Preoperative
"Two-Way" Enteroscopy, Followed by Intraoperative
Enteroscopy in a Patient with Obscure-Overt Gastrointestinal
Bleeding and Severe Iron-Deficiency Anemia
Adrian Saftoiu1, Tudorel Ciurea1, Ion Georgescu2, Claudia Georgescu3
Department of Internal Medicine, Division of Gastroenterology.
2) 1st Surgical Clinic. 3) Department of Pathology, University
of Medicine and Pharmacy, Craiova
Abstract
We present the case of a 69-year-old woman admitted to hospital
because of chronic gastrointestinal bleeding of an unknown source
with a consequent severe iron deficiency anemia (IDA), undiagnosed
for the past 25 years. In the last three years the episodes
of severe bleeding became frequent, usually followed by melena.
The patient was admitted 11 times in different departments without
the identification of the bleeding source. During the evolution
of the disease, the biological exams showed a severe IDA with
low values of hemoglobin, low serum iron, mixed deficiency depicted
by bone-marrow examination, and a reticulocyte crisis after
parenterally administered iron. Repeated upper (6) and lower
(2) gastrointestinal endoscopies failed to find a source of
bleeding.
Push enteroscopy allowed the visualization of approximately
40 cm of the proximal jejunum, after the Treitz angle, and demonstrated
multiple punctiform jejunal angiodysplasias, which bled excessively
after bipolar coagulation. We also performed a total colonoscopy
with intubation of the ileo-cecal valve and visualization of
the terminal ileum on approximately 30 cm, without any pathological
findings. Because endoscopic treatment was ineffective, we decided
to perform a segmentary enterectomy, with the length of small
bowel resection tailored by intraoperative enteroscopy. A favourable
evolution after limited resection of the small bowel indicated
the importance of both preoperative "two-way" enteroscopy
associated with intraoperative enteroscopy for diagnosing and
treating the source of obscure gastrointestinal bleeding.
Key words
Enteroscopy - gastrointestinal bleeding – anemia
