S2788 When VCE Is Not Enough: It Was the Blebs!

Abstract

INTRODUCTION: Although not common, accounting 5-10% of gastrointestinal (GI) bleeding, small bowel bleeding can be clinically significant and challenging to locate and treat. If bleeding is not identified on upper endoscopy (EGD) or colonoscopy, a second look can further exclude upper and lower sources. Push enteroscopy, video capsule endoscopy (VCE), and intraoperative endoscopy are next line diagnostic methods. We describe a challenging case of small bowel bleeding. CASE DESCRIPTION/METHODS: A 79 year-old male with atrial fibrillation, on Rivaroxaban, presented with one week of hematochezia. An EGD and colonoscopy did not reveal a source of bleeding. A VCE found numerous vascular blebs throughout the small intestine and fresh blood distally. Based on appearance, blue rubber bleb nevus syndrome was the initial thought, despite it being unlikely given he had no prior GI bleed. Multiple endoscopies, including push enteroscopy, repeat colonoscopy, and bidirectional balloon enteroscopy revealed scattered non-bleeding vascular blebs but no active bleeding source (Figure 1). CT angiography reported a subcentimeter jejunal lesion without active bleeding. Repeat VCE demonstrated active bleeding and submucosal nodules in the jejunum. He then had a laparotomy-assisted endoscopy that found numerous large vascular malformations (Figure 2) concentrated in the mid-jejunum. Full thickness biopsy was consistent with vascular malformation/hemangioma. Given his age and extent of small bowel involvement, octreotide was given. Due to persistent overt bleeding he ultimately underwent resection of the involved small bowel (approximately 100cm). He had no further episodes of GI bleeding on apixaban and was discharged home. DISCUSSION: Vascular malformations, or hemangiomas, are rare lesions that can cause significant GI bleeding. They generally involve the submucosa to mucosa, can involve the small bowel, and can be localized via CT enterography. They can be seen on endoscopy as soft, dark red to purple masses or blebs; biopsy can cause uncontrollable bleeding and surgical resection is often the treatment of choice. This case was unique given the size and involvement of the small intestine. Our patient's findings initially suggested blue rubber bleb nevus syndrome, however a lack of prior history of GI bleeding made this diagnosis unlikely and the management more challenging. This case highlighted the successful role of surgical intervention in a patient with extensive small bowel involvement of vascular malformations.Figure 1.: Vascular malformations in the jejunum found on anterograde balloon enteroscopy.Figure 2.: Numerous vascular malformations in the jejunum found during laparotomy-assisted endoscopy.