ISSN: 2754-8880
Published 00 11 0000
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Edited by
A.Hussain
Submitted 10 Dec. 2022
Accepted 10 Dec. 2022
Citation
M. Hairulhazuan H, S T
Sambanthan, N. R.
Kosai.Extensive Small Bowel
Ulcers With Overt
Haemorrhage Secondary To
Nsaid Usage, A Case
Report.:BJOSS::2022:(3);104-
107
Extensive Small Bowel Ulcers With Overt
Haemorrhage Secondary To Nsaid Usage, A
Case Report.
M. Hairulhazuan H
1*
, S T Sambanthan
1
, and N. R. Kosai
1
1
Department of General Surgery, Hospital Canselor Tuanku Muhriz, Cheras, Malaysia
*
Corresponding author: E-mail: wackadoodle23@gmail.com
O R IGI N A L
Abstract
Lower gastrointestinal bleeding can be defined as bleeding from the gastrointestinal tract distal
to the ligament of Treitz. Small bowel bleeding accounts for about 5% of the total case of
gastrointestinal bleeding. Angioectasia is the commonest cause of small bowel bleeding accounting
for 30-40% of cases, with a strong association with liver cirrhosis and cardiovascular disease.
NSAID-induced small bowel injury has long been known, but the occurrence of overt bleeding has
been unclear according to a study. With that in mind, I would like to report a case of massive small
bowel bleeding due to extensive small bowel ulceration which was confirmed with intraoperative
enteroscopy and bowel resection specimen. This case report highlights the extensive damage of
NSAID usage and the management of complicated lower gastrointestinal bleeding.
Keywords : Lower Gastrointestinal bleeding, small bowel ulcers, NSAID
Introduction
Lower gastrointestinal bleeding can be defined as bleeding from the gastrointestinal tract distal
to the ligament of Treitz. It can manifest as either occult or overt bleeding. Hematochezia is a
pathognomonic clinical presentation. However, melena may occur in the case of small bowel or
proximal colon bleeding. Small bowel pathology must be suspected in the absence of bleeding
during upper and lower endoscopy.
Management of gastrointestinal bleeding mainly depends on a few factors such as the hemo-
dynamic status of the patient and the site of bleeding. Despite a few algorithms and treatment
modalities has been established for the management of gastrointestinal bleeding, local availability
of facilities, clinician judgment and experience must be taken into consideration while facing the
complicated situation. This case report highlights the extensive damage of NSAID usage and the
management of complicated lower gastrointestinal bleeding.
Case Report
An 84-year-old lady presented to us with a short history of per rectal bleeding. Prior to this
presentation, she gave a history of prolonged NSAID use for her arthritis for more than 2 weeks.
Upon assessment, she was hemodynamically unstable with hypotension. Per abdomen was
unremarkable and per rectal examination revealed a large amount of altered blood. The patient
received a massive amount of blood product due to hemodynamic instability. The provisional
diagnosis was upper GI bleed.
An urgent OGDS was performed within 24 hours of presentation and it was unremarkable. A
colonoscopy was performed and blood clots were seen throughout the colon, with a pooling
of blood seen from the terminal ileum. An urgent computed tomography angiography of the
mesenteric vessels failed to the localized bleeding point. She was brought to the operating theatre
for an exploratory laparotomy.
Intraoperatively, the outer small bowel appears healthy with no signs of chronic inflammation.
An enteroscopy examination through enterotomy shows multiple ulcers throughout the small
bowel mostly at the distal ileum. Limited right hemicolectomy, small bowel resection, and double
barrel stoma due to extensive bleeding and ulcers at the distal ileum. Postoperatively, the patient
developed persistent bleeding from the proximal stoma and CTA mesentery was repeated. 2
bleeders were identified from proximal and distal branches of the superior mesenteric artery, likely
from the jejunal branch. The distal branch of the jejunal vessel was angio-embolized using 20%
glue while the proximal branch was angio-embolized using 45-150micron Polyvinyl alcohol (PVA).
Post-angioembolization shows no further arterial blush during an angiogram. Post-procedure,
bleeders from small bowel resolved.
Gross specimen examination and histopathological findings
The gross specimen shows multiple skipped punch-out ulcers throughout the small bowel. There
is no sign of stricture seen from outside and as well as inside the bowel. Histopathology findings
show acute multiple small bowel ulceration with dense acute inflammation. There is also the
presence of abnormal muscularised submucosal vessels. No evidence of vasculitis, fungal infection,
acid-fast organism, granuloma, dysplasia, or malignancy was seen.
Figure 1. Unopened Limited Right Hemicolectomy With Small Bowel Resection Specimen (No
Sign Of Stricture From Outside
105/107
Figure 2. Opened Limited Right Hemicolectomy And Small Bowel Resection Specimen With
Labelled Showing Multiple Ulcers
Discussion
Small bowel bleeding accounts for about 5% of the total case of GI bleeding (
1
). Angioectasia
is the commonest cause of small bowel bleeding accounting for 30-40% of cases, with a strong
association with liver cirrhosis and cardiovascular disease (
2
;
3
). Usage of NSAID has been
associated with small bowel mucosal injury in about 20% of patient who has been taking NSAID in
one of the hospital-based study (
4
). Even though a small multicentre study shows the occurrence
of overt bleeding is statistically not significant (
5
), the occurrence and possible complication of
the event still cannot be ignored. Initial risk assessment and resuscitation are the earliest steps
that need to be taken prior to any imaging, endoscopic, or surgical intervention (
6
;
1
). Small bowel
bleeding must be suspected if the index upper and lower scope shows no significant finding. The
role of repeat OGDS and colonoscopy has been proposed in the latest AGC updated guideline
of small bowel bleeding in 2016. This is due to the percentage of missed GI lesions being about
25-60% of cases, with angiodysplasia being the commonest missed lesion (7).
Enteroscopy examination has been customarily performed through an oral approach. However, in
certain cases such as incomplete distal small bowel examination or Chron’s disease where colonic
and small bowel examination is needed, retrograde enteroscopy and capsular endoscopy can be
used to visualize the bowel segment (
1
). In the retrograde approach, which was considered more
challenging than the antegrade procedure, the rate of the successful procedure was documented
to be only 21% compared to 2% in the antegrade procedure. The success rate declined if the
patient is having previous abdominal or pelvic surgery (8).
CT angiography has become one of the modalities to determine the site of gastrointestinal
bleeding. It has a sensitivity of 89% and a specificity of 85% in detecting the extravasation of
blood (
9
). Extravasation of blood can be detected as low as 0.3-0.5ml/min (
10
). However, CT
angiography is only able to pick up ongoing active bleeding and this has become a limitation if
bleeding is intermittent, or the bleeding rate is slow.
106/107
Conclusion
Hemorrhage caused by extensive small bowel ulceration can be potentially lethal for the patient
if it’s not treated accordingly. NSAID has been associated with the development of small bowel
ulcers by various literature. However, its association with the development of overt bleeding
is still unclear. Thus judicious usage of NSAID must be emphasized to avoid possible serious
complication.
Conflict Of Interest
All authors declare no conflict of interest of any kind.
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