Cause Of Obscure Gastrointestinal Bleeding Research Articles

A rare cause of obscure gastrointestinal bleeding: Chronic enteropathy associated with SLCO2A1 mutation in a case from India

A rare cause of obscure gastrointestinal bleeding: Chronic enteropathy associated with <i>SLCO2A1</i> mutation in a case from India

Jejunal Dieulafoy's lesion as a cause of difficult-to-manage obscure gastrointestinal bleeding. Combined endoscopic treatment.

Dieulafoy's lesion (DL) is an uncommon vascular malformation-an aberrant, dilated submucosal arteriole (1-3 mm thick, 10 x nv). It runs near the mucosal surface and protrudes, and may potentially induce gastrointestinal bleeding (GIB). It usually originates in the stomach (upper lesser curvature), with endoscopy being the diagnostic, therapeutic modality of choice. Jejunal DL (JDL) is a rare cause of obscure GIB (OGIB) that is challenging for endoscopists and threatens patient lives. Other diagnostic techniques such as Tc99m-labeled red blood cell scintigraphy, well established in the classic armamentarium for OGIB diagnosis, cannot overcome endoscopic procedures. We report the case of a patient with OGIB secondary to an exceptionally located Dieulafoy's lesion who underwent combined endoscopic treatment.

Gastrointestinal: Small bowel hemangioma with unusual endoscopic findings and complicated with obscure gastrointestinal bleeding.

A 68-year-old woman was referred to our hospital for evaluation of severe anemia. Although she had an upper endoscopy and colonoscopy that failed to show the cause of her anemia, there was a small amount of blood in the terminal ileum, which suggested small bowel bleeding. In our hospital, video capsule endoscopy identified a spherically raised lesion in the jejunum, with central erosion of the surface mucosa, which was similar in morphology to a submucosal tumor (Fig. 1a). Balloon-assisted enteroscopy revealed a dark reddish, elevated lesion in the jejunum, the surface of which was extensively peeled off and thickly covered by blood clots (Fig. 1b). Malignant tumors such as angiosarcoma, gastrointestinal stromal tumor, and malignant lymphoma were suspected. A definitive preoperative diagnosis was difficult because of the unusual endoscopic findings. The patient underwent laparoscopic small bowel resection. The lesion was 17 mm in diameter (Fig. 2a). Histological findings revealed that the elevated lesion consisted of exposed vascular components, surrounded by normal small bowel mucosa, and numerous dilatated vessels without atypia were observed from the lamina propria to the muscularis propria. These findings were consistent with cavernous hemangioma (Fig. 2b,c). After surgery, the anemia improved within 6 months. Hemangiomas occur rarely in the small bowel. Thirteen cases of small bowel hemangiomas, observed preoperatively by enteroscopy, have been reported in adults. To the best of our knowledge, a submucosal tumor-like hemangioma with exposed vascular components is extremely rare and has been described in only one case. It was hypothesized that this uncommon morphology was formed by collapse of the tumor due to external stimuli such as small bowel peristalsis and food residue. This case highlights the unusual endoscopic appearance of small bowel hemangioma as a rare cause of obscure gastrointestinal bleeding.

A female with recurrent gastrointestinal bleeding: an obscure diminutive lesion requiring a massive blood transfusion.

Obscure gastrointestinal bleeding (OGIB) is bleeding of unknown origin after a negative initial or primary colonoscopy and upper endoscopy result. Small bowel bleeding accounts for 5% of GI bleeding but it is the most prominent cause of OGIB. We present a case with an obscure diminutive polypoid vascular anomaly of small intestine. In this case, intraoperative enteroscopy seems to be the last trump card for OGIB, especially for large amount loss of blood. It not only helped to find the obscure cause for bleeding, but also preserved the small intestine.

