大量下血による出血性ショックより救命しえた空腸ａｎｇｉｏｄｙｓｐｌａｓｉａの１例

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  • Massive Life-threatening Gastrointestinal Bleeding and Shock in a Patient with Angiodysplasia

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A 47-year-old man passed a massive melena and collapsed. When brought to the hospital by ambulance, he recovered consciousness. Shock resuscitation by intravenous therapy including blood was given. Immediate upper-or lower-GI endoscopy to locate the source of the hemorrhage identified no active bleeding site within the reach of the endoscope, which led to a high suspicion of small intestinal bleeding. Angiography or radio nucleotide imaging was not available in the hospital. Nonetheless, the difficulty encountered in stabilizing the hemo dynamics with fluid therapy served as a diagnostic test for detecting continuing bleeding. After preparing for intraoperative enteroscopy, an emergency surgery to prevent death was performed 12 hrs after admission. On laparotomy, a much more voluminous dark reddish content was translucently seen in the jejunum 50cm distal to the ligament of Traitz, where, in the bowel wall, a 1-cm mass was palpated. A pair of intestinal clamps was applied proximal and distal to the mass. Then, very acutely, the clamped segment began to bulge, which precisely localized the actual bleeding site. A 10-cm segment of the bowel including the mass was removed. The resected specimen revealed an exposed blood vessel 4mm in diameter on the mucosa overlying a 1.0×0.9cm submucosal mass. Histopathology of the mass revealed angiodysplasia. Emphasis on the accurate diag nosis of a massive GI bleeding by angiography is irrefutable. Still, in the presence of life-threatening hemor rhage, life-saving surgery should not be postponed even when the exact cause of bleeding is not clear.

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