British Journal of Radiology (2007) 80, e159-e161
© 2007 British Institute of Radiology
doi: 10.1259/bjr/81844727
Pre-operative localization and embolization for jejunal arteriovenous malformation with massive haemorrhage
K-L Liu, MD
1
C-W Lee, MD
1
H-P Wang, MD
2 and
M-T Lin, MD, PhD
3
1 Departments of Medical Imaging, 2 Emergency Medicine, 3 Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
Correspondence: Dr Ming-Tsan Lin, Department of Surgery, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei 100, Taiwan. E-mail: linmt{at}ha.mc.ntu.edu.tw
 |
Abstract
|
|---|
Arteriovenous malformation of the gastrointestinal tract is relatively rare in adults. The most accurate diagnosis is by angiography and pre-operative localization has been reported, including by coil embolization, catheter or guidewire replacement, and intraoperative staining techniques. We report the case of a 20-year-old man with acute and massive small intestinal haemorrhage due to jejunal ateriovenous malformation, which was embolized immediately with N-butyl-2-cyanoacrylate. The technique is rapid and safe under fluoroscopy control and the method can help surgeons with mini-laparotomy or laparoscopic surgery because of the clear localization and stable condition of the patient.
|
Introduction
|
|---|
With excellent medical treatment for ulcer disease and endoscopic management of bleeding gastric and duodenal ulcers, gastrointestinal haemorrhage that comes to surgical therapy is increasingly caused by unusual lesions. We report the case of a 20-year-old man with acute and massive small intestinal haemorrhage due to jejunal ateriovenous malformation, which was embolized immediately with the tissue adhesive agent N-butyl-2-cyanoacrylate (NBCA). Imaging is therefore helpful for the diagnosis of this problem and the use of NBCA may be a very helpful approach to stop the bleeding or to prepare the patient for mini-laparotomy or laparoscopic surgery, as it enables stabilization of the condition and clear localization.
|
Case report
|
|---|
A 20-year-old man presented with sudden onset of bloody stool. He had previously been healthy. Two days before, tarry stool was noted and the panendoscopy revealed no active ulceration. However, sudden onset of bloody stool was noted with anaemia (haemoglobin 4.5 g dL–1), hypoalbuminaemia (albumin 1.8 g dL–1) and thrombocytopenia (platelet count 39 000 µL–1). Colonofibroscopy was performed and the bleeding source was considered to be above the ileocaecal valve. 12 units of packed red blood cells were transfused and he was transferred to our emergency department (ED).
In our ED his blood pressure was 108/49 mmHg and his heart rate was 71 beats min–1. The repeat haemoglobin test showed 8.5 g dL–1 but the platelet count was 34 000 µL–1 because of massive bleeding. Emergency angiography was performed in the afternoon (3:00 PM). The angiogram showed post-shock vasospasm and a large aneurysmal or pseudoaneurysmal dilatation in the right upper quadrant of the abdomen from a small branch of the jejunal artery with active extravasation of contrast medium and clear opacification of small intestinal mucosa without identification of the early draining vein (Figure 1a
). Transcutaneous arterial embolization (TAE) of the bleeder was performed with 40% glue and iodized oil formulation (Histoacryl–Lipiodol), using a 1.7-French microcatheter (Excelsior SL-10, 1.7-F; Boston Scientific, Natick, MA) at a highly selective branch (Figure 1b). This mixture was prepared by drawing 0.6 ml Lipiodol and 0.4 ml Histoacryl into a 1 ml syringe and then inverting the syringe several times until the components are well mixed. After flushing the microcatheter and hub with 5% glucose, the mixture of glue was delivered slowly until the bleeder filled with glue or regurgitation occurred (Figure 1c).
View larger version (72K):
[in this window]
[in a new window]
|
Figure 1. A 20-year-old young man presented with acute and massive haemorrhage with bloody stool. (a) The superior mesenteric angiogram shows an aneurysmal dilation (arrow) at the right upper abdomen from the jejunal branch. The bowels are distended and the jejunum is rotated to the right upper abdomen. (b) A 1.7-French microcatheter (arrow) is inserted into the distal end of the feeding artery. The bleeder is opacified by the contrast medium. (c) After embolization, the 40% glue solution (Histoacryl–Lipiodol) is retained and confined in the bleeder (arrow). (d) An immediate post-transcutaneous arterial embolization non-enhanced CT scan was performed to exclude the possible etiology of tumour bleeding. There is a dense radiopaque density (arrow) in the jejunum due to glue accumulation, but no definite tumour mass around the glue can be identified. (e) A vascular malformation (arrow) is noted at the submucosal layer with protrusion intraluminally (x10, H&E stain). No evidence of a tumour can be identified.
|
|
Before carrying out this procedure the possibility of segmental infarction of the small bowel was explained to the family. The active extravasation was completely stopped on the post-embolization angiograms, including the jejunal branch and superior mesenteric artery angiograms. From the arterial puncture to the end of the post-TAE angiography, the total time was 40 min, with the fluoroscopy time being 24.48 min.