Application of capsule endoscopy in the management of small intestine angioectasias-case report

Angioectasias lesions are multiple and involve a wide range, gast rointestinal bleeding can occur repeatedly or stop spontaneously, mostly in the colon. We report the real-life case of gastrointestinal bleeding in the small intestine. Small intestinal angioectasias (SBAEs) is a common cause of obscure gastrointestinal bleeding (OGIB). Due to the limited means for small intestine examination, the source cannot be found and missed diagnosis, resulting in delayed treatment. The application of capsule endoscopy not only greatly improves the diagnosis yield but also helps clinicians to formulate the next treatment plan. It is recommended to perform capsule endoscopy for those patients with gastrointestinal bleeding who cannot be identified after conventional gastroenteroscopy.

S2557 An Unusual Cause of Obscure Gastrointestinal Bleeding

Introduction: Obscure gastrointestinal bleeding is bleeding of unknown origin, that persists or recurs, after a negative initial or primary endoscopy. It accounts for approximately 5% of all cases of gastrointestinal bleeding and is usually due to a lesion in the small bowel. We present a case of rare cause of obscure gastrointestinal bleeding. Case Description/Methods: 68 year old male, was admitted with history of passing black coloured stools since last 2 weeks. History of weightloss was present. History of squamous cell carcinoma vocal cord in the past and he underwent radiation therapy. Blood investigations showed anemia. Endoscopy showed antral erosions. Colonoscopy revealed caecal angiodysplasia and was treated with Argon plasma coagulation. In view of persistent melena, patient underwent CT angiography, which revealed bowel wall thickening with cavitation and focal bowel dilatation involving the jejunum (Fig 1). Spiral enteroscopy revealed an ulceroproliferative neoplasm about 4 x 3 cm, involving more than half the circumference of jejunum (Fig 2). He was discharged after stabilisation. Two weeks later, patient was admitted with abdominal pain. CT abdomen revealed dilated jejunal loops with bowel wall thickening and eccentric cavitation. A small loculated collection of size 3.6x1.8cm with a tiny air foci was seen along with minimal free fluid (Fig 3). On laparotomy, a perforated tumor in proximal jejunum, 25 cm away from DJ flexure, was identified. He underwent resection and end to end anastomosis. On histopathology, sections from jejunum showed transmural infiltration by a tumour arranged in sheets. The tumour cells were polygonal to epithelioid, with heterogeneously clumped chromatin. Interspersed proliferated blood vessels were noted. The neoplastic cells show diffuse strong positivity for Pan CK , Vimentin and patchy positivity for CK 7,CD31. CD34 highlighted the vessels. They were negative for p40, CDX2, CK20, CK 5/6, WT1, HMB45, SMA, CD117 and DOG 1. Histopathology was suggestive of a poorly differentiated sarcoma, with IHC suggestive of epitheliod angiosarcoma. Discussion: Primary angiosarcoma of small intestine is very rare. Epithelioid angiosarcomas are rare tumors, accounting for less than 1%. Angiosarcoma of small bowel may be associated with previous radiation treatment, chemotherapy, and chemical toxin exposure, specifically polyvinyl chloride. Angiosarcoma of small intestine can be considered as a rare cause in a patient who presents with obscure gastrointestinal bleed.Figure 1.: Bowel wall thickening with cavitation and focal bowel dilatation involving the jejunum, Fig 2: Spiral enteroscopy , Fig 3: Dilated jejunal loops with bowel wall thickening and eccentric cavitation, Fig 4/5 Histopathology , Fig 6: Immunohistochemistry.

Ileal neuroendocrine tumor as an uncommon cause of obscure gastrointestinal bleeding.

Neuroendocrine tumors (NETs) are heterogeneous, slow-growing tumors whose most common locations are lung, gastrointestinal tract, and pancreas.

Obscure Gastrointestinal Bleeding – A Multimodal Imaging Approach

Gastrointestinal (GI) bleeding represents one of the most frequently encountered clinical case scenarios in the emergency department. In the United States, the annual rate of hospitalization for any type of GI hemorrhage accounts for 300/100,000 population, with more than 1,000,000 hospitalizations each year and an approximately mortality rate of 5%. Upper GI bleeding (UGIB) is more common than lower GI bleeding (LGIB), yet there are many sites and multiple lesions from which bleeding could occur and the source could remain unidentified after upper endoscopy or colonoscopy evaluation. The uncertain etiology of GI hemorrhage is traditionally defined as obscure GI bleeding (OGIB) and constitutes a diagnostic challenge, so accurate investigations are crucial. Even if the mainstay of initial evaluation consists of upper endoscopy, colonoscopy or contrast X-ray studies, current guidelines suggest that video capsule endoscopy, push enteroscopy, angiography and radionuclide imaging are best suited, allowing an appropriate examination of the entire small bowel, which represents the most common source of OGIB. Hence, the aim of this review is to provide a multimodal investigation approach and to highlight the most adequate imaging technique according to the leading cause of OGIB.

