pathognomonic angiomas are associated with Type I11 AVMs. The medical histories of patients with
UniversityHospitak, Morgantown. She earned her bachelor of science degree in nursing from West Virginia Universiiy,Morguntown. Keith N. Apelgren, MD, h an associateprofessor of surgery, Michigan State University College of Human Medicine, East Lansing. He earned hi5 medical degree from the University of Michigan, Ann Arbor.
Becky A. Shoaf: W,BSN, CNOR, is a clinical manager-specialQ, operating room, West Virginia 776
The authors acknowledge E. R. McDannald Jr, MD, for his assistance.
MARCH 1990, VOL. 51, NO 3
AORN JOURNAL
Fig I . The arteriovenous malformation as seen through the flexible colonoscope.
AVMs include melenic stools, bright red rectal bleeding, iron deficiency anemia, and guaiacpositive stools? These patients also may have a history of multiple hospitalizations and blood transfusions. Other commonly associated symptoms are cardiac related, including congestiveheart failure and valvular disease. When these patients are admitted, a complete blood count should be done along with a coagulation profile, including partial thromboplastin time, prothrombin time, and platelet count. Diagnostic testing is complex and time consuming for these patients. They must first undergo esophagogastroduodenoscopy and colonoscopy to rule out bleeding from the upper gastrointestinal tract and the colon.7 The second step is visceral angiography to search for the site of the AVM. A positive angiography may show an enlarged feeding artery, a vascular lake, and an early feeding vein. The vascular lake is the AVM itself. Arteriovenous malformations in the duodenum, ileum, and jejunum are difficult to detect on angiography and may require magnification arteriography. It is not easy to diagnose small bowel hemorrhage because of the slow rate of bleeding, which makes observation of the feeding
artery, vein, and vasculatr lake difficult. The long tube method of identifying AVMs in the small bowel may be used to help pinpoint the general area of the malformations. The physician passes a long tube with a mercury filled balloon into the GI tract. The nurse aspirates the contents of the GI tract through the tube frequently and tests it for occult blood. When a hemo-occult positive aspirate is obtained, the tube is taped securely in place. Thein the patient is taken to the radiology suite where a plain radiograph and a dye study are performed to look for abnormalities of the small bowel. A more sophisticated technique that has been used recently is tagged red blood cell (RBC) scintigraphy.8 Autologous RBCs are labelled in vitro or in vivo with pyrophosphate and then with technetium 99M pertechnetate (a radioactive compound). ‘me patient is then placed under a scintillation counter at various time intervals. The information gained from RBC tagged scintigraphy helps approximate the 1.ocation of bleeding in the small bowel. The advantage of this technique is the ability to detect bleeding too slow to be found with visceral angiography or magnification arteriography.9 The recent advances in fiberoptic endoscopy
MARCH 1990, VOL. 51, NO 3
__-__
AORN JOURNAL
Fig 2. A view of the transilluminated and inflated bowel. The arrow points to the red area that identifies the arteriovenous malformation.
make it possible for the surgeon to easily manipulate the endoscope to position the light against the wall of the inflated small bowel (Fig 2). In the past, endoscopes could be passed only to the duodenum orally, leaving most of the small bowel unexamined. In addition, the use of a cold light allows for transillumination of the lesion without risk of damage to the mucosal lining of the intestine. The use of an external camera or a videocolonoscope provides the opportunity for documentation and teaching as well as allowing two people to view the lesion.
Preoperative Care nce a patient is diagnosed with AVM
of the small bowel, he or she is scheduled for a surgical resection of the area of bowel responsible for the occult bleeding episodes. The preoperative nursing assessment is done by the nurse when the patient arrives in the patient holding area. Nursing diagnoses for the patient undergoing bowel resection include potential for
infection due to spillage of bowel contents, potential for injury due to the supine position, and potential for hypothermia due to exposure of the abdominal contents to the cool room air during the surgical procedure. Nursing interventions aimed at preventing these potential problems are observation of adherence to sterile technique by the surgical team during the bowel resection, correct body alignment and padding of bony prominences, and the use of a hypotherniia blanket and heated irrigating solutions. Other nursing diagnosescommon to any surgical patient are potential for fluid voiume deficit due to blood ICISS, potential for retention of a foreign body, and the potential for anxiety related to the unknown aspects of surgery. Nursing interventions are aimed toward achieving positive patient outcomes by providing adequate fluid and blood replacement, ensuring correct sponge and needle counts, and ensuring open communication between the nurse and the patient. The operating, room is prepared for a dual procedure, the intraoperative endoscopy and the 779
MARCH 1990, VOL. 51, NO 3
_
_
~
_
_ AORN JOURNAL
Fig 3. The surgeon telescopes the bowel over the colonoscope to ensure that the entire mucosal surface of the small bowel is visible.
