Octreotide in the Treatment of Obscure Gastrointestinal Bleed Attributed to Phlebectasias of the Small Bowel

Abstract

Purpose: Small bowel angiodysplasias are responsible for 25-40% of upper gastrointestinal bleed (GIB) regarded as of obscure origin when first assessed. Optimal management is not standardized. Somatostatin analogues have been used for the treatment of massive and chronic obscure GIB. We describe the case of a 52 year-old-male with a two year history of obscure GIB, who presented with symptomatic anemia in the setting of positive fecal occult blood test followed by melena. Screening colonoscopy 6 months prior was negative. He required frequent admissions to the medicine ward for symptomatic anemia and multiple transfusions of packed red blood cells (15 total). He underwent repeat colonoscopy, EGD, capsule endoscopy, multi detector computed tomography angiography and four enteroscopies, which revealed multiple phlebectasias throughout the duodenum and mid jejunum, none of which were actively bleeding or amenable to treatment. He was started on octreotide 50 mcg subcutaneous twice per day. Despite this intervention his hemoglobin continued to drop and one month later he underwent laparoscopic-assisted small-bowel resection. Operative findings included extensive amount of phlebectasias in the small bowel, starting at the ligament of Treitz and extending 150 cm proximal to the ileocecal valve. In an effort to prevent short bowel syndrome only 100 cm of small bowel, with associated lesions, was resected. One year after surgery, the patient denies recurrence of melena and his hemoglobin remains stable at 13. It has been postulated that octreotide acetate reduces fecal occult blood and melena and allows for reduction (and even elimination) of the need for blood transfusions, while its side effect profile is well tolerated. Its discontinuation also leads to bleeding recurrence. Earlier case reports have used high dose octreotide acetate (0.1 mg subcutaneous twice per day) and more recent reports describe the use of long acting monthly intramuscular injection, both with favorable outcomes. The largest, prospective placebo controlled trial used low dose octreotide acetate (50 mcg subcutaneous twice per day) and even though statistical differences were not reached, a strong trend towards bleeding reduction was observed in the octreotide group. In conclusion, the beneficial effect of octreotide in the management of small bowel phlebectasias may be dose dependent and exact doses need to be defined. Our patient was inevitably headed to surgery. Octreotide was ineffective in his case; however, given its benign side effect profile, high dose octreotide should be tried prior to surgical resection in patients with obscure GIB attributed to phlebectasias of the small bowel.