Management of bleeding angiodysplasia of the upper small intestine

Intraoperative angiography with indocyanine green injection for precise localization and resection of small bowel bleeding

Aim

Bleeding in the small bowel rarely occurs, and its treatment is challenging. Surgery is sometimes required in unstable patients; however, intraoperative identification of the bleeding site is extremely difficult. Many methods have been reported, but no standard strategy has been established yet. Here, we aimed to assess the safety and feasibility of intraoperative angiography with indocyanine green staining to accurately identify small bowel bleeding sites.

Methods

This retrospective study analyzed contrast‐enhanced computed tomography images of patients (n = 8) with small bowel extravasation who underwent surgery. If extravasation or other vessel abnormalities that were potential bleeding sites were detected on intraoperative angiography, a microcatheter was placed as close as possible to the extravasation site. Laparotomy was carried out, and 3–5 mL indocyanine green was injected through the microcatheter. The green‐stained segment of the small bowel was resected.

Results

Seven of the eight patients had positive angiographic findings and underwent bowel resection. The eighth patient had no abnormalities and hence did not undergo laparotomy. The rate of hemostatic success among the resected cases was 85.7% (six of seven cases). The resected specimens showed pathologic features in six of the seven patients (85.7%), all of whom achieved hemostasis. One patient had pneumonia and congestive heart failure that required longer hospital stay, but no mortality occurred.

Conclusions

Intraoperative angiography with indocyanine green injection, followed by resection for massive small bowel bleeding is effective. This can be a therapeutic option for hemodynamically unstable patients.

Bleeding angiodysplasia of the gastrointestinal tract

Bleeding angiodysplasia of the gastrointestinal tract poses frustrating challenges to clinicians because these minute vascular lesions are difficult to diagnose pre-operatively and to locate intra-operatively. During the past 12 years, 24 patients were treated for histopathologically confirmed bleeding angiodysplasia of the gastrointestinal tract. Pre-operative investigations and intra-operative localization followed a fixed protocol for patients with gastrointestinal bleeding of obscure origin. The median follow-up of these 24 patients was 51 months and the results of treatment for 22 patients were excellent. Two patients had recurrent bleeding but investigations failed to determine the bleeding source.

Role of intraoperative enteroscopy in obscure gastrointestinal bleeding of small bowel origin

Intraoperative enteroscopy was performed in 12 patients (median age 68 years) with obscure gastrointestinal bleeding probably of small bowel origin, six of whom were men. All the patients were evaluated by routine haematological, coagulation and biochemical profiles, upper and lower gastrointestinal endoscopies, visceral angiography and/or isotope scanning. All the patients were anaemic. Visceral angiography was useful on three of the 12 occasions on which it was used and isotope scanning was valuable on eight of the 11 occasions it was used. Nine patients had undergone previous laparotomy. Enteroscopy was performed successfully in all cases, with fresh blood and discrete vascular lesions being the chief findings (10 of 12 cases). Segmental resections (n = 8) and local resections (n = 2) were performed in ten patients, with two patients having more than one laparotomy for rebleeding. Five patients developed postoperative complications and there was an operative death and one late death. Three of the ten surviving patients experienced further rebleeding. Intraoperative enteroscopy is now an essential adjunct to laparotomy for gastrointestinal bleeding which has been localized to the small bowel before operation.

Push-enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin

Push-enteroscopy using a disinfected colonoscope was performed on 39 patients with gastrointestinal bleeding of obscure origin. Our results show that: (1) A high percentage of patients (38%) have pathological lesions responsible for bleeding located in the distal duodenum and proximal jejunum, which are readily detected by push-enteroscopy. (2) Duodeno-jejunal arteriovenous malformations (AVMs) are the most common cause for bleeding, and these lesions can be conveniently cauterized through the endoscope. (3) An efficient sequence of steps for diagnosis of patients with this problem includes push-enteroscopy when the initial EGD and colonoscopy are normal followed by small bowel radiography. Mesenteric angiography and intraoperative enteroscopy can be reserved for patients with severe bleeding when push-enteroscopy and small bowel radiography are negative. We conclude that push-enteroscopy has an important role to play in the early assessment of patients with gastrointestinal bleeding of obscure origin.

