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Methylene Blue Enteric Mapping for Intraoperative Localization in Obscure Small Bowel Hemorrhage: Report of a New Technique and Literature Review

Combined Intraoperative Methylene Blue Mapping and Enterectomy

  • Case Report
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Small bowel sources of obscure gastrointestinal bleeding present both a diagnostic and therapeutic challenge. Due to the normal external appearance of the vast majority of small bowel lesions that cause obscure gastrointestinal bleeding, multiple methods of intraoperative localization have been reported. When an arteriographic abnormality is found, the use of vital dye enteric mapping is one of the most effective localization techniques.

Case Report

We present a new technique combining superselective mesenteric angiography with methylene blue enteric mapping and small bowel resection performed during the same operative procedure. This technique was successfully applied in a patient with a jejunal arteriovenous malformation. Included is a review of methods of intraoperative localization with a focus on vital dye staining-guided enterectomy.

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References

  1. Raju GS, Gerson L, Das A, Lewis B. American gastroenterological association (AGA) institute technical review on obscure gastrointestinal bleeding. Gastroenterology 2007;133:1697-717.

    Article  PubMed  Google Scholar 

  2. Eshpuniyani PB, Kantharia CV, Prabhu RY, Supe AN. Intraoperative localization of vascular malformation of small bowel by selective intra-arterial dye injection. Saudi J Gastroenterol 2010;16:302-4.

    Article  PubMed  Google Scholar 

  3. Meyer CT, Troncale FJ, Galloway S, Sheahan DG. Arteriovenous malformation of the bowel: an analysis of 22 cases and a review of the literature. Medicine (Baltimore) 1981;60:36-48.

    Article  CAS  Google Scholar 

  4. Moore JD, Thomson NW, Appelman HD, Foley D. Arteriovenous malformations of the gastrointestinal tract. Arch Surg 1976;111:381-9.

    Article  PubMed  CAS  Google Scholar 

  5. Marwick T, Kerlin P. Angiodysplasia of the upper gastrointestinal tract, clinical spectrum in 41 cases. J Clin Gastroenterol 1986;8:404-7.

    Article  PubMed  CAS  Google Scholar 

  6. Richter JH, Christensen MR, Colditz GA, Nishioka NS. Angiodysplasia: natural history and efficacy of therapeutic interventions. Dig Dis Sci 1989;34:1542-6.

    Article  PubMed  CAS  Google Scholar 

  7. Richter JH, Hedberg SE, Athanasoulis CA, Shapiro RH. Angiodysplasia: clinical presentation and colonoscopic diagnosis. Dig Dis Sci 1984;29:481-5.

    Article  PubMed  CAS  Google Scholar 

  8. Lau WY, Chu KW, Yuen WD, Poon GP, Li AK. Bleeding angiodysplasia of the gastrointestinal tract. Aust N Z J Surg 1992;62:344-9.

    Article  PubMed  CAS  Google Scholar 

  9. Lewis BS, Waye JD. Chronic gastrointestinal bleeding of obscure origin: role of small bowel enteroscopy. Gastroenterology 1988;94:1117-20.

    PubMed  CAS  Google Scholar 

  10. Folger R, Golembe E. Methylene blue injection. An intraoperative guide in small bowel resection for arteriovenous malformation. Arch Surg 1978;113:194-5.

    Article  Google Scholar 

  11. Bambach CP, Coupland GA, Sorby W, Roche J. Angiodysplasia of the small bowel: a method of intraoperative identification. Aust N Z J Surg 1978;48:317-21.

    Article  PubMed  CAS  Google Scholar 

  12. Rubio PA, Farrell EM. A new technique for identifying bleeding diverticula of the small bowel utilizing methylene blue infusion. Surgery 1980;86:764.

    Google Scholar 

  13. Athanasoulis CA, Moncure AC, Greenfield AJ, Ryan JA, Dodson TF. Intraoperative localization of small bowel bleeding sites with combined use of angiographic methods and methylene blue injection. Surgery 1980;87:77-84.

    PubMed  CAS  Google Scholar 

  14. Crawford ES, Roehm JO Jr, McGavran MH. Jejunoileal arteriovenous malformation. Localization for resection by segmental bowel staining techniques. Ann Surg 1980;191:404-9.

