A 62-year-old man was referred to Chiba University Hospital with melena. He had previously
suffered from severe peritonitis due to appendicitis and consequently had a giant
abdominal incisional hernia. Although his appearance was pale due to a hemoglobin
concentration of 6.9 g/dL, his vital signs were stable. His abdomen was distended
in the right side because of, not only the hernia, but also his severe obesity; he
had a body mass index of 42.3 kg/m2 ([Fig. 1]).
Fig. 1 Physical examination showed severe obesity, and distension in the right side of the
abdomen.
An abdominal computed tomography scan clearly demonstrated the giant incisional hernia,
which included the jejunum, ileum, and ascending colon ([Fig. 2]). No suspected bleeding point was found during esophagogastroduodenoscopy and small-bowel
capsule endoscopy; however, transoral and transanal double-balloon endoscopy (DBE)
were performed when the patient presented with melena ([Fig. 3]). We found a small Dieulafoy’s lesion with pulsatile bleeding in the lower section
of the ileum, and performed hemostatic clipping for the lesion ([Video 1]). Rebleeding was not seen after clipping, and the patient was discharged.
Fig. 2 Abdominal computed tomography scan. a Giant incisional hernia, including the jejunum, ileum, and ascending colon, was visible
on the X-ray image. b The axial view. c The coronal view.
Fig. 3 Fluoroscopic view of double-balloon endoscopy. a Transoral insertion to the jejunum, including the giant incisional hernia. b Transanal insertion to the ileum and ascending colon, including the giant incisional
hernia.
Video 1 Double-balloon endoscopy was performed to evaluate intestinal bleeding. Hemostatic
clipping was performed for a bleeding intestinal Dieulafoy’s ulcer.
There are no reports on endoscopic hemostasis using DBE for an intestinal hemorrhage
in a giant incisional hernia. The presence of an abdominal hernia is not a contraindication
to colonoscopy [1]. Careful assessment by physical examination and radiological images before endoscopy
is important because this can alert an endoscopist to potential risks, such as perforation
and incarceration, especially in the case of an incisional hernia [2]
[3]. Furthermore, although DBE has not been found to be superior to other deep enteroscopy
techniques, such as single-balloon endoscopy and spiral endoscopy, for increasing
diagnostic or therapeutic yields, the rate of complete enteroscopy with DBE has been
shown to be higher than the rate with other techniques [4]
[5].
To conclude, endoscopic hemostasis by DBE should be considered in cases with a giant
incisional hernia.
Endoscopy_UCTN_Code_CCL_1AC_2AB
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
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