Successful treatment of life-threatening small bowel bleeding in patient with granulomatosis with polyangiitis : sequential clamping with intraoperative endoscopic guidance

A 34-year-old man was referred to our department with a history of rectal bleeding. He was known with glomerulonephritis due to granulomatosis with polyangiitis (GPA) and he was under intravenous pulse steroid treatment. On physical examination he was pale and afebrile, with a blood pressure of 90/60 mmHg and a pulse rate of 115/min. Blood analysis showed a white- cell count of 9540/mm3, the hemoglobin level was 7.4 g/ dl, and creatinine was 5.6 mg/dL. Upper gastrointestinal endoscopy was unremarkable without signs of active bleeding. Ileocolonoscopy revealed a normal appearing rectum, with fresh blood in the right colonic lumen and terminal ileum, but no evidence of any inflammatory lesion or mass. AlsO. there was no evidence of bleeding during catheter angiography. The patient needed 14 units of blood replacement in 48 hours, therefore emergency surgery was performed after aggressive resuscitation and correction of underlying medical conditions. During laparotomy blood was observed in the lumen of the entire small bowel and colon. To determine the bleeding area in the small bowel, intraluminal content was milked by hand from the Treitz ligament towards the ileum. Thereafter, the small bowel was sequentially clamped with 40-50 cm intervals from Treitz ligament to the ileocecal valve and bleeding localization was detected in the proximal jejunum (Fig. 1, arrow). Subsequently, enterotomy was performed in the detected bleeding segment of small bowel and multiple linear extensive deep ulcer craters were observed during intraoperative upper gastrointesinal endoscopy (Fig. 2). A 20 cm small bowel segment was resected with an end-to-end anastomosis.