Dieulafoy Lesion of Ileum: A Case Report

&#x0D; &#x0D; &#x0D; &#x0D; Dieulafoy lesion is a rare cause of massive GI bleeding. It’s an abnormal sub-mucosal artery protruding from a minute mucosal defect (≤3 mm). A 31 yearold male presented with complaints of hematochezia. Preliminary investigations failed to locate the exact source of bleed. Enteroscopy suggested distal ileal bleed. At laparotomy, an ulcerated nodular lesion, approximately 0.5 cm was identified in distal ileum. 30 cm of ileum along with mesentery was resected. Histology revealed it to be Dieulafoy lesion. Dieulafoy lesion is uncommon but one of the causes of obscure gastrointestinal bleeding that could result in treacherous and life-threatening gastrointestinal haemorrhage. This lesion is difficult to identify and high index of suspicion is required to make diagnosis. Hence, it should be considered in the differential diagnosis of active GI bleeding. The definitive diagnosis is based only on histopathology.&#x0D; &#x0D; &#x0D; &#x0D;

Thalidomide targets EGFL6 to inhibit EGFL6/PAX6 axis-driven angiogenesis in small bowel vascular malformation

BackgroundSmall bowel vascular malformation disease (SBVM) is the most common cause of obscure gastrointestinal bleeding (OGIB). Several studies suggested that EGFL6 was able to promote the growth of tumor endothelial cells by forming tumor vessels. To date, it remains unclear how EGFL6 promotes pathological angiogenesis in SBVM and whether EGFL6 is a target of thalidomide.MethodsWe took advantage of SBVM plasma and tissue samples and compared the expression of EGFL6 between SBVM patients and healthy people via ELISA and Immunohistochemistry. We elucidated the underlying function of EGFL6 in SBVM in vitro and by generating a zebrafish model that overexpresses EGFL6, The cycloheximide (CHX)-chase experiment and CoIP assays were conducted to demonstrate that thalidomide can promote the degradation of EGFL6 by targeting CRBN.ResultsThe analysis of SBVM plasma and tissue samples revealed that EGFL6 was overexpressed in the patients compared to healthy people. Using in vitro and in vivo assays, we demonstrated that an EMT pathway triggered by the EGFL6/PAX6 axis is involved in the pathogenesis of SBVM. Furthermore, through in vitro and in vivo assays, we elucidated that thalidomide can function as anti-angiogenesis medicine through the regulation of EGFL6 in a proteasome-dependent manner. Finally, we found that CRBN can mediate the effect of thalidomide on EGFL6 expression and that the CRBN protein interacts with EGFL6 via a Lon N-terminal peptide.ConclusionOur findings revealed a key role for EGFL6 in SBVM pathogenesis and provided a mechanism explaining why thalidomide can cure small bowel bleeding resulting from SBVM.

Cavernous Hemangioma: Uncommon Cause of Obscure Gastrointestinal Bleeding Diagnosed by Video Capsule Endoscopy and Contrast Enhanced Computed Tomography

We present the case of a 63-year-old woman with obscure gastrointestinal bleeding (OGIB) due to jejunal cavernous hemangioma diagnosed by video capsule endoscopy (VCE), contrast enhanced computed tomography (CECT) and CT angiography, who was successfully treated with surgical resection. Small bowel cavernous hemangioma is a rare cause of OGIB, most commonly presenting as an iron-deficiency anemia. Two decades ago, the preoperative diagnosis was quite difficult. Currently, the use of VCE and device assisted enteroscopy (DAE) allow detection of the lesion. Biopsy is not recommended due to the risks of uncontrolled bleeding. The use of CECT and CT angiography may be useful for demonstrate the vascular nature of the lesion, and define localization, number and extension of the lesion preoperatively in order to improve surgical results as was observed in our patient. Surgery is the most frequent treatment, notwithstanding, endoscopic resection of lesions has been recently reported. However, the experience is small and there are serious limitations of this technique.

