Case 24-2004: Recurrent Gastrointestinal Bleeding in a 48-Year-Old Man
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《新英格兰医药杂志》
To the Editor: Although its purpose was to extol the use of video-capsule endoscopy, Case 24-2004 in the July 29 issue1 illustrates the greed for certainty that feeds the increasing costs of medical care. The pictures are educational, but an enteroclysis one month earlier had displayed the lesion — in black and white, to be sure, rather than in living color — and that should have been enough to warrant laparotomy. After that, a computed tomographic scan confirmed it, and then the clearly supernumerary mesenteric angiography followed.
From a heuristic standpoint, I suppose, all the studies may have been justified, but they do seem excessive. It may be old-fashioned to suggest that after two or three episodes of bleeding, many clinicians would have opted for an earlier exploratory laparotomy and removed the lesion much sooner.
Howard Spiro, M.D.
Yale University
New Haven, CT 06510
howard.spiro@yale.edu
References
Case Records of the Massachusetts General Hospital (Case 24-2004). N Engl J Med 2004;351:488-495.
To the Editor: I am puzzled by some aspects of the discussion concerning a middle-aged man with an obscure episode of bleeding secondary to an inverted Meckel's diverticulum. A Meckel's diverticulum is well described as a source of such bleeding in older patients.1,2 Technetium pertechnate scanning was not discussed. This imaging method has less sensitivity for detecting a Meckel's diverticulum in older patients than in younger patients but a positive scan would be suggestive, and the addition of enhancement agents (e.g., somatostatin) would increase the diagnostic yield.3
One wonders why the prolapse of the lesion into the cecum was not noted on colonoscopy or ileoscopy.
David M. Friedel, M.D.
Winthrop University Hospital
Mineola, NY 11501
dfriedel@copper.net
References
Feller AA, Movson J, Shah SA. Meckel's diverticulum: a geriatric disease masquerading as common gastrointestinal disorders. Arch Intern Med 2003;163:2093-2096.
Happe MR, Woodworth PA. Meckel's diverticulum in an adult gastrointestinal bleed. Am J Surg 2003;186:132-133.
Lin S, Suhocki PV, Ludwig KA, Shetzline MA. Gastrointestinal bleeding in adult patients with Meckel's diverticulum: the role of technetium 99m pertechnate scan. South Med J 2002;95:1338-1341.
Dr. Keroack replies: Dr. Spiro suggests that video-capsule endoscopy was an unnecessary procedure in this 48-year-old man with gastrointestinal bleeding and that exploratory laparotomy should have been performed earlier. As medical practitioners, we strive for less invasive means to establish diagnoses and deliver treatment. The enteroclysis was performed after video-capsule endoscopy to confirm the presence of a lesion, characterize it further, and localize it for surgery. Enteroclysis is a more invasive and uncomfortable examination, involving the use of a nasogastric tube and high-speed injection of barium and cellulose. For adults who have obscure small-bowel bleeding, the diagnostic rate for enteroclysis is low (10 percent), because the most common causes are flat, vascular lesions.1
Exploratory laparotomy, without the use of intraoperative endoscopy, has an extremely low diagnostic yield (10 percent) in the setting of gastrointestinal bleeding in which a lesion has not been identified.1 When accompanied by intraoperative endoscopy, the diagnostic rate is high (75 to 85 percent), but this is the most invasive option of all, placing technical demands on both the endoscopist and the surgeon, with frequently prolonged postoperative hospitalization.
Dr. Friedel suggests that Meckel's diverticulum is not an uncommon cause of bleeding in adults and that technetium scanning should have been performed. In support of this argument, he provides references to two case reports — one describing a 24-year-old patient in whom a technetium scan was negative and the other describing a series of seven patients over the age of 65 years, only one of whom had gastrointestinal bleeding. Although Meckel's diverticulum can be found in patients over 40 years of age, it is an uncommon cause of bleeding; vascular lesions, neoplasms, and inflammatory lesions are more common. Although technetium scanning has a high diagnostic yield in children, the sensitivity in patients over 40 years of age is markedly reduced. In one study of 37 patients who were 16 years of age or older, the scan had a sensitivity of 62.5 percent and a positive predictive value of 60.0 percent.2 Furthermore, this patient's diverticulum lacked gastric-fundus–type mucosa, which is the tissue responsible for the technetium uptake; thus, the test would probably have been negative.
Myles Keroack, M.D.
