Post written by Philip T. Chen, MD, FACG, from the United Gastroenterologists, Irvine, California, USA.
We describe a case of an 83-year-old woman presenting with melena and anemia. An actively bleeding ileal Dieulafoy’s lesion was found 30 cm proximal to the ileocecal valve (measurement based on withdrawal) and treated through colonoscopy with deep ileal intubation achieved utilizing a cap-assisted water immersion technique. A pediatric colonoscope (Evis Exera III PCF-PH190L/1; Olympus Medical Systems, Tokyo, Japan) with a distal attachment cap (Reveal: US Endoscopy, Mentor, Ohio, USA) was used for the procedure.
This video highlights a rare cause of GI bleeding and a technique for deep ileoscopy utilizing colonoscopy. There are less than 20 cases of ileal Dieulafoy’s lesions described in the literature, of which a majority are diagnosed through angiography, surgery, and a few cases by capsule endoscopy or single-/double-balloon enteroscopy. This is one of the first few cases diagnosed and treated through colonoscopy and the only one described using cap-assisted water immersion. Underwater colonoscopy techniques thus far have demonstrated the potential of better comfort and higher adenoma detection rates. This case report adds another potential advantage–deeper intubation into the small bowel. In this case, utilizing this technique obviated the need to utilize the above traditional diagnostic and therapeutic studies and demonstrated an efficient, cost-effective means to manage a condition which typically has resulted in compounding costs related to escalating testing, longer hospital stays, and increasing morbidity related to need for blood transfusions as well as potential surgery.
Cap-assisted water immersion colonoscopy can be adopted by anyone performing colonoscopy. Water provides a means to straighten tortuous segments of the colon and limits lengthening of the colon by reducing formation of large loops. Combined with good standard technique of continually reducing the scope, it allows confident cecal intubation and potentially deep intubation of the small bowel without requiring balloon enteroscopy, which commonly has limited availability without transfer to a tertiary care center. The depth of insertion utilizing this technique remains unknown but has encouraging potential. Cap-assisted water immersion may allow us an opportunity to identify some distal small bowel pathology more efficiently and effectively.
Transparent distal cap attachments augment colonoscopy, especially underwater methods. Underwater, caps are less visible and less likely to distract an infrequent user. The cap extends the scope 3-4 mm and when leveraged appropriately allows easier passage of the scope through angulated turns with minor tip deflection and prevents “red outs” and blind passage through these areas. It helps to flatten folds, which not only serves to look behind folds for better adenoma detection rates but, in this case, for deeper scope advancement. It may help anchor the scope forward across a fold in a looped segment where further advancement past the fold cannot be achieved even when the scope is completely “hubbed.” It also helps to stabilize the position of the scope to provide accurate directed therapy.
In our cost conscientious environment, this case argues for optimizing existing technologies and techniques through utilizing, respectively, distal cap attachments and underwater colonoscopy.
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