Obscure Gastrointestinal Bleeding Research Articles

Opioid Use Is Associated With Incomplete Capsule Endoscopy Examinations: A Meta-Analysis and Systematic Review

Introduction: Capsule endoscopy (CE) is a non-invasive imaging modality designed with the purpose of evaluating the small bowel, prominently in the setting of evaluation for obscure gastrointestinal (GI) bleeding. Incomplete examination, which is defined as failure to reach the cecum within the battery lifespan, may result in inadequate diagnosis of small bowel pathologies which can lead to delayed intervention or repeated studies. Opioid medications have been previously shown to affect GI motility. Several studies have attempted to evaluate the association between CE completion and opioid use with contradicting results. The aim of this meta-analysis is to evaluate the previously published studies on the association between opioid use and CE completion. Methods: A systemic review was conducted in PUBMED, Embase, Pubmed Central and ScienceDirect databases from inception through June 2018 to identify the studies that evaluated the association between CE completion and opioid use. We used the following keywords in different combinations: “Capsule”, “Endoscopy”, “Opioids”, “Narcotics”. Effect estimates from the individual studies were extracted and combined using the random-effect, generic inverse variance method of DerSimonian and Laird and a pooled odds ratio (OR) was calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques.1158 Figure 1. Forest Plot showing relationship between opioid use and capsule endoscopy completionResults: Five studies with a total of 1614 patients undergoing capsule endoscopy in the inpatient and outpatient setting were included in this study, 349 of whom had an incomplete CE (21.6%). The pooled OR for CE completion is 0.50 (95%CI: 0.38-0.66, I2=36.9%) in opioid users compared to non-users. We found no publication bias as assessed by the funnel plot. Conclusion: Our results indicate that patients on opioids are 50% less likely to have a complete CE examination compared to those not on opioids. To our knowledge, this study represents the first metaanalysis to assess this association. Future prospective randomized research is needed to confirm this association.

A Rare Dieulafoy Lesion in the Periampullary Duodenum

The calamity of diagnosing a Dieulafoy lesion increases exponentially when it presents atypically. Our case of a periampullary Dieulafoy lesion presents as a diagnostic challenge as it diverges from the usual epidemiological and diagnostic criteria established for these rare defects that account for less than 2% of obscure gastrointestinal bleeding. 87-year-old female patient with a history of GERD, gastritis, diverticulosis and chronic NSAID use presented with melena, diffuse abdominal pain and NBNB emesis. In the setting of her acute anemia with a Hb of 5.9 and tachycardia, an EGD demonstrated a single medium-sized Dieulafoy lesion in the second portion of the duodenum next to the major papilla oozing blood that was controlled with a bipolar diathermy. Daily PPIs, discontinuation of NSAIDs, and appropriate outpatient follow-up were recommended. Dieulafoy lesions are dilated submucosal veins that are exposed to the surface and endoscopically visualized as bleeding points without surrounding erosions or ulcerations. Typically, they present in elderly males with a history of NSAID or blood thinner usage, with 75% of them occurring in the stomach, usually within 6 cm of the gastroesophageal junction. Diagnosis in anatomically inaccessible locations, such as the periampullary portion of the duodenum like our patient, often requires push enteroscopy, side visual scope, angiography, technetium-99m labelled bleeding scan, and in some cases, multiple endoscopies to detect this fatal defect. Primary hemostasis can be achieved with electrocoagulation, which was the treatment of choice with our patient, or with sclerotherapy, thermocoagulation, argon plasma coagulation or clips with equal results. With the recurrence rate ranging from 9% to 40%, secondary hemostasis can be accomplished through repeat endoscopy, angiography, or rarely, surgical wedge resection. With proper diagnosis and treatment, the rate of mortality has decreased from 30% from the 1970s to currently 8%, however the difficulty lies in vigilant detection, especially in anomalous locations, as was the case in our patient. Watch the video: https://goo.gl/DihM7M1691_A Figure 1. Bleeding periampullary Dieulafoy lesion1691_B Figure 2. Primary hemostasis of Dieulafoy lesion through electrocoagulation

