Turgeon D Kim, Brenner Darren, Brown Richard K J, Dimagno Matthew J
Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Mich., USA.
Case Rep Gastroenterol. 2008 Mar 13;2(1):83-90. doi: 10.1159/000119642.
A 27-year-old male presented with recurrent abdominal pain and high volume hematochezia despite undergoing extensive testing and a right hemicolectomy 3 years prior for a linear bleeding ulceration in the ascending colon. Studies at the University of Michigan included esophagogastroduodenoscopy (EGD), colonoscopy and video capsule endoscopy (VCE), revealing an arteriovenous malformation (AVM) in the terminal ileum. He was hospitalized for recurrent symptoms. His presentation suggested a small bowel source of obscure-overt GI bleeding based on prior non-diagnostic colonoscopy and EGD and a bilious nasogastric lavage. Tagged red blood cell scan localized bleeding to the right lower quadrant. Colonoscopy showed fresh blood in the terminal ileum without a clear source. Angiography showed no evidence of bleeding or terminal ileal AVM. A novel Meckel's scan fused with SPECT imaging showed focal uptake in the terminal ileum. The patient underwent Meckel's diverticulectomy with sparing of adjacent bowel and has remained asymptomatic for 19 months. This case illustrates that patients with obscure-overt GI bleeding require a step-wise multi-modality diagnostic work-up. Because Meckel's scans are false-positive in 28% of adults, Meckel's scan fused with SPECT imaging may offer an approach to refine diagnostic accuracy of either scan alone, but requires further investigation. Exploratory laparotomy should be reserved as a last option and is best performed with intraoperative endoscopy.
一名27岁男性，尽管3年前因升结肠线性出血性溃疡接受了广泛检查并进行了右半结肠切除术，但仍反复出现腹痛和大量便血。密歇根大学的检查包括食管胃十二指肠镜检查（EGD）、结肠镜检查和视频胶囊内镜检查（VCE），发现回肠末端有动静脉畸形（AVM）。他因症状反复住院。基于之前非诊断性的结肠镜检查、EGD和胆汁性鼻胃灌洗，他的表现提示小肠是隐匿性显性胃肠道出血的来源。标记红细胞扫描显示出血位于右下腹。结肠镜检查显示回肠末端有新鲜血液，但无明确出血源。血管造影未显示出血或回肠末端AVM的证据。一项与单光子发射计算机断层扫描（SPECT）成像融合的新型梅克尔扫描显示回肠末端有局灶性摄取。患者接受了梅克尔憩室切除术，保留了相邻肠段，19个月来一直无症状。该病例表明，隐匿性显性胃肠道出血患者需要进行逐步的多模式诊断检查。由于梅克尔扫描在28%的成年人中会出现假阳性，与SPECT成像融合的梅克尔扫描可能提供一种提高单独任何一种扫描诊断准确性的方法，但需要进一步研究。剖腹探查术应作为最后选择，最好在术中进行内镜检查时实施。
