Single-balloon enteroscopy in life-threatening small-intestine hemorrhage

We read with interest the article by Mönkemüller et al. [1] on the positive role of emergency double-balloon enteroscopy (DBE) in the diagnosis and treatment of overt obscure gastrointestinal bleeding. We herein describe a life-threatening small-intestine active hemorrhage diagnosed endoscopically with single-balloon enteroscopy (SBE), thus strengthening the significance of enteroscopy in the future as a first-choice examination for active small-bowel bleeding.

A 74-year-old man presented with hypotension, dizziness, and nausea after multiple episodes of “burgundy-colored” stools. Hemoglobin and hematocrit were 9.2 g/dL and 26.8 %, respectively. Emergency upper gastrointestinal endoscopy revealed no lesions. Two units of packed red blood cells were transfused and after vigorous preparation with polyethylene-glycol solution, colonoscopy demonstrated fresh blood exiting the terminal ileum. Given the high suspicion of small-bowel bleeding, capsule endoscopy was performed and revealed active hemorrhage in the middle part of jejunum (68 minutes after the capsule had passed the pylorus), but failed to identify the cause of bleeding. Because diagnosis of the bleeding lesion was not possible, we proceeded with an SBE (Olympus, Tokyo, Japan), which revealed a submucosal jejunal mass with central ulceration ([Fig. 1]) and oozing from a visible vessel (arrow) at the bottom of the ulcerative cavity. The endoscopic features of the lesion suggested a gastrointestinal stromal tumor (GIST). Two clips were placed on the bleeding vessel to arrest the hemorrhage and to help the surgeon find the lesion. The patient was sent for laparoscopic enterectomy. A 3-cm tumor was resected and histologic examination showed a GIST with ulcerated mucosa ([Fig. 2]). The patient had a successful recovery.

Fig. 1 Endoscopic view of a submucosal tumor with a central ulceration and ooze-bleeding from a visible vessel (arrow).

Fig. 2 Gastrointestinal stromal tumor (GIST) comprised predominantly of spindle cells (hematoxylin and eosin stain, original magnification, × 20).

Despite the significant role of capsule endoscopy in the investigation of obscure gastrointestinal bleeding, its endoscopic accuracy during active bleeding is limited, because the bleeding area cannot be inflated and cleansed from blood by irrigation and suction, resulting in an unclear endoscopic picture of the lesion [2]. Moreover, it has limitations because gross pathology may be missed or may be unrecognizable at capsule endoscopy, and biopsies and endoscopic interventions cannot be performed. The introduction of DBE in 2001 [3] and SBE in 2007 [4] to the commercial market and the experience acquired provided the endoscopist with the opportunity to make a more accurate endoscopic and histologic diagnosis, and to perform a more successful endoscopic intervention for bleeding small-intestine lesions. Therefore, despite no current consensus on the timing of enteroscopy in the evaluation of overt obscure gastrointestinal bleeding exists, we believe that if the source of a life-threatening hemorrhage is strongly suspected to be the small intestine, SBE may be used as the easier examination of choice, provided that the endoscopist has sufficient experience, because it provides a more accurate endoscopic picture, the possibility of endoscopic intervention, and is time- and cost-effective.

Competing interests: None

References

• 1 Mönkemüller K, Neumann H, Meyer F. et al . A retrospective analysis of emergency double-balloon enteroscopy for small-bowel bleeding.  Endoscopy. 2009;  41 715-717
• 2 Delvaux M, Gay G. Capsule endoscopy in 2005: facts and perspectives.  Best Pract Res Clin Gastroenterol. 2006;  1 23-39
• 3 Yamamotto H, Sekine Y, Sato Y. et al . Total enteroscopy with a nonsurgical steerable double-balloon method.  Gastrointest Endosc. 2001;  53 216-220
• 4 Hartmann D, Eickhoff A, Tamm R. et al . Balloon-assisted enteroscopy using a single-balloon method.  Endoscopy. 2007;  39 (Suppl. 1) E276