Dear Doctor,

Can't you take a selective angiogram of the gastroduodenal artery? Eventually a super-selective angiogram of the upper jejunal-pancreatic artery? You should be able to make a diagnosis. Detected or not a blush , a blind embolisation of the this arterial district should be effective.

Regards,

Giorgio Vasquez.

Thankyou,Angio did not give any clue as it has stopped bleeding .Interventional radiologist wanted to repeat the procedure again at the time of active bleed rather than blind embolisation.Is surgery be considered now or wait ?

A embolizatiin is good idea to management of acute bleadding, but after 1st time, other bleeding occur, indicating increase risk of re-bledding. In this case, after embolization, could be interesting to think about surgery. 

Surgery represent the last resource because may be not exhaustive. Because of this, surgery should be considered on the base of the amount of blood tranfusion,only. To retray conservative/interventional treatment plus oral & IV administration of gross amount of tranexamic acid, almost always resolves the problem.

It is difficult to be sure of lipoma on CT angio only unless endoscopic visualisation is done and lipoma bleeds not very often. Also the exact site of bleed was not properly llocated in this case. If the bleed has stopped the best way to see the intestine is capsule endoscopy or balloon enteroscopy depending on condition of patient. After that decision regarding endoscopic vs surgical management can be taken depending on number, possible type and location of the lesion especially as the patient is relatively young.

First, the presence of the lipoma itself does not provide evidence as the site of hemorrhage. The location is readily accessible by upper endoscopy and should be done at the time of clinical bleeding. If negative, capsule endoscopy and colonoscopy should be completed. Angiography is not likely to be revealing in the absence of acute bleed. Nuclear medicine gi bleeding study would at least help to localize the site of bleed as upper or lower tract. If the site is an ulcerated lipoma in the duo-upper jejunal zone, consideration for surgery as a last resort will be required as the bleed is not likely peptic and the one cannot rule out sarcomatous degeneration of one of the lipomas.

If intervention radiological/ endoscopy fails and pt. continues to bleed ,surgery is indicated as we have experience of one such case turning out finally as Brunner gland hyperplasia.

Turk J Gastroenterol. 2011 Aug;22(4):419-21.

Brunner's gland hyperplasia: an unusual cause of gastrointestinal bleeding.

Wani ML1, Malik AA, Malik RA, Irshad I.

Abstract

A case of Brunner's gland hyperplasia presenting as gastrointestinal bleeding is reported herein. A 40-year-old male presented to our hospital with features of upper gastrointestinal bleeding. The patient had a history of passing black tarry stools for the last two days. Upper gastrointestinal endoscopy was done, which showed a pedunculated polypoid lesion in the second part of the duodenum with active bleeding at the base of the polyp. Adrenaline was injected around the bleeding site; however, the patient continued to bleed. He was taken for surgery. A laparotomy was done, and the duodenum was mobilized and opened. A large pedunculated polyp measuring approximately 2 cm was found with bleeding at the base. Polypectomy was done. Histopathological examination of the specimen showed mature Brunner's gland with normal duodenal mucosa at the surface. Diagnosis of Brunner's gland hyperplasia was made. The patient is under follow-up and is symptom-free.

I remember one bleeding case of gigant lipoma at  second duodenal portion did identify by endoscopy (lipoma more tan 3cm) we did colcated endoloop and the bleeding stoped and after two months the lipoma dissaperaed. I agree with capsule for determinate another  bleeding site and the use enteroscopy.

This is an interesting and difficult problem.

Firstly, recurrence of bleeding implies treatment.

Secondly, medical treatment will, most probably, not be durably sufficient.

Thirdly, endoscopic localization of the lesion is compulsory. I would start with capsule to have a good over-view. In case of a clear-cut result, i.e. a bleeding and/or ulcerated lesion, its elective destruction seems to be the best way. Access to this lesion will probably be possible with a colonoscope which is largely available with numerous usable  devices. 

Fourthly, in case of an ulcerated lipoma, endoscopic treatment is not so easy. As a matter of fact, hot snaring is difficult (high impedance) and dangerous (thin wall). In case of an intermediate or pseudo-pedonculated shape (frequent because ulceration is, usually, the consequence of invaginations) and a normal elasticity under forceps, I would suggest to put a plastic snare, then cut a macro-biopsy with manual setting, high power, pure section, high manual tension on the wire by the endoscopist himself. The remaining of lipoma will be digested after necrosis of its base. If pathology is not perfectly benign (very improbable) : surgery.

In case of multiple lipoma, without certainty of bleeding location, I would treat the largest snarable by the same way and follow.

In the absence of any snarable, probably responsible lipoma, a surgical, sub-mucosal resection will probably be relatively easy, precisely because of the flatness of the lipoma.

Finally, if the problem fails to be solved, I would wait until a new bleeding and perform urgently endoscopy with colono or enteroscope with tatooing. Injection should be large  (1 ml, eliminate any air in the syringe) to allow dye to be visible on the peritoneal side.

Then, elective surgery will treat the responsible lipoma with resection-anastomosis if jejunal or en-coin resection if duodenal.

The probability of 2 lesions bleeding simultaneously is almost 0. In case of recurrence on another lipoma (improbable) the same algorithm can be applied.

correction 2nd part of Duodenum is normal.Nuclear imaging showed mild pooling of isotope at the duodno-jejunal area.

Sorry, I have forgotten to join the explanative file for electrosurgery

Difficult situation! I would wait as patient is currently stable. I have seen Octreoride/ propranolol help in preventing a re-bleed in such a situation by reducing gut venous back-pressure, even when there is no portal hypertension (purely anecdotal). Not aware of any studies supporting this, happy to be educated if there are any...

cannot be sure they are lipomas---could do SBCE and/ or DBE to visualize, bx, but seems like will ultimately need surgery