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case_images: Nuclear medicine OGIB scan demonstrating active bleeding within the small bowel (blue arrow). OGIB, obscure gastrointestinal bleeding.
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case_images: A nuclear medicine GIB scan was repeated on HD 4 because of continually dropping Hb despite multiple transfusions; this scan demonstrated active GIB within the small bowel (Fig. 2).
case_images: CTA of the abdomen and pelvis demonstrating active bleeding with extravasation of contrast seen within a small bowel loop in the right mid-abdomen, well proximal to the terminal ileum (blue arrow). CTA, computed tomography angiography.
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case_images: The nuclear medicine scan was followed up with a CTA of the abdomen and pelvis, which also showed active bleeding with extravasation of contrast seen within a small bowel loop in the right mid-abdomen, well proximal to the terminal ileum (Fig. 3).
case_images: Angiography demonstrating an irregular area of contrast extravasation from a jejunal branch in the right abdomen, just below the hepatic flexure (blue arrow).
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case_images: A superior mesenteric angiogram was then performed in the standard fashion via the femoral artery route and identified an irregular area of contrast extravasation from a jejunal branch in the right abdomen, just below the hepatic flexure, concerning for a pseudoaneurysm or vascular malformation (Fig. 4).
case_images: Intraoperative methylene blue injection showing area of concern and the small bowel segment subsequently resected (blue arrow).
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case_images: Intraoperatively, the previously mentioned microcatheter was used to inject 0.5 mL of methylene blue (10 mg/mL); an area of concern in a segment of small bowel mesentery immediately changed color (Fig. 5).