At the Focal Point
needle-knife or electrocautery. Rather, we first and foremost need to be clinicians, think logically before taking action, and make sure that other options or pathologic disease processes are not masking the clinical presentation. Once this has been done, we can then move on to minimally invasive, novel endoscopic techniques. Victoria Gomez, MD Advanced Endoscopic Fellow Mayo Clinic Rochester, Minnesota Massimo Raimondo, MD Associate Editor for Focal Points
Massive obscure bleeding from a jejunal diverticulum (with video)
www.giejournal.org
Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1289
At the Focal Point
A 62-year-old previously healthy woman presented with melena and microcytic anemia. The result of an upper endoscopy was normal, and colonoscopy revealed passage of dark black liquid through the ileocecal valve but no sites of active hemorrhage. During the next 3 days she required transfusion of 7 units of packed red blood cells to maintain her hemoglobin above 9 mg/dL. A technetium-99m-labeled red blood cell scan suggested active bleeding in the left upper quadrant, although subsequent angiography did not reveal extravasation (A). Push enteroscopy revealed retrograde passage of fresh blood and clots in the midjejunum but no source (B). Therefore, anterograde single-balloon enteroscopy was performed, and blood and clot were found to emanate from a single large jejunal diverticulum (C). After copious irrigation, oozing from a visible vessel could be seen in the dome of the diverticulum. A hemoclip was placed at the base of the vessel (D). However, given the vessel’s large diameter, the clip did not entirely encircle it, and subtle
oozing continued. Therefore, several additional hemoclips were deployed from different angles to completely surround and compress the base of the vessel, and hemostasis was achieved (E; Video 1, available online at www. giejournal.org). The patient’s condition became stable, and she was discharged the next day. She had no further bleeding at 6-months’ follow-up. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Arthur Yan, Alex Shindel, James Buxbaum, Division of Gastroenterology and Liver Diseases, University of Southern California, Keck School of Medicine, Los Angeles, California http://dx.doi.org/10.1016/j.gie.2014.11.046
Commentary Overt obscure gastrointestinal bleeding (OGIB) is commonly seen in gastroenterology practice, rarely caused by a jejunal diverticulum. On the basis of the available history, this previously healthy female patient in her seventh decade presented with microcytic anemia, melena, and a fairly acute onset of GI bleeding, requiring an average of 2 packed red blood cells per day over a 3-day period. Statistically arteriovenous malformations (AVMs) remain the most common cause of OGIB in the elderly (O60 years). However, the presentation is yet atypical for an AVM hemorrhage, which usually presents with less acuity. Meckel’s diverticulum and inflammatory bowel disease could be considered but overall are less likely, given the patient’s age. The remaining top diagnoses are small-bowel Dieulafoy ulcers, small-bowel tumors (carcinoid, GI stromal), ulcers caused by nonsteroidal anti-inflammatory drugs, and missed upper GI bleeding sources, including Cameron’s erosion and Dieulafoy lesions. Eventually, the authors diagnosed an actively bleeding, visible vessel in a jejunal diverticulum by single-balloon enteroscopy. The bleeding was successfully treated with placement of hemoclips. Jejunal diverticula are rare lesions of the small bowel, with a prevalence of 0.5% to 2.3% on small-bowel imaging studies and 0.3% to 4.6% in autopsy series. They are incidental findings most commonly found in the proximal small bowel of patients in their sixth and seventh decades. Jejunal diverticula are false diverticula suspected to arise in the setting of increased intraluminal pressure, causing herniation of the mucosa and submucosa through the bowel muscle wall at the weakest side where blood vessels penetrate. Hemorrhage is an adverse event of jejunal diverticula, with approximately 50 documented cases in the literature. Historically, a treatment option was surgical exploration with segmental bowel resection. Since the introduction of device-assisted enteroscopy, case reports and small series have been published demonstrating high success rates for bleeding control with the use of epinephrine injection or placement of hemoclips by single- or double-balloon enteroscopy. Interestingly, the injection of 1 to 3 mL of epinephrine (1:10000) was shown in a case series to be safe, without perforation. Yan and colleagues report the second case in the medical literature of jejunal diverticulum hemorrhage treated successfully with single-balloon enteroscopy in conjunction with hemoclip placement. In summary, this is a very rare presentation of obscure GI bleeding that documents once again the successful advancement of new enteroscopy techniques, providing both diagnostic and therapeutic options, including those for rare causes of small-bowel hemorrhage. Michael Bartel, MD Fellow in Gastroenterology at Mayo Clinic Florida Massimo Raimondo, MD Associate Editor of Focal Points
1290 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