2623 Isolated Duodenal Variceal Bleeding Secondary to Metastatic Carcinoid Tumor Obstructing the Superior Mesenteric Vein

INTRODUCTION: Gastrointestinal bleeding secondary to duodenal varices is an uncommon finding, and is typically seen in patients with portal hypertension due to cirrhosis. We report a case of a patient without evidence of liver disease who developed significant bleeding from isolated duodenal varices caused by mesenteric venous obstruction from a carcinoid mass. CASE DESCRIPTION/METHODS: A 71-year-old male with a history of a metastatic mesenteric carcinoid tumor presented with recurrent gastrointestinal bleeding. He was initially diagnosed with carcinoid of the mesentery several years prior, for which he underwent resection followed by Y40 ablation of liver metastases. He had been admitted multiple times at a local hospital for recurrent gastrointestinal bleeding, for which he had undergone extensive endoscopic evaluation. He was then transferred to our facility for a higher level of care. A double balloon push enteroscopy and endoscopic ultrasound were performed with findings of a large cluster of bleeding duodenal varices in the third portion of the duodenum not amenable to endoscopic intervention. CT abdomen and pelvis with contrast and CT angiography of the abdomen showed an irregular 3 cm calcified mass at the root of the mesentery. Additionally, several branches of the superior mesenteric artery and vein (SMA and SMV) were noted to be occluded near the mass. Interventional radiology (IR) performed an IR-guided transhepatic portogram revealing obstruction of the SMV at the level of the mesenteric mass. There appeared to be a large colic branch communicating with an abnormal cluster of varices near the third portion of the duodenum. Two overlapping covered stents were placed at the large colic branch into the SMV, decompressing the varices. The patient was started on plavix, propranolol, and octreotide depot and safely discharged home without further bleeding. DISCUSSION: Duodenal varices are an uncommon but potentially serious complication of portal hypertension, and are most often seen as a sequelae of liver disease. The development of duodenal varices as a result of venous obstruction secondary to a desmoplastic reaction induced by a carcinoid tumor has seldom been reported in the literature. This case illustrates a noteworthy example of bleeding ectopic varices in a patient without liver disease, a rare cause of obscure gastrointestinal bleeding.

Diagnostic Value and Safety of Emergency Single-Balloon Enteroscopy for Obscure Gastrointestinal Bleeding.

Background This study assesses the diagnostic performance of emergency single-balloon enteroscopy (SBE) for obscure gastrointestinal bleeding (OGIB) under general anesthesia versus conscious sedation. Study The data of 102 OGIB in-patients from June 2015 to June 2018 were retrospectively analyzed. The diagnosis and detection rates and adverse events were calculated overall and in relation to age, gender, type of operation and anesthesia, bleeding type, different times of examination, and SBE route. All statistical analyses were performed using SPSS 24.0, and the diagnosis and detection rates were compared using the Chi-square test. Results Among the 102 patients, 66 patients had positive findings, while 11 patients had suspected positive findings, and the diagnosis and detection rates were 64.7% and 75.5%, respectively. Ulcers (19.6%) and tumors (16.7%) were the most common causes of OGIB. There were no statistical differences in diagnosis and detection rates between the ages of ≥60 and <60 and between different genders. Patients with emergency SBE had higher diagnosis and detection rates (68.6% vs. 35.3%, P = 0.023; 80.0% vs. 47.1%, P = 0.016, respectively), when compared with nonemergency SBE patients. The diagnosis rate at 24 hours was higher than that at 2-7 days and one week (88.0% vs. 61.5%, P = 0.030; 88.0% vs. 53.8%, P = 0.007). For overt bleeding, the difference in diagnosis rates at 24 hours, 2-7 days, and one week was statistically significant (100.0% vs. 57.1%, P = 0.006; 100.0% vs. 57.1%, P = 0.006). For occult bleeding, the pairwise comparison revealed no statistical difference. Patients with general anesthesia had a higher detection rate, when compared to patients with conscious sedation (87.9% vs. 63.9%, P = 0.004). In addition, adverse events under general anesthesia were lower, when compared to adverse events under conscious sedation (28.8% vs. 69.4%, P = 0.020). There was no significant difference in adverse events at the different time points (P > 0.05). Conclusion Emergency SBE under general anesthesia achieves higher diagnosis and detection rates, and fewer adverse events under conscious sedation, when compared to nonemergency SBE, regardless of the route. For patients with overt bleeding, it is easier to find lesions by emergency SBE within 24 hours.

