A 45-year-old man with melena and dyspnea on effort that had
persisted for a week was admitted to our hospital. He had serious complications
such as diabetic nephropathy and myocardial infarction, and was given an
antiplatelet agent. His blood hemoglobin level dropped to 4.2 g/dl, but
the vital signs were stable. He underwent esophagogastroduodenoscopy and
colonoscopy on day 1 of hospitalization, but the bleeding source was not
identified. He received blood transfusions for 5 days.
On day 4 in hospital, double-balloon endoscopy (DBE) with an
anterograde approach was done ([Video 1]).
Video
1 Double-balloon endoscopy (DBE): diagnosis and
hemostatic treatments of bleeding angiodysplasia of the jejunum.
Fresh blood was seen in the upper jejunum ([Fig. 1 a]), and when the intestine was filled
with water, active bleeding was found without a visible vessel ([Fig. 1 b]).
Fig. 1 a Double-balloon
endoscopy (DBE) of the upper jejunum showed fresh blood on the mucosal surface.
b DBE in the water-filled intestine showed a bleeding
spot (arrow) without a visible vessel.
After normal saline injection, cauterization was done using argon
plasma coagulation (APC) and hemoclipping ([Fig. 2]).
Fig. 2 Double-balloon endoscopy
(DBE) showed hemostatic state after argon plasma coagulation (APC) and
hemoclipping.
The bleeding was stopped successfully with no sign of
recurrence.
Angiodysplasia of the small intestine has been acknowledged as a
major source of obscure gastrointestinal bleeding [1].
The vascular lesions of the small intestine have a variety of endoscopic
appearances, and some types of vascular disease are difficult to find because
of their subtle appearance. Yano et al. classified vascular lesions of the
small intestine into six categories [2]. In the present
case the lesion was classified as type 1a (punctulate erythema
[< 1 mm], with or without oozing) in the
Yano–Yamamoto classification [2]. This type of
angiodysplasia is considered difficult to find, if spontaneous transit
hemostasis is completed. Therefore, early DBE was essential for accurate
diagnosis and endoscopic hemostasis in the present case.
Endoscopy_UCTN_Code_CCL_1AC_2AB