bowel resection. The advantages of combining the two procedures include sparing the patient from the risk and expense of two anesthetics,eliminating two bowel preps, and increasing the certainty of examining the entire bowel. The back table setup includes instruments for a major abdominal bowel resection and internal stapling instruments. The fiberoptic colonoscope is set up on a separate table. Before the patient arrives in the operating room, the scrub nurse checks the colonoscope to verify proper functioning of the air insumation, irrigation, and suction channels.
Surgical Procedure
T
he circulating nurse takes the patient to the operating room and helps him or her onto the OR bed. After the patient is anesthetized, the nurse performs the surgical prep from xyphoid to pubis. The surgeon and scrub nurse apply the sterile drapes. The surgeon makes a midline incision and
mobilizes the intestines. The endoscopist inserts a colonoscope orally and passes it into the duodenum. The overhead room lights are shut off to enhance the transiillumination process. The anesthesiologist is alerted that the room will be dark and that alternate lighting will be provided for his or her area. The surgeon telescopes the small bowel over the end of the colonoscope until the entire small bowel is visualized from the duodeneum to the ilewml valve (Fig 3). The endoscopist uses the irrigation and air insufflation channels to permit the best possible inspection of the lumen. The suction channel is not used while the coloinoscope is being inserted. The surgeon places a noncrushing-type intestinal clamp at the rleocecal valve to increase trapping of air within the lumen of the small intestine, which increases the visible surface area. The techniques of telescoping and transillumination show the abnormal vasculature of the AVM that would be invisible under normal lighting.1° Any areas that contain susphcious lesions are marked with a nonabsorbable suture.
MARCH 1990, VOL. 51, NO 3
AORN J O U R N A L
As the endoscopist withdraws the colonoscope, he or she suctions out the air and irrigation channels. After the colonoxope is withdrawn, the anesthesiologist inserts a nasogastric (NG) tube. The surgeon then resects the suspect bowel. The specimens are handled in a manner not to dislodge the marking sutures. Specimen radiography may be performed in the operating room to confirm the resection.” The surgeon closes the abdominal incision, and the scrub and circulating nurses do sponge and instrument counts.
Postoperative Care
T
he anesthesiologist reverses the patient’s anesthesia, and the anesthesiologist and circulating nurse take the patient to the postanesthesia care unit (PACU). The circulating nurse evaluates the nursing interventions and documents any deviations from the desired patient outcomes. The PACU nurse connects the NG tube to low intermittent suction. The NG tube will remain on suction postoperatively until there is evidence that gastric motility has returned. The nurse assesses the NG tube drainage for amount, color, and odor. It is common for the patient to experience bright red drainage for the first 24 hours after surgery. After the first 24 hours, the drainage will change to a darker color. Nursing care interventions related to the NG tube include relieving mouth dryness and ensuring that the tube is taped in a comfortable manner. The nurse also observes the patient for excessive drainage from the incision and/or drains. The patient is discharged from the PACU when his or her vital signs are stable, no bleeding is noted, and the airway is patent. Discharge from the hospital will normally occur in three to four days. Discharge criteria include evidence that gastric motility has returned, and that the patient is afebrile and tolerating a regular diet.