Diagnosis and therapeutic strategies for small bowel vascular lesions.

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

A case of ectopic pancreas in the ileum presenting as obscure gastrointestinal bleeding and abdominal pain

BackgroundEctopic pancreas is an infrequent submucosal tumor in the gastrointestinal tract defined as a pancreatic tissue lacking vascular or anatomic continuity with the main body of the pancreas. Ectopic pancreas in the ileum is a rare and often an incidental finding. We report a case of ectopic pancreas in the ileum causing obscure gastrointestinal bleeding and episodes of abdominal pain.Case presentation59-year-old man with 3 months history of intermittent melena, accompanied by the episodes of abdominal pain in the left upper quadrant and generalized fatigue was admitted to our department. The investigations showed that the patient had a low hemoglobin level, i.e. 10.9 g/dL with hypochromic microcytic anemia pattern seen in complete blood count (MCV 70.2 fl, MCH 21.4 pg). Esophagogastroduodenoscopy and colonoscopy did not reveal any abnormalities. Magnetic resonance enterography revealed a large (2.5 × 2.3 cm) pedunculated polyp in the ileum. Examination by single-balloon enteroscopy revealed a polyp with long pedicle located approximately 1.5 m distal to terminal ileum. Polypectomy was performed. Histopathologic examination stated, that the specimen contained ectopic pancreatic tissue which was involving muscular layer of the ileum. Ectopic pancreatic tissue included acinar cells and cystically dilated secretory ducts without islets of Langerhans.ConclusionOur case report reveals a very rare cause of obscure gastrointestinal bleeding accompanied by the episodes of abdominal pain – an ectopic pancreas located in the ileum.

The impact of inpatient capsule endoscopy on the need for therapeutic interventions in patients with obscure gastrointestinal bleeding.

Background/Aim:There are limited data evaluating the impact of inpatient video capsule endoscopy (VCE) on the need for therapeutic interventions in hospitalized patients with obscure gastrointestinal bleeding (OGIB). The objective of this study was to determine the impact of inpatient VCE on the need for therapeutic interventions and rehospitalization for recurrent bleeding.Patients and Methods:Hospitalized patients who underwent VCE for OGIB indication were retrospectively included. Clinical data were collected including therapeutic interventions performed after VCE. Specific therapeutic interventions were defined as the medical, endoscopic, or surgical treatment directly targeting the cause of OGIB. Patients were followed up to determine the rate of rehospitalization.Results:A total of 48 inpatient VCE were identified, of which 43 VCE were performed for OGIB indication and were included for analysis. The completion rate and the diagnostic yield were 78.5% and 55.8%, respectively. Subsequent specific therapeutic interventions were performed in 65.2% and 5.8% of patients with positive and negative VCE, respectively (P < 0.001). After a median follow up of 30 months (minimum 12, maximum 58), rehospitalization for recurrent bleeding occurred in 30.4% and 17% of patients with positive and negative VCE, respectively. Patients with angiodysplasia on VCE were significantly more likely to be readmitted (P = 0.02). Throughout the course of the follow-up, only 2 (11.7%) patients with negative VCE underwent specific therapeutic interventions.Conclusion:Inpatient VCE is an effective tool to identify patients who need specific therapeutic interventions. Patients with negative VCE are unlikely to be readmitted or require specific therapeutic interventions in the index admission.