Acquired Von Willebrand Disease as a Cause of Obscure Gastrointestinal Bleeding

Acquired Von Willebrand Disease as a Cause of Obscure Gastrointestinal Bleeding

Impact of Double Balloon Enteroscopy (DBE) on Resource Utilization for Evaluation of Obscure Gastrointestinal Bleeding

Introduction: Gastrointestinal bleeding (GIB) is a common health care issue associated with significant utilization of economic resources. Evaluation requires the use of multiple modalities such as EGD, colonoscopy, video capsule endoscopy (VCE) and CT angiography. In approximately 5% of patients no source is identified via said methods. Double balloon enteroscopy (DBE) has emerged as a diagnostic and therapeutic procedure for obscure GIB. We aimed to determine if performing DBE reduced resource utilization in terms of subsequent procedures and interventions. Methods: A retrospective cohort study was conducted of patients (n=356) who underwent DBE for evaluation of OGIB between Nov 2012 and Aug 2016. Outcomes assessed include procedures performed (EGD, colonoscopy, VCE, blood transfusions) within 6 months prior to initial DBE and for repeat procedures including repeat DBE (antegrade and retrograde) 6 months after initial intervention. The relative risk ratio (RR) and its 95% confidence interval (95%CI) was used indicate the difference between post and pre-intervention. Generalized estimating equation (GEE) approach was used to evaluate the relative risk (RR), accounting for repeated measures. Results: Of 356 patients, a total of 256 were performed in 121 patients prior to initial intervention. Amongst these patients, 25 % (n=89) had at least one EGD, 11.5 % (n=41) colonoscopy, 18.3 % (n=65) VCE and 3.9% (n=14) CT angiography performed before intervention. Post intervention, a total of 145 procedures was applied to 82 patients including antegrade and retrograde DBE. The GEE analysis suggested that the risk of receiving procedures significantly decreased post intervention, with relative ratio RR=0.57 (0.42, 0.76), p<.0001. Similarly, for blood transfusions: before the intervention 311 blood transfusions were applied to 47 patients; while after the intervention, only 181 blood transfusions were applied to 38 patients. The risk of receiving blood transfusions significantly decreased post intervention, with RR=0.58 (0.34, 0.98), p=0.0431. Conclusion: DBE is an effective procedure for identifying and treating obscure gastrointestinal bleeding. It results in a significant decrease in number of procedures employed for identifying GIB, if utilized earlier during the course evaluation. The lack of availability of DBE at most centers is a limitation to its utility. There is a need for more frequent use of DBE for GIB to limit the expenditure on unwanted interventions.

Dieula-Foiled: Diagnosis and Management of Obscure Gastrointestinal Bleeding Secondary to a Duodenal Dieulafoy

Dieula-Foiled: Diagnosis and Management of Obscure Gastrointestinal Bleeding Secondary to a Duodenal Dieulafoy

Hemosuccus Pancreaticus in a Patient With Pancreatic Neuroendocrine Tumor

Hemosuccus pancreaticus is a rare cause of gastrointestinal bleeding, which is most commonly caused by splenic artery pseudoaneurysm secondary to chronic pancreatitis. It can also be seen with pancreatic malignancies. Though often severe, the bleeding is typically intermittent, which makes it challenging to diagnose. A 71-year-old female with pancreatic neuroendocrine tumor presented with a 3-month history of obscure gastrointestinal bleeding. Previous endoscopic studies did not identify a source of bleeding. On presentation, she was experiencing intermittent episodes of hematochezia and melena, though she remained hemodynamically stable. Physical examination was normal. Laboratory testing revealed hemoglobin 7.3 (normal, 12.0-15.5 g/dL), platelets 212 x 109/L (normal, 150-450 x 109/L), and international normalized ratio 1.0. She underwent CT angiography which was negative for active small bowel hemorrhage, but did show extensive tumoral involvement of the pancreas with extension near the ampulla with multiple regional small arteries. Given the CT findings and recurrent nature of her bleed, she underwent EGD with endoscopic ultrasound, which demonstrated active blood extravasation from the Ampulla of Vater, consistent with hemosuccus pancreaticus. Our patient underwent mesenteric arteriogram with embolization of the gastroduodenal, dorsal pancreatic, and inferior pancreaticoduodenal arteries. Following this, her hemoglobin improved, and she has had no further bleeding. Hemosuccus pancreaticus is extremely rare, and is described by hemorrhage from the Ampulla of Vater through the pancreatic duct.1 In clinical practice, it remains a diagnostic challenge, and can sometimes be identified by angiography or upper gastrointestinal endoscopy. If found, bleeding is typically treated with percutaneous angiographic embolization. Anecdotally, hemosuccus pancreaticus carries a high risk of mortality if left untreated.1993_A Figure 1. EGD-obtained image showing blood extravasation from the Ampulla of Vater (white arrow) within the second portion of the duodenum.1993_B Figure 2. CTA scan of the abdomen with oral and IV contrast using triphase enterography protocol showing protrusion of the pancreatic tumor into the second portion of the duodenum (yellow arrow) with small arteries surrounding the tumor (red circle).