Conclusion
T
he use of intraoperative endoscopy combined with the resection of portions of small intestine is an effective method
182
of dealing with occult small intestinal bleeding. Good communication between all members of the surgical team is essential for the success of the 0 procedure and the benefit of the patient. Notes 1. 0 Gunnlaugsson,“Angicdysplasiaof the stomach and duodenum,” GastrointestinalEndoscopy 4 (August 1985) 251-254. 2. C T Meyer et al, “Arteriovenous malformations of the bowel: An analysis of 22 cases and a review of the literature,” Medicine (Baltimore) 60 (January 1981) 36-48. 3. Ibid. 4. S Fataar, P Morton, A Schulman, “Arteriovenous malformations of the gastrointestinal tract,” Clinical RadiologV 32 (November 1981) 623-628. 5. Meyer et al, “Arteriovenous malformations of the bowel An analysis of 22 cases and a review of the literature,” 36-48. 6. G A Weaver et al, “Gastrointestinal angiodysplasia associated with aortic valve disease: Part of a spectrum of angiodysplasia of the gut,” Gastroenterology 77 (July 1979) 1-11. 7. K N Apelgren, T Vargish, F Al-Kawas, “Principles for use of intraoperative enteroscopy for hemorrhage from the small bowel,” American Surgeon 54 (February 1988) 85-88. 8. S S Tu’meh et al, “Detection of bleeding from
angiodysplasia of the jejunum by blood pool scintigraphy,” Clinics of Nuclear Medicine 8 (March 1983) 127-128. 9. Zbid. 10. T A Bowden, Jr, V H Hooks, 111, A R Mansberger, Jr, “Intestinal vascular ectasias: A new look at an old disease,” Southern Medicine Journal 75 (November 1982) 1310-1317. 11. J R Hines et al, “Intraoperative angiography in intestinal angiodysplasia,” Surgery, Gynecologv & Obstetrics 152 (April 1981) 453-460.
MARCH 1990, VOL. 51, NO 3
Intraoperative Endoscopy of the Small Bowel TREATMENT FOR OCCULT HEMORRHAGE Becky A. Shoaf, RN; Keith N. Apelgren, MD
A
rteriovenous malformation (AVM) of the bowel is one of the most common causes of lower gastrointestinal (GI) hemorrhage.' Identification of the AVM in the small intestine is difficult using conventional endoscopy and angiography. The latest in fiberoptic transoral endoscopic technology combined with transillumination of the small bowel, however, allows the surgical team to localize the AVM (Fig 1). This technique provides for accurate resection of the area of small intestine responsible for occult bleeding. There are three types of AVMs.* Type I AVMs are solitary lesions found frequently in the older population. These are thought to be an acquired dysplasia. Type I1 lesions are found in younger patients and are characterized by abnormal vessels in the submucosa. The third type of lesion is associated with Rendu-Osler-Weber syndrome. These are characterized by unique punctuate angiomas in the lip and cheek mucosa, as well
as angiomas of the face, fingers, and small bowel. The condition is familial, and spontaneous epistaxis is the primary manifestation. The etiology of AVMs is unknown. The major controversy on the etiology is whether AVMs are congenital or acq~ired.~ The occurrence of AVMs in younger patients as well as the association of AVMs with valvular stenosis support the congenital theory! Other authors suggest that the lesions result from the acquired degenerative changes of aging.5
Diagnosis
A
complete history and physical examination must be performed on patients suspected of having AVMs of the small bowel. The physician must pay particular attention to the condition of the skin because pathognomonic angiomas are associated with Type I11 AVMs. The medical histories of patients with
UniversityHospitak, Morgantown. She earned her bachelor of science degree in nursing from West Virginia Universiiy,Morguntown. Keith N. Apelgren, MD, h an associateprofessor of surgery, Michigan State University College of Human Medicine, East Lansing. He earned hi5 medical degree from the University of Michigan, Ann Arbor.
Becky A. Shoaf: W,BSN, CNOR, is a clinical manager-specialQ, operating room, West Virginia 776
The authors acknowledge E. R. McDannald Jr, MD, for his assistance.
MARCH 1990, VOL. 51, NO 3
AORN JOURNAL
Fig I . The arteriovenous malformation as seen through the flexible colonoscope.
