Preoperative Superselective Mesenteric Angiography and Methylene Blue Injection for Localization of Obscure Gastrointestinal Bleeding

Abstract

Localizing obscure gastrointestinal bleeding can be a clinical challenge, despite the availability of various endoscopic, imaging, and visceral angiographic techniques. We reviewed the management of patients presenting with obscure gastrointestinal bleeding during the period from 2005 to 2011. Four patients had preoperative localization of the bleeding site with superselective mesenteric angiography, which was confirmed by the use of intraoperative methylene blue injection. This novel technique allowed us to identify the abnormal pathology, and, consequently, resection of the implicated segment of small bowel was performed without any postoperative complications. Final histology showed that 2 patients had arteriovenous malformations: one had a benign hemangioma of the small bowel, and the other had chronic ischemic ulceration in the ileum. Superselective mesenteric angiography combined with intraoperative localization with methylene blue is an important and innovative technique in the management of patients with unclear sources of gastrointestinal bleeding and allows for effective hemorrhage control with a focused and therefore limited bowel resection.

Methylene Blue injection via superior mesenteric artery microcatheter for focused enterectomy in the treatment of a bleeding small intestinal arteriovenous malformation

“…Refinements on the technique have been described in subsequent reports which have paralleled advancement in angiographic methods, including provocative angiography with fibrinolytic agents [4-8]. …”

“…From this highly invasive and non-selective approach, several refinements on this technique have been pioneered over the years to result in a less invasive and more focused surgical resection in the treatment of GI bleeding from the small intestine [3-8]. In this report, we describe how pathological findings on CTA in a non-actively, obscure GIB patient prompted super-selective angiographic catheter placement and, ultimately, limited enterectomy directed by intra-operative methylene blue injection.…”

Interventional digital subtraction angiography for small bowel gastrointestinal stromal tumors with bleeding

“…Routine diagnostic imaging modalities mainly consist of endoscopic examination, computed tomography (CT) scanning, and magnetic resonance imaging (MRI) [7][8][9][10][11][12] . However, doctors who admit patients with acute or subacute obscure gastrointestinal bleeding (OGIB) prefer to conduct emergency interventional digital subtraction angiography (DSA), whereas some routine exams are not able to identify the bleeding [13][14][15] . To our knowledge, few detailed reports on the use of interventional DSA for small bowel GISTs have been published to date.…”

Bleeding small bowel: methylene blue guided resection

“…Using methylene blue to map the area of small bowel resection was described as far back as the 1970s . Several small case series have since reported successful use of the technique to localize bleeding . Fluorescein has been used as an alternative; however, this requires special equipment to enable visualization in contrast to methylene blue being obvious under standard operating theatre lighting.…”

“…2 Several small case series have since reported successful use of the technique to localize bleeding. 3,4 Fluorescein has been used as an alternative; 5 however, this requires special equipment to enable visualization in contrast to methylene blue being obvious under standard operating theatre lighting. In this patient, as bleeding was from within a diverticulum, an on-table enteroscopy would most probably have been unsuccessful as well.…”