A Unique Presentation of Jejunal Submucosal Pancreatic Heterotopia as Overt Obscure Gastrointestinal Bleeding

A Unique Presentation of Jejunal Submucosal Pancreatic Heterotopia as Overt Obscure Gastrointestinal Bleeding

The Efficacy and Safety of Device-Assisted Enteroscopy and Small Bowel Enteroscopy in Cirrhosis Patients

Introduction: Small bowel enteroscopy (SBE) and device-assisted enteroscopy(double balloon enteroscopy, single balloon enteroscopy or SBE-spirus) are commonly used in evaluating and treating obscure gastrointestinal bleeding and lesions in the small bowel. In cirrhotic population, the safety and the success rate of these devices is not well studied in the North America. Our aim in this study is to assess the efficacy and the safety of the device-assisted enteroscopy and SBE and to determine the risk of complications. Methods: A single center, retrospective chart review and analysis of cirrhotic patients between the age of 18 and 80 who had SBE or device-assisted enteroscopy procedure between 2006 and January 2016. We studied the success rate, duration of the procedure, the anesthesia time and complications of the procedures. We also studied the age, sex, MELD score, child-Pugh score (CTP) of the patients. Results: Forty two procedures, 22 SBE and 20 device-assisted enteroscopy, were performed on 33 patients. The average age was 59.3 years (range: 29-86 years). The most common etiologies of cirrhosis were chronic alcohol abuse followed by Non Alcoholic Steatohepatitis (NASH) and chronic hepatitis c virus (HCV). The average MELD score was 16. (Table. 1) The most common abnormal findings were AVM followed by ulcers and inflammatory changes. Longer time needed in the device-assisted enteroscopy than the SBE group as the average time was 58 and 37 minutes respectively (P-value of 0.03). The anesthesia time was longer in the device-assisted enteroscopy with an average of 84 minutes while the average time in the SBE group was 46 minutes (p-value of 0.04). Endoscopic evaluation of the small intestine was successful in 95% of the cohort. The SBE success rate was 100% while the device assisted success rate was 90%. None of the patients had complications or perforation in both groups. (Table 2) Conclusion: Device-assisted enteroscopy and SBE are safe procedures in cirrhotic patients with high success rate. Longer duration and anesthesia time needed for the DAE but no difference was found in the duration of the procedure and the anesthesia time between the decompensated cirrhotic and compensated groups<./p>2888_A Figure 1 No Caption available.2888_B Figure 2 No Caption available.

Differences in Diagnostic Yield of Video Capsule Endoscopy Based on Definition of Obscure GI Bleeding

Differences in Diagnostic Yield of Video Capsule Endoscopy Based on Definition of Obscure GI Bleeding

Antithrombotic Treatment Is Associated with Small-Bowel Video Capsule Endoscopy Positive Findings in Obscure Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

