Management of Multiple Arteriovenous Malformations of the Small Bowel

Abstract

A 62-year-old Japanese female was referred to our hospital with gastrointestinal bleeding. Although small-bowel bleeding was suspected, no bleeding source was identified by enhanced computed tomography (CT), video capsule endoscopy (VCE), and double-balloon enteroscopy (DBE). Five years later, the patient had recurrent intermittent bloody stools with a significant decrease in hemoglobin levels. Although no active bleeding was observed on antegrade DBE, we detected a pulsatile submucosal uplift accompanied by a small red patch on the top of the uplift in the jejunum. Arteriovenous malformation (AVM) was suspected as the cause of small-bowel bleeding. Multiple-phase CT showed a number of small vascular ectasias during the arterial phase in the jejunum, and we confirmed the presence of multiple AVMs in the jejunum by selective angiography. To identify the location of the lesions and determine the minimal surgical margins, we performed intraoperative selective angiography with indocyanine green (ICG) injection. This technique allowed us to clearly observe the region and perform segmental small-bowel resection with minimal surgical margin. The patient reported that she has had no gastrointestinal bleeding at the two years follow-up visit.

Figure 1

Antegrade double-balloon enteroscopy. A pulsatile submucosal uplift accompanied by a small red patch on the top of the uplift in the jejunum (a). Two clips were placed in close proximity to the submucosal uplift (b).

Figure 2

Multiple-phase computed tomography. Small vascular ectasias (yellow arrows) during the arterial phase were observed adjacent to the clips (red arrow).

Figure 3

Selective angiography: multifocal niduses were detected in the jejunum and were supplied by the second jejunal arteries (yellow arrows).

Figure 4

Intraoperative selective angiography with ICG injection: selective angiography from the second jejunal artery detected multifocal niduses in the jejunum (a). ICG was intraoperatively injected from the second jejunal artery. The region of ICG fluorescence was clearly recognized (b).

Figure 5

Histological findings: Elastica van Gieson staining revealed tortuous, dilated veins and arteries in the submucosal layer. The image in the right panel is a magnified view of the red box in the left panel. (a) ×magnifying glass imaging and (b) ×40.