title: Combined use of preoperative provocative angiography and highly selective methylene blue injection to localize an occult small-bowel bleeding site in a patient with Crohn's disease: report of a case.
abstract: OBJECTIVE
  Gastrointestinal bleeding in patients with Crohn's disease presents both a diagnostic and therapeutic challenge. The bleeding site may be difficult to localize preoperatively and multiple segments of gross disease can lead to uncertainty as to the precise source at the time of laparotomy.
  
  
  METHODS
  We describe a patient with Crohn's disease and recurrent gastrointestinal bleeding in whom the combined use of provocative angiography and highly selective methylene blue injection was used preoperatively to accurately identify the site of hemorrhage and direct bowel resection.
  
  
  RESULTS
  Provocative angiography identified the bleeding point in the jejunum. Methylene blue, which had been injected distally into the bleeding vessel during angiography, stained the bowel wall at the bleeding site. Segmental bowel resection was subsequently performed and no further bleeding occurred during the 18-month follow-up period.
  
  
  CONCLUSIONS
  The combined use of provocative angiography and highly selective methylene blue injection may aid in the preoperative and intraoperative localization of occult bleeding sites in patients with Crohn's disease. This allows the bleeding lesion to be removed with a limited resection, thus preserving bowel length.
authors.affiliation: Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
authors.forename: Feza H
authors.initials: FH
authors.lastname: Remzi
authors.forename: David W
authors.initials: DW
authors.lastname: Dietz
authors.forename: Ethem
authors.initials: E
authors.lastname: Unal
authors.forename: Abraham
authors.initials: A
authors.lastname: Levitin
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Sands
authors.forename: Victor W
authors.initials: VW
authors.lastname: Fazio
mesh_terms: D000328:Adult; D003424:Crohn Disease / Q000150:complications / Q000601:surgery; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis* / Q000601:surgery; D006801:Humans; D007267:Injections; D007579:Jejunal Diseases / Q000175:diagnosis* / Q000601:surgery; D007583:Jejunum / Q000098:blood supply* / Q000000981:diagnostic imaging; D007813:Laparotomy / Q000379:methods; D008297:Male; D008638:Mesenteric Arteries / Q000000981:diagnostic imaging / Q000187:drug effects / Q000473:pathology; D008751:Methylene Blue; D011300:Preoperative Care; D011859:Radiography; D016896:Treatment Outcome
chemical_list: D008751:Methylene Blue