Massive Life-threatening Gastrointestinal Bleeding and Shock in a Patient with Angiodysplasia

Yukihiro Itabashi¹⁾²⁾, Toshiaki Baba¹⁾²⁾, Satoru Kato¹⁾ and Mutsuo Sasaki²⁾

Division of Surgery, Tsugaru Adult Disease Center Hospital¹⁾
Department of Surgery, Hirosaki University School of Medicine and Hospital²⁾

A 47-year-old man passed a massive melena and collapsed. When brought to the hospital by ambulance, he recovered consciousness. Shock resuscitation by intravenous therapy including blood was given. Immediate upper-or lower-GI endoscopy to locate the source of the hemorrhage identified no active bleeding site within the reach of the endoscope, which led to a high suspicion of small intestinal bleeding. Angiography or radio nucleotide imaging was not available in the hospital. Nonetheless, the difficulty encountered in stabilizing the hemodynamics with fluid therapy served as a diagnostic test for detecting continuing bleeding. After preparing for intraoperative enteroscopy, an emergency surgery to prevent death was performed 12 hrs after admission. On laparotomy, a much more voluminous dark reddish content was translucently seen in the jejunum 50 cm distal to the ligament of Traitz, where, in the bowel wall, a 1-cm mass was palpated. A pair of intestinal clamps was applied proximal and distal to the mass. Then, very acutely, the clamped segment began to bulge, which precisely localized the actual bleeding site. A 10-cm segment of the bowel including the mass was removed. The resected specimen revealed an exposed blood vessel 4 mm in diameter on the mucosa overlying a 1.0×0.9 cm submucosal mass. Histopathology of the mass revealed angiodysplasia. Emphasis on the accurate diagnosis of a massive GI bleeding by angiography is irrefutable. Still, in the presence of life-threatening hemorrhage, life-saving surgery should not be postponed even when the exact cause of bleeding is not clear.

Key words
angiodysplasia, intestinal bleeding, massive GI bleeding

Reprint requests
Yukihiro Itabashi Department of Surgery, Hirosaki University School of Medicine
5 Zaifu-cho, Hirosaki, 036-8562 JAPAN

Accepted
December 16, 2005

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