SUMMARYIn the past six years, 37 patients with gastrointestinal bleeding of obscure origin had their bleeding sites localised preoperatively or intraoperatively. Preoperative investigations followed a regime consisting of endoscopy, barium meal and follow through, small bowel enema, 9mTc pertechnetate scan, 'mTc-labelled red blood cell scan and selective coeliac and mesenteric angiography. Bleeding lesions were localised preoperatively in 36 patients. In one patient, diagnostic laparotomy had to be carried out immediately before any investigation because the bleeding was severe. At operation, angiosarcoma of ileum was found. Unless preoperative investigations showed the lesions to be in anatomically fixed organs like the duodenum or colon, the lesions had still to be found at operation. Palpation and transillumination detected the lesion intraoperatively in 21 patients while only some lesions were found in three patients with multiple lesions. Sigmoidoscopy through enterotomies was required in one patient. Intraoperative enteroscopy was done for small lesions not found grossly at operation in nine patients, to detect additional lesions in three patients or to rule out suspicious lesion shown on preoperative tests in one patient. In another patient with diffuse lymphoma of small bowel with bleeding from only a small segment of jejunum, injection of methylene blue intraoperatively through a previously placed angiographic catheter stained the bleeding segment of jejunum blue. This segment was identified easily and resected. These preoperative and intraoperative localisation procedures were simple and effective and we recommend them to be used more freely.
A 22-year-old man with blue rubber-bleb nevus syndrome is reported on. This is a rare syndrome. This patient is of particular interest because he had a combination of rare features: (1) five ileo-ileal intussusceptions each with a hemangioma acting as the lead point, were present during operation; (2) there was an angiomatous lesion of the glans penis; (3) this is the first case reported in a Chinese person. An aggressive surgical approach was used with success. Preoperative and perioperative investigations, including operative colonoscopy, were used to localize the gastrointestinal hemangiomas.
A clinical practice improvement project, to improve the quality of care for patients with metastatic spinal cord compression, can shorten response time to start steroidal therapy and definitive radiotherapy resulting in shorter length of stay and smaller hospitalization bill.
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