Contribution of Capsule Endoscopy Early in a Bleeding Episode to Treatment of Small Bowel Angioectasia: A Case Report

Abstract

Background: Recent advances in endoscopic devices such as small bowel capsule endoscopy and balloon-assisted endoscopy have improved the level of medical care for small bowel bleeding. However, treating small bowel angioectasia remains challenging because repeated intermittent bleeding can occur from the multiple minute lesions (about 1 mm in size) that develop in a synchronous and metachronous manner. Here, we report a case of small bowel angioectasia in which capsule endoscopy performed early in a bleeding episode contributed to treatment. Case Summary: A 66-year-old man with suspected small bowel bleeding underwent small bowel capsule endoscopy and balloon-assisted endoscopy with argon plasma coagulation hemostasis for a small intestinal angioectasia. Because small bowel bleeding recurred intermittently after the treatment, small bowel capsule endoscopy and balloon-assisted endoscopy were repeated when there was no bleeding, but no abnormalities were found. Subsequent small bowel capsule endoscopy during a bleeding episode revealed bloody intestinal fluid in the proximal small intestine. Peroral balloon-assisted endoscopy was performed 2 days after SBCE for detailed observation of the small intestinal mucosa at the suspected bleeding site, and there a 1-mm Dieulafoy's lesion with no active bleeding was identified. We performed argon plasma coagulation, and no bleeding was observed thereafter. Conclusions: Small bowel capsule endoscopy immediately after bleeding onset can identify the bleeding source of multiple minute lesions in small bowel angioectasia.

Keywords: argon plasma coagulation; balloon-assisted endoscopy; small bowel angioectasia; small bowel bleeding; small bowel capsule endoscopy.

Figure 1

Small bowel capsule endoscopy findings at first examination. A 2-mm angioectasia (arrows) is apparent in the proximal small intestine, with no bleeding source identified.

Figure 2

Balloon-assisted endoscopy findings at first examination. (a): A 2-mm angioectasia 120 cm distal to the ligament of Treitz in the small intestine with no bleeding source identified; (b): Argon plasma coagulation for the angioectasia.

Figure 3

Small bowel capsule endoscopy findings at third examination. (a): Yellow and transparent intestinal fluid; (b): Boundary where the color of the intestinal fluid changes. Intestinal fluid on the proximal side to the boundary is yellow and transparent, while that on the distal side is bloody; (c): Bloody intestinal fluid.

Figure 4

Balloon-assisted endoscopy findings at third examination. (a): A 1-mm Dieulafoy’s lesion (arrows) 150 cm distal to the ligament of Treitz in the small intestine; (b): Near-field image showing the lesion; (c): Overt bleeding caused by local injection of physiological saline; (d): Argon plasma coagulation for the lesion.