Obscure gastrointestinal bleeding localization using preoperative super-selective mesenteric angiography and intraoperative methylene blue injection: A case report and literature review

• Published in: International journal of surgery case reports Vol. 65; pp. 69 - 72
• Main Authors: Bhuller, Sidra B., Lieser, Mark, Ismail, Naveed, Woods, Bradley
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Ltd 01.01.2019; Elsevier
• Subjects: Angiodysplasia; Arteriovenous malformation; Methylene blue; Obscure gastrointestinal bleeding; Superselective angiography; GI; EGD; Obscure gastrointestinal bleeding; Superselective angiography; LTAC; Methylene blue; CT; CTA; SSMA; Angiodysplasia; OGIB; pRBC; AVM; Hb; BRBPR; HD; Arteriovenous malformation; ED
• ISSN: 2210-2612; 2210-2612
• DOI: 10.1016/j.ijscr.2019.10.059

•OGIB can be a diagnostic challenge.•Superselective mesenteric angiography with intraoperative methylene blue injection can be used as an adjunct to pre-existing diagnostic modalities.•Superselective mesenteric angiography can guide surgical intervention to control hemorrhage and limit the amount of bowel resected. Currently available diagnostic tests for localizing the source of gastrointestinal bleeding include esophagogastroduodenoscopy, colonoscopy, push enteroscopy, video capsule endoscopy, deep enteroscopy, nuclear scan, angiography, radiographic contrast studies of the small bowel, intraoperative enteroscopy, and computed tomography scanning. Despite these diagnostic modalities obscure gastrointestinal bleeding (OGIB) can be difficult to localize, making surgical intervention challenging. We report the case of a 78-year-old patient who presented with OGIB, melena and passing bright red blood per rectum, with a hemoglobin of 4.8 g/dl requiring multiple blood transfusions. Initially the source of the bleeding was difficult to identify. Eventually, a preoperative superior mesenteric angiogram was performed, identifying an arteriovenous malformation (AVM) within the small bowel as the source of OGIB. Intraoperative methylene blue was then injected through the previously placed angiogram catheter to further localize the bowel segment with the lesion. Despite multiple diagnostic modalities, OGIB, especially originating in the small bowel, is challenging to localize, making surgical intervention difficult. Methylene blue is frequently used intraoperatively to properly identify anatomic landmarks. In cases of OGIB, superselective mesenteric angiography (SSMA) with intraoperative methylene blue injection can be used as an adjunct to routine diagnostic modalities to guide surgical interventions for controlling hemorrhage and for limiting the extent of bowel resection.