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Keywords
Angiodysplasia, argon plasma coagulation,
capsule endoscopy, occult bleeding.
Introduction
Occult gastrointestinal bleeding can be
a difficult challenge in clinical medicine. This case demonstrates
the utility of new technologies in the diagnosis and therapy
of occult bleeding separate localities in the gastrointestinal
tract.
Methods for EUS Capture
SVHS tape of endoscopy was digitally captured
using Dazzle Movie Star software. Givens Capsule film clips
were captured using the Givens software. Film clips were combined
using Adobe Premiere 6.0.
Case/Body
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| Figure
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Figure
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Video
Clip 1: A combined video clip showing
the colonic bleeding by capsule endoscopy, the
colonic angiodysplasia by colonoscopy and argon
plasma coagulation of the colonic angiodysplasia.
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A 64-year-old man was evaluated for occult
gastrointestinal bleeding. The patient has had chronic transfusion-requiring
blood loss anemia for the previous four years. Evaluations
at three different medical centers including two upper endoscopies,
a barium small bowel follow through, two colonoscopies, and
capsule have all been negative to date.
The patient received transfusions every two to four weeks
to keep his hemoglobin greater than or equal to 10.5 g/dl.
He presented with a hemoglobin was 8.8g/dl and black "like
coal" stools which were new for him.
His past history includes mitral valve replacement and chronic
coumadin therapy, and underlying coronary artery disease.
His physical exam revealed stable vital signs, a mechanical
click consistent with an artificial heart valve, and dark
stool.
An upper endoscopy was performed which was unremarkable. This
was followed by a capsule endoscopy. The capsule endoscopy
revealed active bleeding in the colon (Figure 1). A colonoscopy
was performed, which demonstrated several large angiodysplastic
lesions in the right colon, which were cauterized using argon
plasma coagulation (Video Clip 1). A model from the Visible
Human Interactive Atlas (Figure 2) shows the location of the
bleeding site seen at capsule endoscopy.
The patient seemed to stabilize, but after a few weeks, was
noted to again have a falling hemoglobin. A repeat colonoscopy
showed other large angiodysplastic lesions in the right colon
which were again treated with argon plasma coagulation. Over
the next few weeks, the dark stools persisted, and transfusions
were again required. The patient was admitted in anticipation
of a right hemicolectomy.
On admission, the patient had stable vital signs, dark stools,
a hemoglobin of 7 g/dl, and a prolonged INR at 4.8. Plasma
was given, and his coagulopathy corrected with vitamin K.
The patient was then placed on heparin. Since he was a relatively
high surgical risk, the patient was given a cleansing colonic
preparation and a preoperative capsule endoscopy was performed
(eight weeks after the previous capsule endoscopy) to insure
there were no bleeding sites outside of the anticipated surgical
field.
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| Figure
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Figure
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Video
Clip 2: A combined video clip showing
the duodenal bleeding by capsule endoscopy, the
active duodenal bleeding by upper endoscopy and
argon plasma coagulation of the duodenal bleeding
site.
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Active hemorrhage was seen in the duodenum
by capsule endoscopy (Figure 3). An upper endoscopy revealed
an ongoing bleeding site which was treated with argon plasma
coagulation (Video Clip 2). The Visible Human Interactive
Atlas model of the duodenum shows the location of the bleeding
site seen at endoscopy (Figure 4).
Since the latest treatment, the patient's hemoglobin has remained
stable, and he is now being followed as an outpatient.
Discussion/Summary
Statement
Angiodysplasia is a well-described cause
of bleeding from both the upper and lower gastrointestinal
tract (1-5). If not actively bleeding, the offending site
can be difficult to identify, as these vascular anomalies
are often small and may be multiple.
Our case exemplifies the difficulties in diagnosing this condition,
in that his evaluations at several centers were unremarkable,
despite upper and lower endoscopies and a capsule endoscopy.
Even though this patient had an initial negative capsule endoscopy
at an outside center, this case shows that the advent of capsule
endoscopy has significantly improved the diagnostic abilities
of physicians involved in caring for subjects with occult
bleeding.
The treatment of angiodysplasia has generally been through
thermal methods. Recently, argon plasma coagulation has become
a preferred thermal method to treat bleeding in many centers
(6,7), and appears to be quite effective as shown in our case.
A unique feature of our patient was the documentation of hemorrhage
by capsule endoscopy at two very distinct ends of the gastrointestional
tract at two separate times during the patient's course. The
second capsule endoscopy performed in our center was fortuitous
in finding active bleeding in the duodenum which prevented
a planned right hemicolectomy. Capsule endoscopy has been
recently introduced into clinical practice, and is rapidly
becoming a procedure of choice in the evaluation of occult
gastrointestinal bleeding (8).
Based on the patient's previous course of events, it would
not be surprising if this particular patient returns with
more bleeding in the future. Based on our recent experience,
we would likely begin our next evaluation with capsule endoscopy
in this interesting individual.
References
1. Marwick T, Kerlin P. Angiodysplasia
of the upper gastrointestinal tract. Clinical spectrum in
41 cases.J Clin Gastroenterol. 1986 Aug;8(4):404-7.
2. Clouse RE, Costigan DJ, Mills BA, Zuckerman GR.
Angiodysplasia as a cause of upper gastrointestinal bleeding.
Arch Intern Med. 1985 Mar;145(3):458-61.
3. Descamps C, Schmit A, Van Gossum A. "Missed"
upper gastrointestinal tract lesions may explain "occult"
bleeding. Endoscopy. 1999 Aug;31(6):452-5.
4. Foutch PG. Colonic angiodysplasia.Gastroenterologist. 1997 Jun;5(2):148-56. Review.
5. Sharma R, Gorbien MJ. Angiodysplasia and lower gastrointestinal tract bleeding in elderly patients.Arch Intern Med. 1995 Apr 24;155(8):807-12. Review.
6. Chang YT, Wang HP, Huang SP, Lee YC, Chang MC, Wu MS, Lin JT. Clinical application of argon plasma coagulation in endoscopic hemostasis for non-ulcer non-variceal gastrointestinal bleeding--a pilot study in Taiwan.Hepatogastroenterology. 2002 Mar-Apr;49(44):441-3.
7. Wahab PJ, Mulder CJ, den Hartog G, Thies
JE. Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences.Am J Gastroenterol 2002 Nov;97(11):2776-9.
8. Scapa E, Jacob H, Lewkowicz S, Migdal M, Gat D, Gluckhovski A, Gutmann N, Fireman Z. Initial experience of wireless-capsule endoscopy for evaluating occult gastrointestinal bleeding and suspected small bowel pathology.Arch Intern Med 1995 Apr 24;155(8):807-12.
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