    Article  PubMed  CAS  Google Scholar 

  15. Beaton HL. Small intestinal bleeding. Method for intraoperative localization. N Y State J Med 1982;82:171-4.

    PubMed  CAS  Google Scholar 

  16. Becker GJ, Park HM, O’Connor KW, Tarver RD, Scott JA, Jackson VP, Lappas JC, Broadie TA, Holden RW. Portal hypertension due to jejunal vascular malformation. Gastrointest Radiol 1985;10:349-51.

    Article  PubMed  CAS  Google Scholar 

  17. Zuckerman DA, Gaz RD. Catheter-guided intraoperative localization of a jejunal angiodysplasia using the Tracker-18 coaxial catheter system: case report. Cardiovasc Intervent Radiol 1991;14:358-9.

    Article  CAS  Google Scholar 

  18. Lau WY, Yuen WK, Chu KW, Poon GP, Li AK. Obscure bleeding in the gastrointestinal tract originating in the small intestine. Surg Gynecol Obstet 1992;174:119-24.

    PubMed  CAS  Google Scholar 

  19. Ohri SK, Jackson J, Desa LA, Spencer J. The intraoperative localization of the obscure bleeding site using fluoroscein. J Clin Gastroineterol 1992;14:331-4.

    Article  CAS  Google Scholar 

  20. McDonald ML, Farnell MB, Stanson AW, Ress AM. Preoperative highly selective catheter localization of occult small-intestinal hemorrhage with methylene blue. Arch Surg 1995;130:106-8.

    Article  PubMed  CAS  Google Scholar 

  21. Schrodt JF, Bradford WR. Presurgical angiographic localization of small bowel bleeding site with methylene blue injection. J KY Med Assoc 1996;94:192-5.

    PubMed  CAS  Google Scholar 

  22. Phillips DA, Wertheimer MD, Patwardhan N, Swanson R, Zawacki J. Preoperative angiography and embolization of the site of intermittent acute small bowel bleeding with a radiopaque microcoil: facilitated precise surgical excision of the source. Surgery 1996;119:714-7.

    Article  PubMed  CAS  Google Scholar 

  23. Defreyne L, Verstraeten V, De Potter C, Pattyn P, De Vos M, Kunnen M. Jejunal arteriovenous malformation, diagnosed by angiography and treated by embolization and catheter-guided surgery: case report and review of literature. Abdom Imaging 1998;23:127-31.

    Article  PubMed  CAS  Google Scholar 

  24. Mazziotti MV, Muldowney S, Darcy M, Hackett BP, Skinner MA. Intraoperative localization of small intestinal bleeding in an infant by methylene blue injection: a case report. J Pediatr Surg 1998;33:754-5.

    Article  PubMed  CAS  Google Scholar 

  25. Robinson MH, Hussain SA. Selective angiographic catheterisation for jejunal angiodysplasia Postgrad Med J 2001;77:205.

    Article  PubMed  CAS  Google Scholar 

  26. Schechter S, Deorchis D, Bass J, Marcoux DA. Angiographic selective methylene blue staining of an occult small-bowel arteriovenous malformation. Am Surg 2002;68:15-7.

    PubMed  Google Scholar 

  27. Remzi FH, Dietz DW, Unal E, Levitin A, Sands MJ, Fazio VW. Combined use of preoperative provocative angiography and highly selective methylene blue injection to localize an occult small-bowel bleeding site in a patient with Crohn’s disease. Report of a case. Dis Colon Rectum 2003;46:260-3.

    Article  PubMed  Google Scholar 

  28. Pasupathy S, Lau TN, Chia KH. Methylene blue injection to localize the site of small intestinal hemorrhage. ANZ J Surg 2004;74:1133-4.

    Article  PubMed  Google Scholar 

  29. Mukai M, Ibusuki K, Gotoh T, Yamamoto A, Nakashima K, Mutoh M, Taniquchi S, Kawano M, Kihara Y, Koga K. Intraoperative fluoroscopic detection of an occult jejunal arteriovenous malformation. J Laparoendosc Adv Surg Tech 2006;16:45-7.

    Article  Google Scholar 

  30. Stauffer JA, Shaddix KK, Achem SR, Stark M, Adelson A, Metzger PP, Landmann RG. Intra-operative use of super-selective or highly selective angiography with methylene blue injection to localize arterial-venous malformation. Colorectal Dis 2011;13:e65-6.

