Utility of preoperative small-bowel endoscopy for hemorrhagic lesions in the small intestine

King Abdulaziz University Hospital Capsule dataset: A novel small-bowel endoscopic image repository from Saudi Arabia

Wireless Capsule Endoscopy (WCE) has fundamentally transformed diagnostic methodologies for small-bowel (SB) abnormalities, providing a comprehensive and non-invasive gastrointestinal assessment in contrast to conventional endoscopic procedures. The King Abdulaziz University Hospital Capsule (KAUHC) dataset comprises annotated WCE images specifically curated for Saudi Arabian residents. Comprising 10.7 million frames derived from 157 studies, KAUHC has been classified into Normal, Arteriovenous Malformations, and Ulcer categories. Following the application of specific inclusion and exclusion criteria, 3301 labeled frames derived from WCE 86 studies were identified. Upon admission of patients, the data collection phase of KAUHC was initiated, involving the administration of the OMOM capsule and the use of the OMOM recording device for video documentation. A thorough evaluation of these recordings was undertaken by multiple gastroenterologists to identify any pathological abnormalities. The identified observations are subsequently extracted, categorized, and prepared for validation using Machine Learning (ML) classifiers. The dataset aims not only to address the scarcity of annotated endoscopic imaging resources in the Middle East but also to advance the development of diagnostic tools for ML applications in SB abnormalities and exploratory research on gastrointestinal diseases.

Arteriovenous malformation of the small intestine presenting with a transfusion-dependent anaemia in pregnancy

Gastrointestinal bleeding that originates in the small intestine is often difficult to diagnose. Bleeding from a small intestinal arteriovenous malformation (AVM) is rare, with congenital AVMs more commonly located in the rectum or sigmoid. There is a relative paucity of cases reported in the literature. In the gastrointestinal tract, it can cause acute and chronic bleeding, which can be fatal. Although the incidence of small bowel AVMs is quite low, such lesions can be identified as the bleeding source in patients with obscure gastrointestinal bleeding (OGIB) harbouring severe, transfusion-dependent anaemia. It can be exceedingly difficult to localise and diagnose gastrointestinal tract bleeding, particularly in cases of occult small bowel AVMs. CT angiography and capsule endoscopy can help to establish the diagnosis. Laparoscopy is an appropriate and beneficial treatment modality for small bowel resection. The authors present the case of a primigravida woman in her late 20s diagnosed with a symptomatic transfusion-dependent anaemia during her pregnancy. She developed OGIB and despite no history of chronic liver disease became encephalopathic. Due to her physical deterioration and uncertain diagnosis, her caesarean section was performed at 36+6 weeks to expedite investigations and treatment. She was diagnosed with a jejunal AVM and underwent coiled embolisation of her superior mesenteric artery. She became haemodynamically unstable and underwent a laparotomy and small bowel resection. A full non-invasive liver screen was negative, however, her MRI liver described multiple focal nodular hyperplasia (FNH) lesions raising the possibility of FNH syndrome in the context of a previous AVM malformation. A prompt stepwise, multimodality diagnostic approach is required to prevent patient morbidity and mortality.

Emergent single-balloon enteroscopy for overt bleeding of small intestinal vascular malformation

A 28-year-old man presented with anemia symptoms and intermittent tarry stool passage for three days. No stigmata of hemorrhage were identified using esophagogastroduodenoscopy, ileocolonoscopy, and contrast-enhanced computed tomography. He then developed massive tarry stool passage with profound hypovolemic shock and hypoxic respiratory failure. Emergent angiography revealed active bleeder, probably from the jejunal branches of the superior mesenteric artery, but embolization was not performed due to possible subsequent extensive bowel ischemia. His airway was secured via endotracheal intubation with ventilator support, and emergent antegrade single-balloon enteroscopy was performed at 8 h after clinical overt bleeding occurrence; the procedure revealed a 2-cm pulsating subepithelial tumor with a protruding blood plug at the distal jejunum. Laparoscopic segmental resection of the jejunum with end-to-end anastomosis was performed after emergent endoscopic tattooing localization. Pathological examination revealed a vascular malformation in the submucosa with an organizing thrombus. He was uneventfully discharged 5 d later. This case report highlights the benefit of early deep enteroscopy for the treatment of small intestinal bleeding.

Recurrent Midgut Bleeding due to Jejunal Angioleiomyoma

Angioleiomyoma being a type of true smooth muscle gastrointestinal tumors can lead to serious life-threatening gastrointestinal bleeding. We report a case of 21-year-old male patient with recurrent midgut bleeding. Contrast-enhanced CT revealed highly vascular small bowel neoplasm. The patient underwent laparotomy with bowel resection and recovered uneventfully. Histopathology revealed jejunal angioleiomyoma.

