Ten patients were diagnosed as gastrointestinal bleeding in our department from March 2006 to October 2010. No bleeding lesions were detected with gastroscopy and colonoscopy. They underwent enteroscopy through mouth and/or anus. In the patients with active bleeding lesions suspected of small intestinal vascular bleeding, abdominal vascular-enhanced CT examination was performed. The patients without active bleeding lesions also underwent abdominal contrast-enhanced CT examination. Among the ten patients, there were seven males and three females, age range was 35–65 years, mean age was 51 years. All the patients lacked the contraindications for enteroscopy, including severe heart, lung, and liver disease, severe weakness, and complete intestinal obstruction.

Double-balloon enteroscopy with the Fujinon EN-450P5/20 (Fujinon company, Japan) was accomplished with the repeated charge and discharge of the balloons, and the repeated push and pull of the trocar sheath to advanced the enteroscope [¹⁰].

Electrocardiogram, blood tests, liver and renal function, blood type, and blood coagulation tests were performed for the patients. Twelve hours of fasting was necessary for examination through mouth, small intestine clearing was necessary for examination through anus. Liquid diet the day before examination, 33% magnesium sulfate of 100 mL at 8 pm the night before examination, followed 30 min later by drinking 2000 mL of water. Disoprofol was injected 10 min before examination for the patients who needed intravenous anesthesia. For the patients who needed no intravenous anesthesia, ansiolin of 10 mg, scopolamine butylbromide of 10 mg, and dolantin of 50 mg were injected 10 min before examination. Oxygen supply, electrocardiogram, and blood oxygen saturation monitoring were performed through the whole procedure.

The assistant and doctor cooperate to fulfill the procedure: in enteroscopy examination through the mouth the enteroscope progresses to the inferior segment of the ileum: the enteroscope advances to the junctional zone of the jejunoileum. When a bleeding lesion was not detected through one side, diluent methylene blue of 0.5 mL was injected beneath the mucous membrane at several sites, which facilitates confirming the site when the examination is performed through the other side. For some patients, X-ray was used to observe the extent of penetration by the enteroscope [¹¹, ¹²].

Light speed VCT 64 layer spiral CT (GE company, USA) was used, scan range included the entire abdomen, plain scan was performed first, parameters: tube tension was 120 kV, tube current was 36 mAs, width of collimator was 40 mm, rack rotation time was 0.6 s/circle, pitch was 1.375:1, and slice thickness was 1.25 mm. Then enhancement scanning was performed, non-ionotropic contrast agent of ultravist 370 was used, injected as a bolus through a peripheral vein, the dosage was 1.5 mL/kg body weight, the flow rate was 3.5–4.5 mL/s. After enhancement scanning, image reconstruction was performed with the original data, after reconstruction all the images were transmitted to the work station, where post processing was taken, including multi-planar reformation (MPR) and curved planar reconstruction (CPR). The best images were screened for analysis and diagnosis.

The CT images were separately analyzed by two radiologists with rich experience; when the conclusion was not the same, the two radiologists discussed the images until the same conclusion was reached. The images of enteroscopy and CT were compared with the surgical result. The clinical value of applying multi-slice spiral CT (MSCT) in the diagnosis of small intestinal vascular malformation was evaluated.

Of the ten patients who underwent double-balloon enteroscopy examination, active bleeding lesions were detected in seven patients, and no active bleeding sites were detected in three patients (shown in Fig. 1, Table 1).

Of the ten patients who underwent contrast-enhanced CT, small intestinal vascular malformations were detected in all and these were confirmed with surgical and pathologic results (shown in Table 1).

All the ten patients with intestinal vascular malformation underwent surgical operation. The vascular malformation was confirmed with surgical detection and pathologic diagnosis, and segmental resection was done for intestinal vascular malformation and angioma (shown in Table 1).

Patient no. 2 had undergone a surgical operation 4 years previously for a cutaneous hemangioma of the right knee (Fig. 2A). He was admitted for dark stools. Several jejunal angiomas were detected with enteroscopy through the mouth (Fig. 2B), but no active bleeding was observed. No lesion was detected with enteroscopy through the anus. Ileal vascular malformation was detected with abdominal contrast-enhanced CT (Fig. 2C–E). Ileal angioma (Fig. 2F) and vascular malformation (Fig. 2G) were detected with laparoscopic approach. Segmental resection was done for the angioma and vascular malformation, and the lesions were confirmed with pathologic diagnosis (Fig. 2H).

^aIndicated that no active bleeding sites were detected with enteroscopy examination