PMC6927056_01
Antegrade double-balloon enteroscopy. A pulsatile submucosal uplift accompanied by a small red patch on the top of the uplift in the jejunum (a). Two clips were placed in close proximity to the submucosal uplift (b).
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On DBE, a pulsatile submucosal uplift, which was accompanied by a small red patch on the top of the uplift without active bleeding, was revealed in the jejunum 30 cm on the anal side from the ligament of Treitz (Figure 1(a)). As an AVM was suspected as the cause of small-bowel bleeding, two clips were placed in close proximity to the submucosal uplift to control the arterial inflow for temporary bleeding prevention, which resulted in disappearance of pulsation and a color change by deterioration of blood flow in the lesion (Figure 1(b)).
Multiple-phase computed tomography. Small vascular ectasias (yellow arrows) during the arterial phase were observed adjacent to the clips (red arrow).
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Multiple-phase CT revealed multiple small vascular ectasias during the arterial phase and their early draining veins adjacent to the clips that had been placed in the jejunum on DBE (Figure 2).
Selective angiography: multifocal niduses were detected in the jejunum and were supplied by the second jejunal arteries (yellow arrows).
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Multifocal niduses were detected adjacent to the clips in the jejunum supplied by the second jejunal arteries (Figure 3).
Intraoperative selective angiography with ICG injection: selective angiography from the second jejunal artery detected multifocal niduses in the jejunum (a). ICG was intraoperatively injected from the second jejunal artery. The region of ICG fluorescence was clearly recognized (b).
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ICG injection. 2.5 mg/ml of ICG in a total volume of 0.2 ml was injected intraoperatively from the second jejunal artery via a selective angiographic microcatheter, which immediately stained a 30 cm segment of the jejunum (Figures 4(a) and 4(b)). ICG fluorescence enabled us to easily and clearly recognize the region and perform a segmental small-bowel resection with the minimal surgical margins.
Histological findings: Elastica van Gieson staining revealed tortuous, dilated veins and arteries in the submucosal layer. The image in the right panel is a magnified view of the red box in the left panel. (a) xmagnifying glass imaging and (b) x40.
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Pathological examination confirmed the presence of AVMs with features of tortuous, dilated veins, and arteries in the submucosal layer (Figure 5).