Massachusetts General Hospital
Boston, MA 02114
References
Lewis BS. Small intestinal bleeding. Gastroenterol Clin North Am 2000;29:67-95.
Schwartz MJ, Lewis JH. Meckel's diverticulum: pitfalls in scintigraphic detection in the adult. Am J Gastroenterol 1984;79:611-618.
From a heuristic standpoint, I suppose, all the studies may have been justified, but they do seem excessive. It may be old-fashioned to suggest that after two or three episodes of bleeding, many clinicians would have opted for an earlier exploratory laparotomy and removed the lesion much sooner.
Howard Spiro, M.D.
Yale University
New Haven, CT 06510
howard.spiro@yale.edu
References
Case Records of the Massachusetts General Hospital (Case 24-2004). N Engl J Med 2004;351:488-495.
To the Editor: I am puzzled by some aspects of the discussion concerning a middle-aged man with an obscure episode of bleeding secondary to an inverted Meckel's diverticulum. A Meckel's diverticulum is well described as a source of such bleeding in older patients.1,2 Technetium pertechnate scanning was not discussed. This imaging method has less sensitivity for detecting a Meckel's diverticulum in older patients than in younger patients but a positive scan would be suggestive, and the addition of enhancement agents (e.g., somatostatin) would increase the diagnostic yield.3
One wonders why the prolapse of the lesion into the cecum was not noted on colonoscopy or ileoscopy.
David M. Friedel, M.D.
Winthrop University Hospital
Mineola, NY 11501
dfriedel@copper.net
References
Feller AA, Movson J, Shah SA. Meckel's diverticulum: a geriatric disease masquerading as common gastrointestinal disorders. Arch Intern Med 2003;163:2093-2096.
Happe MR, Woodworth PA. Meckel's diverticulum in an adult gastrointestinal bleed. Am J Surg 2003;186:132-133.
Lin S, Suhocki PV, Ludwig KA, Shetzline MA. Gastrointestinal bleeding in adult patients with Meckel's diverticulum: the role of technetium 99m pertechnate scan. South Med J 2002;95:1338-1341.
Dr. Keroack replies: Dr. Spiro suggests that video-capsule endoscopy was an unnecessary procedure in this 48-year-old man with gastrointestinal bleeding and that exploratory laparotomy should have been performed earlier. As medical practitioners, we strive for less invasive means to establish diagnoses and deliver treatment. The enteroclysis was performed after video-capsule endoscopy to confirm the presence of a lesion, characterize it further, and localize it for surgery. Enteroclysis is a more invasive and uncomfortable examination, involving the use of a nasogastric tube and high-speed injection of barium and cellulose. For adults who have obscure small-bowel bleeding, the diagnostic rate for enteroclysis is low (10 percent), because the most common causes are flat, vascular lesions.1
Exploratory laparotomy, without the use of intraoperative endoscopy, has an extremely low diagnostic yield (10 percent) in the setting of gastrointestinal bleeding in which a lesion has not been identified.1 When accompanied by intraoperative endoscopy, the diagnostic rate is high (75 to 85 percent), but this is the most invasive option of all, placing technical demands on both the endoscopist and the surgeon, with frequently prolonged postoperative hospitalization.
Dr. Friedel suggests that Meckel's diverticulum is not an uncommon cause of bleeding in adults and that technetium scanning should have been performed. In support of this argument, he provides references to two case reports — one describing a 24-year-old patient in whom a technetium scan was negative and the other describing a series of seven patients over the age of 65 years, only one of whom had gastrointestinal bleeding. Although Meckel's diverticulum can be found in patients over 40 years of age, it is an uncommon cause of bleeding; vascular lesions, neoplasms, and inflammatory lesions are more common. Although technetium scanning has a high diagnostic yield in children, the sensitivity in patients over 40 years of age is markedly reduced. In one study of 37 patients who were 16 years of age or older, the scan had a sensitivity of 62.5 percent and a positive predictive value of 60.0 percent.2 Furthermore, this patient's diverticulum lacked gastric-fundus–type mucosa, which is the tissue responsible for the technetium uptake; thus, the test would probably have been negative.
Myles Keroack, M.D.
Massachusetts General Hospital
Boston, MA 02114
References
Lewis BS. Small intestinal bleeding. Gastroenterol Clin North Am 2000;29:67-95.
Schwartz MJ, Lewis JH. Meckel's diverticulum: pitfalls in scintigraphic detection in the adult. Am J Gastroenterol 1984;79:611-618.