AVMs include melenic stools, bright red rectal bleeding, iron deficiency anemia, and guaiacpositive stools? These patients also may have a history of multiple hospitalizations and blood transfusions. Other commonly associated symptoms are cardiac related, including congestiveheart failure and valvular disease. When these patients are admitted, a complete blood count should be done along with a coagulation profile, including partial thromboplastin time, prothrombin time, and platelet count. Diagnostic testing is complex and time consuming for these patients. They must first undergo esophagogastroduodenoscopy and colonoscopy to rule out bleeding from the upper gastrointestinal tract and the colon.7 The second step is visceral angiography to search for the site of the AVM. A positive angiography may show an enlarged feeding artery, a vascular lake, and an early feeding vein. The vascular lake is the AVM itself. Arteriovenous malformations in the duodenum, ileum, and jejunum are difficult to detect on angiography and may require magnification arteriography. It is not easy to diagnose small bowel hemorrhage because of the slow rate of bleeding, which makes observation of the feeding
artery, vein, and vasculatr lake difficult. The long tube method of identifying AVMs in the small bowel may be used to help pinpoint the general area of the malformations. The physician passes a long tube with a mercury filled balloon into the GI tract. The nurse aspirates the contents of the GI tract through the tube frequently and tests it for occult blood. When a hemo-occult positive aspirate is obtained, the tube is taped securely in place. Thein the patient is taken to the radiology suite where a plain radiograph and a dye study are performed to look for abnormalities of the small bowel. A more sophisticated technique that has been used recently is tagged red blood cell (RBC) scintigraphy.8 Autologous RBCs are labelled in vitro or in vivo with pyrophosphate and then with technetium 99M pertechnetate (a radioactive compound). ‘me patient is then placed under a scintillation counter at various time intervals. The information gained from RBC tagged scintigraphy helps approximate the 1.ocation of bleeding in the small bowel. The advantage of this technique is the ability to detect bleeding too slow to be found with visceral angiography or magnification arteriography.9 The recent advances in fiberoptic endoscopy
MARCH 1990, VOL. 51, NO 3
__-__
AORN JOURNAL
Fig 2. A view of the transilluminated and inflated bowel. The arrow points to the red area that identifies the arteriovenous malformation.
make it possible for the surgeon to easily manipulate the endoscope to position the light against the wall of the inflated small bowel (Fig 2). In the past, endoscopes could be passed only to the duodenum orally, leaving most of the small bowel unexamined. In addition, the use of a cold light allows for transillumination of the lesion without risk of damage to the mucosal lining of the intestine. The use of an external camera or a videocolonoscope provides the opportunity for documentation and teaching as well as allowing two people to view the lesion.
Preoperative Care nce a patient is diagnosed with AVM
of the small bowel, he or she is scheduled for a surgical resection of the area of bowel responsible for the occult bleeding episodes. The preoperative nursing assessment is done by the nurse when the patient arrives in the patient holding area. Nursing diagnoses for the patient undergoing bowel resection include potential for
infection due to spillage of bowel contents, potential for injury due to the supine position, and potential for hypothermia due to exposure of the abdominal contents to the cool room air during the surgical procedure. Nursing interventions aimed at preventing these potential problems are observation of adherence to sterile technique by the surgical team during the bowel resection, correct body alignment and padding of bony prominences, and the use of a hypotherniia blanket and heated irrigating solutions. Other nursing diagnosescommon to any surgical patient are potential for fluid voiume deficit due to blood ICISS, potential for retention of a foreign body, and the potential for anxiety related to the unknown aspects of surgery. Nursing interventions are aimed toward achieving positive patient outcomes by providing adequate fluid and blood replacement, ensuring correct sponge and needle counts, and ensuring open communication between the nurse and the patient. The operating, room is prepared for a dual procedure, the intraoperative endoscopy and the 779
MARCH 1990, VOL. 51, NO 3
_
_
~
_
_ AORN JOURNAL
Fig 3. The surgeon telescopes the bowel over the colonoscope to ensure that the entire mucosal surface of the small bowel is visible.
bowel resection. The advantages of combining the two procedures include sparing the patient from the risk and expense of two anesthetics,eliminating two bowel preps, and increasing the certainty of examining the entire bowel. The back table setup includes instruments for a major abdominal bowel resection and internal stapling instruments. The fiberoptic colonoscope is set up on a separate table. Before the patient arrives in the operating room, the scrub nurse checks the colonoscope to verify proper functioning of the air insumation, irrigation, and suction channels.
