Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding

Does Intraoperative Endoscopy Still Apply in Obscure Gastrointestinal Bleeding Treatment? A Case Report and a Literature Review with a Diagnostic Algorithm Proposal

“…In our patient, aged 68-years old, there were confirmed vascular malformations as a reason of bleeding, with no other pathologies of gastrointestinal tract. Small bowel is sometimes called "the dark continent of the gastrointestinal tract" because of its intraperitoneal localization with free mobility that makes endoscopic investigation very difficult [1,11,12]. According to literature medium time from first signs of obscure bleeding to diagnosis is 18-26 months.…”

“…Push enteroscopy is easy to perform even in a small diagnostic centers/hospitals, gives possibility of intervention such as small resection, coagulation or lesion marking. Complication rate is low, most common are duodenum perforation and acute pancreatitis [11,14]. Another endoscopic method of investigation, with sensitivity of 65% to 100%, is an intraoperative endoscopy (IOE).…”

“…Despite this, second look should be considered in case of active bleeding or after poor visualization of stomach fundus or colon during first procedure [4,7]. As there are no existing homogenous guidelines of investigation in case of OGIB, we propose diagnostic algorithm based on literature and depending on clinical situation (Figures 1 and 2) [4,11]. Conventional radiological methods as computer tomography and/or magnetic resonance, with their sensitivity up to 6% to 7% are usually not helpful in OGIB investigation.…”

“…Other reasons were presented in Table 2 [1,2,4,5,10-14]. Group of rare reason of GI bleeding accounting less than 0,5% are: hamartoma, hemangioma, Rendu-Osler-Weber disease, fistulas, radiotherapy dependent lesions, amyloidosis, Schὃenlein-Henoch disease, hypertension related enteropathy, ileal melanoma, B-cell lymphoma [3,11]. A very rare reason can be Heyde's syndrome which is coincidence of aortic valve stenosis and bleeding from angiodysplasia [8].…”

“…Small bowel angiodysplasia 32% to 61% [1,2,4,5,10,12,14] Arteriovenous malformation (AVM) 9,1% [5] Ulceration 85 to 14,7% [1,4,5] Small bowel tumors 45 to 20% [1,4,5,14] Cameron erosion 5% to 15% [14] Upper GI tract angiodysplasia 45 to 10% [11,14] Crohn's disease 2% to 10% [14] Small bowel diverticula 3,3% to 5% [1,5,14] Colon dysplasia 2% to 4% [5] Varices haemorrhoidalis 0,4% to 5% [4,5,14] Dieulafoy lesions 0,4% to 3,5% [5,12,14] Unknown 16% to 20,7% [1,5] of cases transfusion of PRBC and FFP units is required [1,3,7]. It is discussed whether repeated endoscopy after failed first investigation is indicated because it was proven that it is not efficient enough and it enables visualization of only 3.5% to 5% of lesions responsible for bleeding.…”