The impact of antithrombotic treatment on the findings of small-bowel capsule endoscopy for patients with obscure gastrointestinal bleeding remains contentious. We aimed to determine the effect of these agents on small-bowel video capsule endoscopy positive findings. MEDLINE, Cochrane Library, and Google Scholar were searched for studies reporting on patients receiving concurrent antithrombotic treatment, while undergoing capsule endoscopy for obscure gastrointestinal bleeding (OGIB). Outcomes were the effect of antithrombotic therapy-overall and per type of antithrombotic agent-on the examination's positive findings and re-bleeding risk. The effect size of study outcomes is presented as odds ratio (OR) with 95% confidence interval (CI). Fourteen studies with 1023 patients were included. We detected significant heterogeneity with no evidence of publication bias. Compared to antithrombotic drug nonusers, antithrombotic treatment was associated with an increased prevalence of positive findings [OR 1.98 (95% CI 1.34-2.93); P = 0.0006]. This effect did not differ between antiplatelet and anticoagulant treatments [OR 2.22 (95% CI 1.28-3.84); P = 0.005 and 2.53 (95% CI 1.66-3.87); P < 0.0001, respectively]. Antithrombotic use over no use was not associated either with overt [OR 1.17 (95% CI 0.51-2.66); P = 0.71] or with occult [OR 0.86 (95% CI 0.38-1.95); P = 0.71] bleeding pattern. However, concurrent antithrombotic treatment was associated with higher odds for re-bleeding compared to no treatment [OR 2.53 (95% CI 1.46-4.37); P = 0.0009]. Antithrombotic treatment is associated with more positive findings in small-bowel video capsule endoscopy in OGIB as well as higher odds of re-bleeding.

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.

Diagnostic features of Meckel's diverticulum using single‐balloon enteroscopy: A case series

Diagnosis of Meckel's diverticulum, the most common congenital anomaly of the gastrointestinal tract, has improved with the development of deep bowel enteroscopy. Few studies have demonstrated the imaging of Meckel's as seen through single‐balloon enteroscopy (SBE). The present case series describes six patients with Meckel's diverticulum diagnosed by SBE. Six patients (six men) underwent SBE at the National Taiwan University Hospital for obscure gastrointestinal bleeding from June 2011 to January 2016. Mean age was 39 ± 22.1 years (range 18‐79). Meckel's was diagnosed by retrograde enteroscopy in all cases and accounted for bleeding in four. Meckel's scan was performed in two cases, and computed tomography scan was performed in four patients, none of which identified the Meckel's. Endoscopic hemostasis was performed in two patients, and Meckel's diverticulectomy was performed in one patient. We found SBE to be a viable first‐line modality for diagnosing Meckel's diverticulum. We found that SBE, similar to double‐balloon enteroscopy, provides the significant benefits of direct observation and intervention for bleeding in the small bowel, including Meckel's.

Video capsule endoscopy as a tool for evaluation of obscure overt gastrointestinal bleeding in the intensive care unit.

Background and study aims Video capsule endoscopy (VCE) is a minimally invasive tool that helps visualize the gastrointestinal tract from the esophagus to the right colon without the need for sedation or preparation. VCE is safe with very few contraindications. However, its role and safety profile in the intensive care unit (ICU) population have not been reported. The aim of this study is to evaluate the safety, efficacy, and feasibility of VCE use in ICU patients. Patients and methods We conducted a single-center retrospective observational study of patients who underwent VCE for evaluation of obscure overt gastrointestinal bleeding in the ICU between 2008 and 2016. Results This study included 48 patients who were admitted to the UMass Memorial Medical Center ICUs for gastrointestinal bleeding. VCE was successfully completed in 43/48 (90 %) patients. The entire length of small bowel could be evaluated in 75 % and the source of bleeding was identified in 44 % of the patients. The most commonly identified source of bleeding included small bowel angioectasias, duodenal erosions/ulcers, and small bowel polyps. No major complications could be attributed to the VCE. Only 1 capsule was retained after 2 wk; however, there was no incidence of bowel obstruction, perforation, or capsule aspiration. Conclusions This observational retrospective study demonstrates that VCE may be a safe, feasible, and effective diagnostic tool in evaluation of gastrointestinal bleeding in the ICU population with few complications. VCE may be a safe diagnostic prelude and be a guide to the correct therapeutic procedure if needed, in the context of patients who are seriously ill.

Enteroscopy in children.