Ileal Dieulafoy Lesion: a rare case report

BackgroundDieulafoy lesion, also known as calibre persistent artery is a rare cause of massive GI bleeding. It’s an abnormal sub-mucosal artery protruding from a minute mucosal defect (≤3 mm). Commonest location is in proximal stomach while occurrence in small intestine, especially ileum is extremely rare.Case presentationA 26 year old female presented with lower gastrointestinal bleeding. Preliminary investigations failed to locate the exact source of bleed. At laparotomy, an ulcerated nodular lesion, approximately 0.8 cm in diameter was identified in distal ileum. Histology revealed it to be Dieulafoy lesion.ConclusionAlthough uncommon, ileal dieulafoy is one of the causes of obscure gastrointestinal bleeding that could result in treacherous and life-threatening gastrointestinal haemorrhage. Hence, it should be considered in the differential diagnosis of active GI bleeding. The definitive diagnosis is based only on histopathology.

Capsule Endoscopy for Obscure Gastrointestinal Bleeding: A Single‑Center Experience

ABSTRACT Background: Capsule endoscopy (CE) has an established role in evaluating obscure gastrointestinal bleeding (OGIB). The aim was to know the diagnostic yield of CE and spectrum of OGIB. Materials and Methods: In this retrospective study, we evaluated all the patients with obscure gastrointestinal bleed using MiroCam capsule endoscope (IntroMedic, Seoul, Korea) between February 2014 and March 2018. Clinical data, ancillary investigations, and response to specific treatment were considered to confirm CE findings. Results: Out of 102 patients included in the study (mean age 54.5 ± 16.1 years, male: female ratio = 1.83:1) OGIB‑overt and OGIB‑occult was present in 46 and 56 patients, respectively. Diagnostic yield of CE was similar in both the groups (overt‑37/46, 80.4% versus occult‑37/56, 66.5%) (P ≥ 0.05), although there was trend to find more lesions in overt group. Overall positive diagnostic yield was 72.5%. Lesions detected were vascular malformations in 21 (20.5%), nonsteroidal anti‑inflammatory drug enteropathy in 13 (12.7%), small bowel ulcerations in 27 (26.4%), which were further divided into three subgroups (a) nonspecific ulcerations 11 (10.7%), (b) tubercular ulcer with/without stricture in 7 (6.8%) and (c) serpiginous ulcers and fissuring with cobble‑stone appearance suggestive of Crohn’s disease in 9 (8.8%), portal hypertensive enteropathy in 5 (4.9%), worm infestation (hookworms in 3, roundworms 1) in 4 (3.9%), and small bowel tumour in 1 (0.98%) patient. Overall, 56.7% patients were having definitive (P2) lesions (Saurin classification). Two patients had retention of capsule, but none developed intestinal obstruction. Capsule was removed with surgical intervention. Conclusion: CE has high diagnostic yield, relative safety and tolerability, and it is an important diagnostic tool for OGIB. Small bowel tuberculosis, Crohn’s disease and Worm infestation continue to be commonly recognized causes of OGIB in developing countries like India.

Balloon‐assisted enteroscopy for symptomatic Meckel's diverticulum: High diagnostic accuracy and possible endoscopic intervention

