0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Brief Report | Resident's Forum

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

Madhava Pai, MS, FRCS1; Adam E. Frampton, MSc, MRCS1; Jagdeep S. Virk, MRCS1; Nyooti Nehru, MBBS1; Charis Kyriakides, MD1; Paolo Limongelli, MD1; James E. Jackson, FRCR2; Long R. Jiao, MD, FRCS1
[+] Author Affiliations
1Hepatopancreaticobiliary Surgical Unit, Department of Surgery and Cancer, Imperial College, Healthcare NHS Trust, Hammersmith Hospital, London, England
2Department of Radiology, Imperial College, Healthcare NHS Trust, Hammersmith Hospital, London, England
JAMA Surg. 2013;148(7):665-668. doi:10.1001/jamasurg.2013.345.
Text Size: A A A
Published online

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.

Figures in this Article

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Figures

Place holder to copy figure label and caption
Figure.
Superselective Mesenteric Angiography, Which Localizes a Vascular Abnormality in the Small Bowel

A patient with an actively bleeding arteriovenous malformation in the jejunum, despite attempted embolization, underwent SSMA and catheter localization prior to exploration in the operating room. Visceral angiography was performed via a right femoral artery puncture using a 7F sheath and catheter and a 3F coaxial catheter. A contrast agent (Ultravist 300; Bayer) was injected into the inferior mesenteric artery, the superior mesenteric artery, and the fifth and sixth jejunal arteries to delineate the pathology. The patient was found to have arteriosclerotic vessels and no signs of active extravasation. The site of previous embolization in the territory of the sixth jejunal artery can be seen (black arrow), as well as a small vessel bypassing the embolized segment (white arrow) to supply an abnormal-looking area of jejunum containing prominent vascular spaces and early venous drainage. These appearances were consistent with revascularization of the previously embolized arteriovenous malformation. The abnormality was situated at the junction of the territory supplied by the fifth and sixth jejunal arteries. The coaxial catheter was left in the sixth jejunal artery (gray arrow), and the patient was transferred to the operating room for laparotomy and resection following methylene blue injection.

Graphic Jump Location

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Video.

Selective Intraoperative Methylene Blue Injection Highlighting Source of Obscure Gastrointestinal Bleeding

After superselective mesenteric angiography was performed, the coaxial catheter was left in the artery supplying the abnormal segment of small bowel. Methylene blue (1 mL) was injected selectively through the bleeding artery to stain the bowel at the point of hemorrhage. The injection of methylene blue dye immediately demarcated the territory of small bowel supplied by this mesenteric artery by a brilliant blue color and therefore guided the extent of the resection. The source of the bleeding can be seen at the end of the video as a concentrated dark blue area.

Some tools below are only available to our subscribers or users with an online account.

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
Jobs
JAMAevidence.com

Users' Guides to the Medical Literature
Gastrointestinal Bleeding

The Rational Clinical Examination
Make the Diagnosis: Upper Gastrointestinal Bleed

brightcove.createExperiences();