Successful laparoscopic surgery combined with selective arterial embolization for bleeding due to jejunal angiodysplasia: a case report

Abstract

Background: Angiodysplasia of the gastrointestinal tract is a rare vascular pathology that sometimes causes massive hemorrhage. Angiodysplasias are particularly difficult to find in the small intestine for anatomical reasons, often impeding their diagnosis and treatment. Lesion localization is a major challenge in cases of small bowel bleeding requiring surgical intervention.

Case presentation: The present case was a 52-year-old woman who was urgently hospitalized with repeated tarry stools. Surgical intervention was chosen after conservative treatment failed to improve her condition. The source of bleeding was suspected to be a vascular lesion discovered in the small intestine during a past double-balloon endoscopy. Abdominal contrast computed tomography revealed a jejunal hemorrhage. We chose selective arterial embolization to stabilize her hemodynamics followed by surgical intervention as her treatment plan. Several embolic and contrast agents (cyanoacrylate, indigo carmine, and Lipiodol) were combined to help identify the location of the lesion during surgery. This multi-pronged approach allowed us to localize the lesion under laparoscopic guidance with high confidence and accuracy, and to excise a 6-cm segment of the small intestine. The lesion was histologically diagnosed as angiodysplasia. No re-bleeding has been observed since the operation.

Conclusion: We report our experience with a case of jejunal angiodysplasia, which was localized with selective arterial embolization using an array of embolic and contrast agents, and then excised laparoscopically. Selective arterial embolization with indigo carmine dye to treat small bowel bleeding preoperatively not only makes the surgery safer by stabilizing the patient's hemodynamics, but is also very useful for localizing the lesion intraoperatively.

Keywords: Indigo carmine; Laparoscopic surgery; Selective arterial embolization; Small bowel bleeding; Small intestinal angiodysplasia.

Fig. 1

a Double-balloon endoscopy image. A vascular lesion is visible. b Contrast CT image. Arrow indicates contrast extravasation at the small intestinal wall. c Selective angiography images. Arrow indicates contrast extravasation peripheral to the first jejunal branch of the superior mesenteric artery

Fig. 2

a Intraoperative photograph. The solid arrow indicates the ink tattoo matching the lesion site; the dashed arrow indicates the indigo carmine’s light-blue staining; the dot-dash arrow indicates the cyanoacrylate mass detected by palpation. b Intraoperative fluoroscopic image. Lipiodol accumulation was visualized at the same site using fluoroscopy

Fig. 3

a Excised tissue. A polypoid lesion with a dark-red center is visible. b Histopathological findings. Irregularly dilated blood vessels lined by the endothelium were noted in the submucosal area. There were very few smooth muscles in the vessel wall. The submucosa was edematous, although the inflammatory findings were minor. The mucosal surface was locally eroded (Hematoxylin and Eosin staining, × 2.5)