needle-knife or electrocautery. Rather, we first and foremost need to be clinicians, think logically before taking action, and make sure that other options or pathologic disease processes are not masking the clinical presentation. Once this has been done, we can then move on to minimally invasive, novel endoscopic techniques. Victoria Gomez, MD Advanced Endoscopic Fellow Mayo Clinic Rochester, Minnesota Massimo Raimondo, MD Associate Editor for Focal Points
Massive obscure bleeding from a jejunal diverticulum (with video)
www.giejournal.org
Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1289
At the Focal Point
A 62-year-old previously healthy woman presented with melena and microcytic anemia. The result of an upper endoscopy was normal, and colonoscopy revealed passage of dark black liquid through the ileocecal valve but no sites of active hemorrhage. During the next 3 days she required transfusion of 7 units of packed red blood cells to maintain her hemoglobin above 9 mg/dL. A technetium-99m-labeled red blood cell scan suggested active bleeding in the left upper quadrant, although subsequent angiography did not reveal extravasation (A). Push enteroscopy revealed retrograde passage of fresh blood and clots in the midjejunum but no source (B). Therefore, anterograde single-balloon enteroscopy was performed, and blood and clot were found to emanate from a single large jejunal diverticulum (C). After copious irrigation, oozing from a visible vessel could be seen in the dome of the diverticulum. A hemoclip was placed at the base of the vessel (D). However, given the vessel’s large diameter, the clip did not entirely encircle it, and subtle
oozing continued. Therefore, several additional hemoclips were deployed from different angles to completely surround and compress the base of the vessel, and hemostasis was achieved (E; Video 1, available online at www. giejournal.org). The patient’s condition became stable, and she was discharged the next day. She had no further bleeding at 6-months’ follow-up. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Arthur Yan, Alex Shindel, James Buxbaum, Division of Gastroenterology and Liver Diseases, University of Southern California, Keck School of Medicine, Los Angeles, California http://dx.doi.org/10.1016/j.gie.2014.11.046
Commentary Overt obscure gastrointestinal bleeding (OGIB) is commonly seen in gastroenterology practice, rarely caused by a jejunal diverticulum. On the basis of the available history, this previously healthy female patient in her seventh decade presented with microcytic anemia, melena, and a fairly acute onset of GI bleeding, requiring an average of 2 packed red blood cells per day over a 3-day period. Statistically arteriovenous malformations (AVMs) remain the most common cause of OGIB in the elderly (O60 years). However, the presentation is yet atypical for an AVM hemorrhage, which usually presents with less acuity. Meckel’s diverticulum and inflammatory bowel disease could be considered but overall are less likely, given the patient’s age. The remaining top diagnoses are small-bowel Dieulafoy ulcers, small-bowel tumors (carcinoid, GI stromal), ulcers caused by nonsteroidal anti-inflammatory drugs, and missed upper GI bleeding sources, including Cameron’s erosion and Dieulafoy lesions. Eventually, the authors diagnosed an actively bleeding, visible vessel in a jejunal diverticulum by single-balloon enteroscopy. The bleeding was successfully treated with placement of hemoclips. Jejunal diverticula are rare lesions of the small bowel, with a prevalence of 0.5% to 2.3% on small-bowel imaging studies and 0.3% to 4.6% in autopsy series. They are incidental findings most commonly found in the proximal small bowel of patients in their sixth and seventh decades. Jejunal diverticula are false diverticula suspected to arise in the setting of increased intraluminal pressure, causing herniation of the mucosa and submucosa through the bowel muscle wall at the weakest side where blood vessels penetrate. Hemorrhage is an adverse event of jejunal diverticula, with approximately 50 documented cases in the literature. Historically, a treatment option was surgical exploration with segmental bowel resection. Since the introduction of device-assisted enteroscopy, case reports and small series have been published demonstrating high success rates for bleeding control with the use of epinephrine injection or placement of hemoclips by single- or double-balloon enteroscopy. Interestingly, the injection of 1 to 3 mL of epinephrine (1:10000) was shown in a case series to be safe, without perforation. Yan and colleagues report the second case in the medical literature of jejunal diverticulum hemorrhage treated successfully with single-balloon enteroscopy in conjunction with hemoclip placement. In summary, this is a very rare presentation of obscure GI bleeding that documents once again the successful advancement of new enteroscopy techniques, providing both diagnostic and therapeutic options, including those for rare causes of small-bowel hemorrhage. Michael Bartel, MD Fellow in Gastroenterology at Mayo Clinic Florida Massimo Raimondo, MD Associate Editor of Focal Points
1290 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
