If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
An 84-year-old man was admitted to our inpatient ward with melena. He had a history of coronary artery disease treated with aspirin and clopidogrel and atrial fibrillation treated with apixaban. Initial laboratory analysis showed a hemoglobin level of 7.7 g/dL; hemoglobin level was normal 1 month before admission.
He underwent EGD and colonoscopy, neither of which revealed the source of bleeding. Video capsule endoscopy revealed many nonbleeding, submucosal, nodular venous malformations from the proximal duodenum to the distal jejunum as well as an area of fresh bleeding in the midjejunum (Fig. 1).
Figure 1Still from video capsule endoscopy showing phlebectasias as blue-tinted, submucosal nodular structures.
During these evaluations, the patient had an ongoing blood transfusion requirement, requiring 1 or 2 units of packed red blood cells daily. CT angiography showed isolated submucosal vascular lesions in the duodenum and jejunum (Fig. 2). There was no obvious vascular supply to suggest varices.
Figure 2CT image of an isolated small-bowel phlebectasia.
Double-balloon enteroscopy revealed the same venous malformations diffusely through the distal duodenum and jejunum (Fig. 3). One of these lesions had a nipple sign and was targeted for cyanoacrylate sclerotherapy (Fig. 4). Cyanoacrylate injection was performed, as shown in Figure 5. The patient’s melena ceased after this intervention, and he required no further transfusions. He was discharged on postprocedure day 2.
Figure 3Still from balloon-assisted enteroscopy showing numerous phlebectasias that are not bleeding.
Cyanoacrylate has been used in the small bowel specifically for venous malformations occurring as ectopic varices and in a case report on blue rubber bleb nevus syndrome.
Double-balloon enteroscopy–facilitated cyanoacrylate-injection endotherapy of small-bowel varices: an international experience from 2 European tertiary centers (with videos).
It was unlikely this patient had the latter syndrome without presentation at a younger age and with a lack of characteristic skin findings. Vascular embolization cannot be used in these cases because no obvious vascular sources can be identified. The technique shown in Video 1 (available online at www.VideoGIE.org) may demonstrate an effective hemostatic therapy for isolated small-bowel phlebectasias.
Disclosure
Dr Ahmed is consultant for Boston Scientific, Cook Medical, and Olympus Corporation of the Americas. Dr Kyanam Kabir Baig is a consultant for Olympus Corporation of the Americas. All other authors disclosed no financial relationships.
Double-balloon enteroscopy–facilitated cyanoacrylate-injection endotherapy of small-bowel varices: an international experience from 2 European tertiary centers (with videos).
30171-5&id=gr1.jpg){kind=link}
30171-5&id=gr2.jpg){kind=link}
30171-5&id=gr3.jpg){kind=link}
30171-5&id=gr4.jpg){kind=link}
30171-5&id=gr5.jpg){kind=link}