Surgical Procedure
T
he circulating nurse takes the patient to the operating room and helps him or her onto the OR bed. After the patient is anesthetized, the nurse performs the surgical prep from xyphoid to pubis. The surgeon and scrub nurse apply the sterile drapes. The surgeon makes a midline incision and
mobilizes the intestines. The endoscopist inserts a colonoscope orally and passes it into the duodenum. The overhead room lights are shut off to enhance the transiillumination process. The anesthesiologist is alerted that the room will be dark and that alternate lighting will be provided for his or her area. The surgeon telescopes the small bowel over the end of the colonoscope until the entire small bowel is visualized from the duodeneum to the ilewml valve (Fig 3). The endoscopist uses the irrigation and air insufflation channels to permit the best possible inspection of the lumen. The suction channel is not used while the coloinoscope is being inserted. The surgeon places a noncrushing-type intestinal clamp at the rleocecal valve to increase trapping of air within the lumen of the small intestine, which increases the visible surface area. The techniques of telescoping and transillumination show the abnormal vasculature of the AVM that would be invisible under normal lighting.1° Any areas that contain susphcious lesions are marked with a nonabsorbable suture.
MARCH 1990, VOL. 51, NO 3
AORN J O U R N A L
As the endoscopist withdraws the colonoscope, he or she suctions out the air and irrigation channels. After the colonoxope is withdrawn, the anesthesiologist inserts a nasogastric (NG) tube. The surgeon then resects the suspect bowel. The specimens are handled in a manner not to dislodge the marking sutures. Specimen radiography may be performed in the operating room to confirm the resection.” The surgeon closes the abdominal incision, and the scrub and circulating nurses do sponge and instrument counts.
Postoperative Care
T
he anesthesiologist reverses the patient’s anesthesia, and the anesthesiologist and circulating nurse take the patient to the postanesthesia care unit (PACU). The circulating nurse evaluates the nursing interventions and documents any deviations from the desired patient outcomes. The PACU nurse connects the NG tube to low intermittent suction. The NG tube will remain on suction postoperatively until there is evidence that gastric motility has returned. The nurse assesses the NG tube drainage for amount, color, and odor. It is common for the patient to experience bright red drainage for the first 24 hours after surgery. After the first 24 hours, the drainage will change to a darker color. Nursing care interventions related to the NG tube include relieving mouth dryness and ensuring that the tube is taped in a comfortable manner. The nurse also observes the patient for excessive drainage from the incision and/or drains. The patient is discharged from the PACU when his or her vital signs are stable, no bleeding is noted, and the airway is patent. Discharge from the hospital will normally occur in three to four days. Discharge criteria include evidence that gastric motility has returned, and that the patient is afebrile and tolerating a regular diet.
Conclusion
T
he use of intraoperative endoscopy combined with the resection of portions of small intestine is an effective method
182
of dealing with occult small intestinal bleeding. Good communication between all members of the surgical team is essential for the success of the 0 procedure and the benefit of the patient. Notes 1. 0 Gunnlaugsson,“Angicdysplasiaof the stomach and duodenum,” GastrointestinalEndoscopy 4 (August 1985) 251-254. 2. C T Meyer et al, “Arteriovenous malformations of the bowel: An analysis of 22 cases and a review of the literature,” Medicine (Baltimore) 60 (January 1981) 36-48. 3. Ibid. 4. S Fataar, P Morton, A Schulman, “Arteriovenous malformations of the gastrointestinal tract,” Clinical RadiologV 32 (November 1981) 623-628. 5. Meyer et al, “Arteriovenous malformations of the bowel An analysis of 22 cases and a review of the literature,” 36-48. 6. G A Weaver et al, “Gastrointestinal angiodysplasia associated with aortic valve disease: Part of a spectrum of angiodysplasia of the gut,” Gastroenterology 77 (July 1979) 1-11. 7. K N Apelgren, T Vargish, F Al-Kawas, “Principles for use of intraoperative enteroscopy for hemorrhage from the small bowel,” American Surgeon 54 (February 1988) 85-88. 8. S S Tu’meh et al, “Detection of bleeding from
angiodysplasia of the jejunum by blood pool scintigraphy,” Clinics of Nuclear Medicine 8 (March 1983) 127-128. 9. Zbid. 10. T A Bowden, Jr, V H Hooks, 111, A R Mansberger, Jr, “Intestinal vascular ectasias: A new look at an old disease,” Southern Medicine Journal 75 (November 1982) 1310-1317. 11. J R Hines et al, “Intraoperative angiography in intestinal angiodysplasia,” Surgery, Gynecologv & Obstetrics 152 (April 1981) 453-460.