Role of double-balloon enteroscopy in malignant small bowel tumors

AIM

To assess the double-balloon enteroscopy (DBE) role in malignant small bowel tumors (MSBT).

METHODS

This is a retrospective descriptive study performed in a single center. All consecutive patients who underwent a DBE with final diagnosis of a malignant neoplasm from 2004 to 2014 in our referral center were included. Patient demographic and clinical pathological characteristics were recorded and reviewed. MSBT diagnosis was achieved either by DBE directed biopsy with multiple tissue sampling, endoscopic findings or histological analysis of surgical specimen. We have analyzed double-balloon enteroscopy impact in outcome and clinical course of these patients.

RESULTS

Of 627 patients, 28 (4.5%) (mean age = 60 ± 17.3 years) underwent 30 procedures (25 anterograde, 5 retrograde) and were diagnosed of a malignant tumor. Patients presented with obscure gastrointestinal bleeding (n = 19, 67.9%), occlusion syndrome (n = 7, 25%) and diarrhea (n = 1, 3.6%). They were diagnosed by DBE biopsy (n = 18, 64.3%), histological analysis of surgical specimen (n = 7, 25%) and unequivocal endoscopic findings (n = 2, 7.1%). Gastrointestinal stromal tumor (n = 8, 28.6%), adenocarcinoma (n = 7, 25%), lymphoma (n = 4, 14.3%), neuroendocrine tumor (n = 4, 14.3%), metastatic (n = 3, 10.7%) and Kaposi sarcoma (n = 1, 3.6%) were identified. DBE modified outcome in 7 cases (25%), delaying or avoiding emergency surgery (n = 3), modifying surgery approach (n = 2) and indicating emergency SB partial resection instead of elective approach (n = 2).

CONCLUSION

DBE may be critical in the management of MSBT providing additional information that may be decisive in the clinical course of these patients.

Arteriovenous malformation detected by small bowel endoscopy

Gastrointestinal bleeding that originates in the small intestine is often difficult to diagnose. When successful diagnosis reveals a lesion that can be localized preoperatively, the laparoscopic approach is an appropriate and beneficial treatment modality for small bowel resection. A 69-year-old man presented with a 6-month history of gastrointestinal bleeding and symptomatic transfusion-dependent anemia. Upper and lower endoscopy were normal. Double-balloon endoscopy established the source of the bleeding as a 0.5-cm polypoid mass appearing as a submucosal tumor with redness and pulsation in the lower ileum, suggesting a vascular lesion. Laparoscopic small bowel resection was successful in removing the mass in the ileum. Histological evaluation of the mass revealed an arteriovenous malformation. Preoperative small bowel endoscopy can be useful for diagnosing the cause and localization of arteriovenous malformation in the small intestine.

Clinical value of double balloon endoscopy in small intestinal diseases

AIM: To evaluate the diagnostic and therapeutic value and safety of double balloon endoscopy (DBE) in small intestinal diseases.

METHODS: A retrospective analysis of 123 patients who underwent DBE under conscious sedation anesthesia with suspected small intestinal diseases from January 2009 to February 2013 was performed. Oral and anal DBE was performed in 52 and 55 patients, respectively, while 16 patients underwent a combination of both approaches. Endoscopic tissue biopsy of suspicious lesions was performed routinely.

RESULTS: The overall diagnostic yield of DBE was 75.6% (93/123), with nonspecific intestinal inflammations in 37 patients and Crohn's diseases in 17 patients. There were benign or malignant tumors in 13 patients, including small intestine adenocarcinoma in 5 patients, stromal tumors and lymphomas in 3, lipomas in 2, and polyps in 11 (including inflammatory polyps in 8 and Peutz-Jeghers syndrome in 3), vascular diseases in 6 (including vascular malformations in 4 and angiotelectasia in 2), ulcers in 4 and other lesions in 5 (including lymphangiectasia, small intestinal diverticulum, Behcet's disease, entericintussusception and portal hypertensive enteropathy). In addition, there were three cases of external compressive lesions. The overall therapeutic yield of DBE was 9.8% (12/123), including endoscopic snare and electric coagulation or cutting in all polyps and clipping (with a titanium clip) in one case of vascular malformation with active bleeding. There were no severe complications such as bleeding, perforation, and pancreatitis.

CONCLUSION: DBE is a method with high diagnostic value, safety and reliability for small intestinal diseases, and can be used for endoscopic treatment.