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract, with reported prevalence of 1% to 3% and male predominance. As MD is usually asymptomatic and discovered incidentally, the true prevalence and characteristics are still unclear. Most MD patients are identified with the onset of complications, including bleeding, intussusception, diverticulitis, or bowel obstruction. Bleeding is the most common complication.1 MD is also the most common cause of obscure gastrointestinal bleeding in children and young adults. Diagnosis is challenging because no standardized diagnostic criteria are available. Before the introduction of balloon-assisted enteroscopy (BAE), the diagnostic accuracy of conventional modalities (computed tomography, small-bowel follow-through, angiography, or Technetium-99 m pertechnetate scintigraphy) was limited. Technetium-99 m pertechnetate scintigraphy (Meckel's scan) is a well-established tool for the diagnosis of MD, with high accuracy in children.2, 3 However, accuracy is not as high (less than 50%) in adults,4 because some MD patients may have little or no ectopic gastric tissue within the diverticulum. Capsule endoscopy is recommended as a first-line diagnostic tool for suspected small bowel bleeding in patients without bowel stenosis, but it has a limited role in MD because the bowel lumen cannot be inflated and good visibility of the distal small bowel is required.5 The development of BAE (including single-balloon and double-balloon enteroscopy) has provided a new diagnostic tool with high accuracy for MD.6 BAE also provides the possibility of treatment. Selected MD patients have reportedly been treated with endoscopic intervention.7-9 One recent study showed that BAE has the highest accuracy for diagnosis of a bleeding MD in adults, with diagnostic accuracy higher than that of a Meckel's scan (85.0% vs 21.4%, P < 0.001).5 When MD is suspected but conventional modalities provide no definite conclusion, retrograde BAE could be an alternative tool for confirmation of the diagnosis with high accuracy. Although the accuracy of BAE in patients with MD is high, some challenges persist in clinical practice. First, BAE is an invasive procedure and requires bowel preparation. Second, MD may be overlooked when the orifice is small or hidden by a mucosal-fold. To date, reports of BAE for MD have mostly employed double-balloon enteroscopy, while single-balloon enteroscopy has rarely been reported.10, 11 In this issue of the journal, Wei et al reported the clinical experience with single-balloon enteroscopy for diagnosis of adult MD in a single medical center in Taiwan. Compared to double-balloon enteroscopy, single-balloon enteroscopy is easier to perform and less time-consuming, and a previous meta-analysis found that the diagnostic rate is similar in patients with small bowel diseases.12 This technique could be considered as a first-line diagnostic tool in selected cases with strongly suspected MD. However, a conventional noninvasive modality (especially a Meckel's scan) should be performed first in children and young adults because retrograde BAE is a technical and invasive procedure and not available at some medical institutions. For symptomatic MD, surgical intervention is the standard method of treatment, and can prevent recurrent complications. BAE can be used for endoscopic intervention in selected patients with MD. Some cases with inverted MD were successfully resected with BAE.7, 8 As inverted MD can resemble a pedunculated polyp, careful manipulation during endoscopic intervention is necessary to prevent complications.11 Wei et al reported that some cases did not have recurrent bleeding on follow-up after endoscopic hemoclipping, but the possibility still exists because of the retained MD. Close follow-up is recommended. In conclusion, retrograde BAE could provide a reliable and useful modality with high diagnostic accuracy and the possibility of endoscopic intervention in selected patients with MD. The author declares no conflict of interest. The author transfers all copyright ownership of the above manuscript to the journal in the event the work is published.

Small intestinal diverticulum with bleeding: Case report and literature review.

Rationale:Small intestinal diverticulum with bleeding is an important reason for obscure gastrointestinal bleeding (OGB) , in addition to tumor and vascular diseases. Small intestinal diverticulum with bleeding is difficult to detect by barium meal and angiographic methods and has been regarded as an important cause of obscure gastrointestinal tract bleeding in adolescents. Because of its complicated etiology and non-specific clinical manifestations, it is relatively difficult to detect small intestinal diverticulum with bleeding, especially in patients with a large amount of bleeding and hemodynamic instability.Patient concerns:This retrospective study collects clinical statistics of 19 patients admitted to our hospital from January 2010 to December 2016. Patients who had small intestinal diverticulum patients with bleeding were included in this study. Patients who were taking anticoagulants were excludedDiagnoses:Small intestinal diverticulum patients with bleeding.Interventions:This retrospective study describes the clinical features of patients with small intestinal diverticulum whose main symptom was gastrointestinal bleeding and analyze the literature on this topic, with particular reference to the clinical characteristics, pathological features, and choice of examination methods.Lessons:Small intestinal diverticulum with bleeding is a common cause of obscure gastrointestinal bleeding, but it is difficult to detect using normal examination methods. For patients with repeated gastrointestinal bleeding and no positive results found on gastroscopy and colonoscopy, endoscopy of the small intestine and CTE with contrast can be considered as a diagnostic modality.