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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.
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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.

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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.

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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.

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