Intraoperative enteroscopy--indications and limitations

Over the past 9 years we were called upon to operate on 47 patients because of bleeding lesions of the small intestine. The procedure of intraoperative endoscopy was selected for 17 of these patients. One or more of the following indications for intraoperative endoscopy pertained: to detect otherwise occult lesions (nine patients), to define the location of multiple small lesions (six patients), to confirm bleeding from known lesions (two patients), to exclude the presence of lesions suspected of bleeding (two patients), and to aid in determining the length of required resection (two patients). Fourteen of these 17 patients survived the immediate post-operative period, and in a median follow-up of 37 months bleeding has not recurred. No complication of intraoperative enteroscopy was encountered in this series.

Repeat selective visceral angiography in patients with gastrointestinal bleeding of obscure origin

In the past 9 years, we have operated on 56 patients with gastrointestinal bleeding of obscure origin. Selective visceral angiography demonstrated the bleeding lesions in 24 of the 30 patients who underwent this investigation. Six of these 24 patients, however, had a negative angiogram initially and the lesions were only demonstrated on a repeat angiogram. The negative initial angiograms were due to: (1) slow bleeding from lesions in two patients; (2) a small bleeding tumour that caused only intermittent jejunojejunal intussusception in one patient; (3) technical fault in one patient; and (4) spasm of the bleeding vascular lesions and their feeding arteries in two patients. We advocate repeat angiography the following day in all patients in whom profuse bleeding continues, and during the next intestinal bleeding in those whose bleeding stops after the initial negative angiography. In patients who have repeated episodes of massive bleeding, and in whom full investigations fail to reveal the bleeding source, repeat angiography carried out 4 weeks after the bleeding has stopped can sometimes demonstrate the vascular lesions.

Mucosal vascular malformations of the gastrointestinal tract: clinical observations and results of endoscopic neodymium: yttrium-aluminum-garnet laser therapy

Ninety-three consecutive patients with transfusion-dependent gastrointestinal bleeding from vascular malformations (VMs) underwent systematic assessment in our gastrointestinal laser suite with extended upper gastrointestinal endoscopy and colonoscopy. Of these patients, 83 had angiodysplasia and 10 had the Osler-Weber-Rendu (OWR) syndrome. The median age in each of these groups was 70 and 63 years, respectively. Cardiovascular disease, especially valvular disease, was common. A poor correlation existed between the results of endoscopically identified VMs and visceral angiography in patients with angiodysplasia. A combination of upper and lower gastrointestinal VMs was found in 11% of patients with angiodysplasia and 60% of those with the OWR syndrome. All identified VMs were completely obliterated by photocoagulation with use of a neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. Bleeding was successfully controlled in 9 patients with the OWR syndrome and in 72 patients with angiodysplasia (range of follow-up, 1 to 39 months). In 243 laser treatments, 3 perforations and 5 episodes of delayed bleeding occurred. This experience demonstrates that extended upper endoscopy is useful in identifying VMs and that gastrointestinal bleeding from VMs can be safely and successfully controlled with use of endoscopic Nd:YAG laser therapy.

Intra-operative localization of bleeding small intestinal lesions

We prospectively studied 12 patients to compare fibreoptic enteroscopy and methylene blue injection through superselectively prepositioned angiographic catheters in intra-operative localization of bleeding small intestinal lesions. Four patients were excluded because the lesions were easily detected by gross examination. Eight patients were subjected to study by these two methods. As methylene blue injection required a positive angiography, it was possible only in five patients. In two of these five patients, non-bleeding lesions were present outside the intestinal segments localized by this method. Enteroscopy was simple, accurate and reliable in seven patients. Complete enteroscopy was impossible in one patient with advanced lymphoma because the intestine and its mesentery were matted together. Fortunately, the bleeding ulcers were still within the reach of the endoscope. Enteroscopy localized bleeding small intestinal lesions more exactly than methylene blue injection so that the length of gut resection could be shorter. We, therefore, conclude that enteroscopy is the better intra-operative localization procedure.