Case Author(s): Jerold Wallis , 1/16/97 . Rating: #D2, #Q4

Diagnosis: Small bowel GI bleeding site

Brief history:

History of blood per rectum. Multiple negative GI bleeding studies in the past.

Images:

Anterior images at two minute time intervals

View main image(gi) in a separate image viewer

Full history/Diagnosis is available below

Diagnosis: Small bowel GI bleeding site

Full history:

The patient has had multiple hospital admissions for GI bleeding, with workup (including prior GI bleeding scintigraphies) negative on prior admissions.

On this admission, the patient was again admitted again with blood per rectum, but appeared to have stopped bleeding the following day. Given the multiple negative prior exams and repeated hospitalizations, a decision was made to administer heparin during the current study, in a closely monitored setting.

Radiopharmaceutical:

Tc-99m labeled red blood cells, i.v.

Findings:

Part way through the examination, a bleeding focus is seen in the mid upper abdomen. Based on these images, this was felt to represent a proximal small bowel source, as the activity appears more diffuse than would be expected for a transverse colon source.

Subsequent images (not shown) show progressive transit through small bowel to the cecum.

Discussion:

Cine of GI bleeding studies is valuable in helping identify bleeding sites. Bleeding is frequently intermittent, and observation for relatively long times (e.g. 90 minutes) is frequently needed.

As in this case, anticoagulation may occasionally be useful in a patient with multiple bleeding events that otherwise elude diagnosis.

Followup:

The patient underwent angiography, which confirmed a mid-jejunal bleeding source. Dye was injected for subsequent operative localization.

The patient then had resection of a small portion of the jejunum, and pathology revealed an arterio-venous malformation with a small overlying mucosal ulcer.

Major teaching point(s):

Cine display of GI bleeding studies is useful

Bleeding is frequently intermittent.

Continued imaging after initial visualization of a bleeding focus with following of the blood through the bowel lumen may be needed to anatomically localize the bleeding site. While one is still imaging to help in localization of an observed active bleeding site, remember to check the patient's blood pressure and notify the patient's physician in case he/she wants to arrange for angiography.

ACR Codes and Keywords:

References and General Discussion of Gastrointestinal Bleeding Scintigraphy (Anatomic field:Gasterointestinal System, Category:Organ specific)

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Case number: gi004

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