Device-assisted enteroscopy is a new endoscopic technique for the evaluation of small bowel in adults and children. Data in pediatric population are limited. This review aims to identify diagnostic and therapeutic benefits of enteroscopy in children. We have analysed paediatric literature on device-assisted enteroscopy focusing on indications, technical aspects and complications, with attention given to adult publications that may be applicable to the paediatric population. Obscure gastrointestinal bleeding, Crohn's disease and small bowel polyps are the main indications of enteroscopy in children. Device-assisted enteroscopy has high diagnostic yield for the main paediatric indications, but MR-enterography and capsule endoscopy should be used beforehand in diagnostic work-up to better identify candidates for enteroscopy and to improve its diagnostic and therapeutic yield. Major complications are rare and mostly related to therapeutic procedures. Despite limited data in the paediatric population, device-assisted enteroscopy represents a useful and safe endoscopic technique in children. Its use, combined with MR-enterography and capsule endoscopy, allows identification and treatment of many of the small bowel paediatric diseases with a low risk of complications.

Jejunal Diverticulosis Presenting as an Obscure Gastrointestinal Bleed—a Challenge in Diagnosis and Management

Obscure gastrointestinal bleeding is defined as persistent or recurrent bleeding without an obvious cause after endoscopic and radiological evaluation. Obscure gastrointestinal bleeding originates most commonly from the small intestine. Jejunal diverticulosis is an uncommon diagnosis in which multiple mucosal herniations are present in the mesenteric border of jejunum. There is always a delay in diagnosis as it is a rare clinical entity. This is a case report of a 35-year-old male who presented with overt gastrointestinal bleeding and was managed at another center with surgery and embolization. He was evaluated, and a bleeding jejunal diverticulum was identified as the source of bleed during on-table enteroscopy after exhausting other investigation modalities and having delay in definitive management due to difficulty in localizing the source of bleed. Awareness of jejunal diverticulosis and its complications is very important in obscure gastrointestinal hemorrhage to prevent the diagnostic delay. A stepwise approach is very important to identify the source of obscure gastrointestinal bleed.

Long-term follow up of patients with obscure gastrointestinal bleeding examined with video capsule endoscopy.

Video capsule endoscopy (VCE) is a commonly used test for the evaluation of obscure gastrointestinal bleeding. However, long-term outcomes of patients undergoing VCE are unclear. To evaluate the long-term outcomes in patients undergoing VCE for suspected obscure bleeding including iron deficiency anemia (IDA), and determine the need for additional intervention for persistence or recurrence of symptoms in patients with a diagnostic as well as non-diagnostic VCE. Retrospective cohort study within a large county hospital system. We collected information on indications and findings of VCE and outcomes including further testing, bleeding, and hemoglobin (Hgb) at last follow-up through structured review of the electronic health records. VCE findings were classified as active bleeding or high potential for bleeding (P2), intermediate potential (P1) or without any disruption of the mucosa, and no potential for bleeding (P0). We compared demographic and clinical characteristics between patients with and without normal Hgb at the time of last follow up. We examined 116 patients who underwent VCEs performed for obscure gastrointestinal (GI) bleeding during 2010 to 2012 with mean duration of follow up after VCE completion of 571 days (standard deviation [SD] = 248). Abnormal VCE findings (37.9% for P1 lesions, 44.8% for P2 lesions) were seen in 106 (87.9%) patients. Additional diagnostic testing was performed in 55/116 (47.4%) (67.7% GI procedures). Hgb was restored to normal range in 59/116 (50.9%) by end of follow up which were attributed to iron supplementation and/or discontinuation of non-steroidal anti-inflammatory drugs (NSAIDs) in a majority. Twenty six of 116 patients experienced rebleeding (22.4%). The diagnostic yield of VCE is high among patients with obscure GI bleeding. More than 50% of patients achieve normal Hgb in the long term with conservative measures such as iron supplementation and the discontinuation of NSAIDs.

Usefulness of small bowel reexamination in obscure gastrointestinal bleeding patients with negative capsule endoscopy findings: Comparison of repeat capsule endoscopy and double-balloon enteroscopy.