An immediate, non-enhanced CT scan was performed to exclude the possibility of a small intestinal tumour. Dense glue accumulation was identified in the jejunum but no definite tumour mass was visible around it (Figure 1d
). Profuse blood clots mixed with extravasated contrast medium in the small bowels were also found, consistent with massive haemorrhage. After embolization, the vital signs were stable. The patient was admitted to the ward.
However, bloody stool occurred again (8:00 PM). Although the vital signs were stable, it was decided to perform emergent surgery with a mini-laparotomy with an approximately 4–5 cm incision wound. A localized bruise appearance was clearly identified in a segment of jejunum, about 160 cm away from Treitz's ligament. It was well localized by visualization, without the need for palpation or intraoperative endoscopy. In the specimen, a mass of about 1.5 cm was disclosed intraluminally. There were many blood clots within the small intestine but no obvious fresh blood was noted. The bloody stool was considered as the retained hematoma before TAE. Segmental resection with end-to-end anastomosis was performed. The patient was discharged uneventfully 7 days after surgery. Before discharge, laboratory data revealed a haemoglobin score of 10.5 g dL–1, platelet count of 284 000 µL–1 and albumin score of 3.5 g dL–1.
The pathological findings revealed that the submitted specimen was 8.3 cm in length. Microscopically, aneurysmal dilatation of the vein with perforation was discerned by an attenuated elastic lamina under orcein and Masson's trichrome stains (Figure 1e). The picture was compatible with vascular malformation with bleeding. The mesentery was unremarkable.
|
Discussion
|
|---|
Arteriovenous malformation of the gastrointestinal tract is relatively rare in adults, although it has been reported from the stomach to the rectum [1, 2]. Clinical symptoms can include acute massive haemorrhage, chronic gastrointestinal bleeding, perforation or haemoperitoneum. The most accurate diagnostic methods are angiography [1], endoscopy, exploratory laparotomy or intraoperative endoscopy. A bleeding scintigraphy can be helpful in chronic cases without a definite source. Other reported diagnostic methods include CT [3] and enteroclysis. Pre-operative localization includes angiography, coil embolization [4], catheter, guidewire and intraoperative staining techniques [5]. For acute and massive gastrointestinal haemorrhage, immediate embolization can stop bleeding and maintain vital signs of positive bleeders. The patients are usually in shock status, which may result in the microcoils being unable to be pushed into the distal bleeders. Although the majority of cases embolized with NBCA can also be embolized with microcoils, using the liquid embosylate NBCA can enable a smaller microcatheter to be inserted more easily into the distal branch and the embolization can be performed more rapidly and completely. If the bleeder can be embolized completely until glue extravasation, the possibility of re-bleeding from collateral vessels is decreased. In addition, pre-operative embolization stabilizes vital signs and the pre-operative localization results in easier patient management, so the mini-laparotomy or laparoscopic surgery can be performed with a minimal segment of bowel resection; in our case, a minimal segmental resection of only 8 cm jejunum was achieved.
NBCA has been used in the treatment of arteriovenous malformations intra- and extracranially for many years. It has been used to embolize intracranial arteriovenous malformations in our institute for many years with favourable outcomes [6]. However, it has so far rarely been applied in the gastrointestinal tract except for variceal bleeding. In this case, the bleeder was completely embolized with NBCA and the "re-bleeding" was considered as previously retained blood because of the stable vital signs and intraoperative findings of no fresh blood. NBCA may be an alternative choice for treatment of acute and massive bleeding in the gastrointestinal tract as it is an easy and rapid method [7].
Received for publication October 12, 2005.
Revision received January 17, 2006.
Accepted for publication March 6, 2006.
|
References
|
|---|
- Kurihara H, Mochizuki H, Yamamoto S, Tamakuma S, Makita K, Furui S, et al. Massive intestinal bleeding caused by an ileal arteriovenous malformation: report of a case. Surg Today 1994;24:552–5.[CrossRef][Medline]
- Eastman J, Nazek M, Mangels D. Localized arteriovenous malformation of the jejunum. Arch Pathol Lab Med 1994;118:181–3.[Medline]
- Nakabayashi T, Kudo M, Hirasawa T, Kuwano H. Arteriovenous malformation of the jejunum detected by arterial-phase enhanced helical CT, a case report. Hepatogastroenterology 2004;51:1066–8.[Medline]
- Kandarpa K, Fellows KE, Eraklis A, Flores A. Solitary ileal arteriovenous malformation: preoperative localization by coil embolization. AJR Am J Roentgenol 1986;146:787–8.[Free Full Text]
- Crawford ES, Roehm JO, Jr, McGavran MH. Jejunoileal arteriovenous malformation: localization for resection by segmental bowel staining techniques. Ann Surg 1980;191:404–9.[Medline]
- Liu HM, Huang YC, Wang YH. Embolization of cerebral arteriovenous malformations with n-butyl-2-cyanoacrylate. J Formos Med Assoc 2000;99:906–13.[Medline]
- Tai CM, Liu KL, Chen CC, Lin JT, Wang HP. Lateral abdominal wall hematoma due to tear of internal abdominal oblique muscle in a patient under warfarin therapy. Am J Emerg Med 2005;23:911–2.[CrossRef][Medline]
Top
Abstract
Introduction