    Article  PubMed  CAS  Google Scholar 

  31. Scherer K, Bircher AJ, Figueiredo V. Blue dyes in medicine—a confusing terminology. Contact Dermatitis 2006;54:231-2.

    Article  PubMed  Google Scholar 

  32. Jasinski RW, Smith DC, Chase DR, Field FL. Angiographic preoperative bowel segment localization using methylene blue, isosulfan blue, and fluoroscein. Invest Radiol 1987;22:462-6.

    Article  PubMed  CAS  Google Scholar 

  33. Lau WY, Wong SY, Ngan H, et al. Intra-operative localization of bleeding small intestinal lesions. Br J Surg 1988;76:249-51.

    Article  Google Scholar 

  34. Richardson JD, Max MH, Flint LM Jr, Schweisinger W, Howard M, Aust JB. Bleeding vascular malformations of the intestine. Surgery 1978;84:430-6.

    PubMed  CAS  Google Scholar 

  35. Boley SJ, Sammartano R, Adams A, DiBiase A, Kleinhaus S, Sprayregen S. On the nature and etiology of vascular ectasias of the colon. Gastroenterology 1977;72:650-60.

    PubMed  CAS  Google Scholar 

  36. Baum S, Athanasoulis CA, Waltman AC, Galdabini J, Schapiro RH, Warshaw AL, Ottinger LW. Angiodysplasia of the right colon. A cause of gastrointestinal bleeding. AJR Am J Roentgenol 1977;129:789-94

    PubMed  CAS  Google Scholar 

  37. Retzlaff JA, Hegldorn AB, Bartholomew LG. Abdominal exploration for bleeding of obscure origin. JAMA 1961;177:104-7.

    Article  PubMed  CAS  Google Scholar 

  38. Reed DK, Porter LE, Zajko AB, Moore SF, Bron KM, Van Thiel DH. Pre- and intraoperative localization of small bowel arteriovenous malformation. J Clin Gastroenterol 1986;8:166-70.

    Article  PubMed  CAS  Google Scholar 

  39. Nazem Z, Petrocelli J, Hobson RW. Arteriovenous malformations of the cecum: operative localization by Doppler ultrasound. Am Surg 1979;45:538-40.

    Google Scholar 

  40. Pinkerton JA. Intraoperative Doppler localization of intestinal arteriovenous malformation. Surgery 1979;85:472-4.

    PubMed  Google Scholar 

  41. Evans WE, O’Dorisio TM, Molnar W, Martin EW Jr, Wooley CF, Cooperman M. Intraoperative localization of arteriovenous malformation. Arch Surg 1978;113:410-2.

    Article  PubMed  CAS  Google Scholar 

  42. Fazio VW, Zelas P, Weakley FL. Intraoperative angiography and the localization of bleeding from the small bowel. Surg Gynecol Obstet 1980;151:637-40.

    PubMed  CAS  Google Scholar 

  43. Alfidi RJ, Esseltyn CD, Tarar R, Klein HJ, Hermann RE, Weakley FL, Turnbull RB Jr. Recognition and angio-surgical detection of arteriovenous malformation of the bowel. Ann Surg 1971;174:573-82.

    Article  PubMed  CAS  Google Scholar 

  44. 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.

    PubMed  CAS  Google Scholar 

  45. Schmidt SP, Boskind JF, Smith DC, Catalano RD. Angiographic localization of small bowel angiodysplasia with use of platinum coils. J Vasc Interv Radiol 1993;4:737-9.

    Article  PubMed  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Vascular Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX, USA

    Shaun M. Gifford & Michael A. Peck

  2. Department of General Surgery, Womack Army Medical Center, Fort Bragg, NC, USA

    Angel M. Reyes

  3. Division of Trauma and Acute Care Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX, 78234, USA

    Jonathan B. Lundy

Authors
  1. Shaun M. Gifford
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  2. Michael A. Peck
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  3. Angel M. Reyes
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  4. Jonathan B. Lundy
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Correspondence to Jonathan B. Lundy.

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Gifford, S.M., Peck, M.A., Reyes, A.M. et al. Methylene Blue Enteric Mapping for Intraoperative Localization in Obscure Small Bowel Hemorrhage: Report of a New Technique and Literature Review. J Gastrointest Surg 16, 2177–2181 (2012). https://doi.org/10.1007/s11605-012-1964-9

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  • DOI: https://doi.org/10.1007/s11605-012-1964-9

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