A 53 yrs Male was referred to us for the favor of diagnosis and management of occult G.I. bleed leading to drop in Hb. Patient has undergone several OGD scopy and Colonoscopy elsewhere over a period of 11 months and was hospitalized few times for blood transfusions.

Finally when he was referred to us, during careful clinical history, patient did mention that he had passed frank blood in stools once and therefore we considered him for an Ileo-colonoscopy.

On Ileo-colonoscopy we found a small visible superficial ulcer with active oozing in the terminal ileum about 10 cms from the ileo-caecal junction (most likely Dieulafoy lesion). The lesion could be well appreciated on NBI (Narrow Band Imaging) and then in view of the type of pathology we decided to apply haemoclips rather than coagulation with heater probe or other thermal methods. Complete haemostasis was achieved.

Patient was admitted for few days and observed. Now after 1 year of follow up patient has maintained Hb and does not have any episode of malena or frank bleeding per rectum and FOBT is negative.

Expert comments

As we can see that this patient has undergone several endoscopic procedures at different places and terminal ileum was not evaluated in previous colonoscopies done elsewhere. Therefore it is imperative to evaluate terminal ileum. It is a standard protocol at WGI that whenever a patient is referred to us for the favor of Colonoscopy intubation of terminal ileum is attempted in all cases and achieved in most.

Hence it is our policy that if a patient is sent to us for diagnosis of occult G.I. bleed, even if patient has undergone OGD scopy and Colonoscopy elsewhere we feel that it is useful to repeat these procedures again carefully before performing more cost intensive procedures such as Capsule endoscopy or Single/ Double balloon Enteroscopy to look for any bleeding lesion in the small bowel. We preferred hemoclips to thermal coagulation mainly due to technical considerations and usually thin wall of terminal ileum.

 

Take home message: A careful and detailed high resolution ileo-colonoscopy allowed us accurate detection of bleeding site and effective endoscopic treatment. Terminal ileal intubation is mandatory in patients with suspected Occult G.I. bleed.

Oozing seen from a lesion? Dieulofoy’s
In the terminal ileum

On flushing water the lesion started bleeding
Actively

 

 

 

 

 

 

 

 

Actively bleeding lesion seen on NBI

After applying the first hemoclip the lesion
started oozing actively

 

 

 

 

 

 

 

One more hemoclip applied, however the oozing
Persisted and therefore three hemoclips were applied

Follow up ileo-colonoscopy after few days showed Complete hemostasis

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