Although capsule endoscopy (CE) is a noninvasive diagnostic tool for patients with obscure gastrointestinal bleeding (OGIB), bleeding lesions are often not detected. No strategies have been established to determine whether CE or double-balloon enteroscopy (DBE) should be performed after negative CE. Among 652 patients who underwent CE for OGIB, a total of 359 patients had negative findings. Of these, 41 and 48 patients underwent repeat CE and DBE for small bowel reexamination, respectively. We compared the rate of positive findings between the two groups. The findings were considered positive if mucosal break, vascular lesion, tumor, or active bleeding was observed. The rate of positive findings in the repeat CE group was significantly higher than that in the DBE group (73.2% vs. 39.6%; p = 0.001). Logistic regression analysis showed that the repeat CE group was significantly associated with positive findings (odds ratio (OR), 4.2; 95% confidence interval (CI), 1.7-10.2; p = 0.002). Inverse probability of treatment-weighted analysis revealed that repeat CE was significantly associated with positive findings (OR, 4.4; 95% CI, 1.6-12.2; p = 0.004). Reexamination via CE appears to have more diagnostic value than DBE for OGIB patients with negative CE findings.

A Rare Case of Obscure Gastrointestinal Bleeding in a Young Patient

The case is reported of obscure gastrointestinal bleeding in a young male. A 14-year-old male presented with severe anemia and a one-month history of passage of black colored stools with occasional fresh blood. Investigations revealed a gastrointestinal stromal tumor (GIST) in the jejunum which was managed by resection and jejuno-jejunal anastomosis.

Treatment of Refractory Small Bowel Bleeding With Thalidomide after Living Donor Kidney Transplantation

Introduction Small bowel bleeding after kidney transplantation is a complication that can occur from long-term multiple immunosuppressant use that can be fatal if it is not managed appropriately. We present a case of intractable small bowel bleeding that was treated successfully with thalidomide after multiple failed attempts of embolization and small bowel surgical resection. Case A 65-year-old male patient with diabetic nephropathy underwent living donor kidney transplantation. The patient received the kidney from his daughter, who was a blood group-compatible donor. Immunosuppressive therapy consisted of tacrolimus, mycophenolic acid, and steroids. On the 11th day of post-operation, the patient developed severe melena for which he received massive red blood cell transfusions due to unstable vital signs. The dose of immunosuppressants was also reduced to half of the standard dose. However, the patient developed more frequent hematochezia. Concurrent gastroscopy, colonoscopy and abdominal computed tomographic angiography showed active bleeding from the proximal jejunum. Therefore the patient underwent laparoscopic small bowel segmental resection. Unfortunately, hematochezia recurred 4 days after the first re-operation. Mycophenolic acid was ceased and tacrolimus was replaced by cyclosporine A. Diffuse bleeding from multiple ulcerative lesions between the jejunum and the ileum was detected by balloon enteroscopy. A second re-operation was performed which consisted of a laparoscopy-assisted small bowel resection with double barrel ileostomy. Despite these attempts, the patient showed deteriorated melena through the ileostomy 7 days after the second re-operation. Repeated enteroscopy was performed through the ileostomy and evidence of diffuse bleeding at the duodenal 3rd portion was found, together with multiple superficial ulcerations and tendency for angiodysplasias. This time, embolization of the branches of the pancreaticoduodenal artery was performed, and the procedure successfully stabilized the patient’s vital signs. The decision was made to introduce a new medical therapy to prevent recurrent small bowel bleeding of the patient as the ACG (American College of Gastroenterology) Clinical Guideline suggested. We initiated thalidomide 100 mg/day after obtaining informed consent from the patient’s family. The patient’s small bowel bleeding was no longer evident after treatment with thalidomide. Conclusion Several studies have shown the successful outcome of thalidomide treatment on obscure gastrointestinal bleeding due to angiodysplasia, but this is the first study to describe its effect on post-transplant patients.

Cystic Artery Pseudoaneurysm: A Rare Cause to Obscure Upper Gastrointestinal Bleeding

Obscure gastrointestinal bleeding is a surgical enigma of disastrous proportions. Patient’s haemodynamic status often dictates the path of management ranging from endoscopy, embolization and/or surgery. Minority of the cases has failed to identify the exact source of bleeding during endoscopic and imaging techniques. Emergency surgery is warranted in hypovolaemic shock which has failed to respond to fluid and blood resuscitation. We present a 72-year-old male with an obscure upper gastrointestinal bleeding due to ruptured cystic artery pseudoaneurysm and illustrate the rarity of the presentation with successful management.