14. Ohta M, Yasumori K, Saku M, Saitou H, Muranaka T, Yoshida K. Successful treatment of bleeding duodenal varices by balloon-occluded retrograde transvenous obliteration: a transjugular venous approach. Surgery 1999;126:581-3. 15. Ponec RJ, Kowdley KV. Paradoxical cerebral emboli after transjugular intrahepatic portosystemic shunt and coil embolization for treatment of duodenal varices. Am J Gastroenterol 1997;92:1372-3. 16. Fukuda T, Hirota S, Sugimura K. Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. J Vasc Interv Radiol 2001;12:327-36. Embolotherapy for small bowel angiodysplasia Nam Nguyen, MBBS, David Croser, MBBS, FRACR, Dan Madigan, MBBS, FRACR, Awni Abu-Sneineh, MD, Dylan Bartholomeusz, MBBS, FRACP, MD, Mark Schoeman, MBBS, FRACP, PhD Angiodysplasia is an important cause of occult as well as overt GI bleeding, especially in the elderly. These lesions are ectatic, dilated, thin-walled vessels that are lined by endothelium either alone or with small amounts of smooth muscle. The thin-walled vessels can rupture readily and cause bleeding. 1 The colon, in particular the cecum, is the most common site of involvement. 2 The incidence of small intestinal angiodysplasia is unknown. In patients with un- explained iron deficiency anemia and no source of bleeding found by endoscopy and colonoscopy, small intestinal angiodysplastic lesions have been found in 40% by push enteroscopy. 3 The role of angiography and embolization therapy (embolotherapy) for gastric and colonic angiodyspla- sia is well established. 1,4-8 Localization of small intestinal angiodysplastic bleeding by using angiog- raphy, and subsequent embolization with platinum coils, has been reported as useful for achieving immediate hemostasis and to guide subsequent cura- tive surgery. 9 Therapeutic embolotherapy, used as the sole procedure to achieve short-term hemostasis, has been described in two case reports. 10,11 No immediate or short-term complication was observed. The safety of this procedure for small intestinal angiodysplasia remains unknown. A case is re- ported of successful embolotherapy in the long-term management of small intestinal angiodysplasia bleeding. CASE REPORT A 74-year-old man presented with melena of 1 week’s duration. The Hb was 5.6 g/dL (normal: 13.5-16.0 g/dL). There was a 2-year history of iron deficiency anemia with no site of blood loss having been found at two previous EGDs and one colonoscopy. The medical history included ischemic heart disease and a cerebral vascular accident from which the patient made an excellent recovery. He was taking aspirin, 150 mg daily. The patient was hemo- dynamically stable and mild epigastric tenderness was elicited on examination. Melena was present on digital rectal examination. Initial management included blood transfusion (total 6 units). At urgent enteroscopy a slit-like ulcer with adherent clot was noted at the duodenojejunal flexure. Further in- spection revealed an adjacent ‘‘bluish’’ mucosal swelling. There initially was no evidence of active bleeding. After examination of the small intestine had been completed, the enteroscope was slowly withdrawn. The small intestine distal to the ulcer was normal. Upon withdrawal to the duodenojejunal flexure, active arterial bleeding from the previously documented ulcer was noted. The area was injected with 16 mL of a 1:10,000 solution of epinephrine, which appeared to control the bleeding. Thermal treatment methods were not applied because it appeared that the injections had adequately controlled the bleeding. There was no further clinical evidence of bleeding over the next few days. Abdominal CT, performed to exclude a mass lesion in the region, was normal, with no corresponding pancreatic or small bowel mural abnormality at the duodenojejunal flexure. Because of the history of longstanding anemia, the bluish mucosal swelling adjacent to the ulcer, and the arterial nature of the bleeding, it was assumed that the presumed vascular lesion was large and would probably bleed again. It was decided that the risk of recurrent bleeding was significant and that definitive therapy was required. In the absence of clinical signs of recurrent bleeding, the patient was referred for selective superior mesenteric artery (SMA) angiography. This revealed an abnormal blush of contrast arising from a small proximal branch of the SMA supplying the region of the duodenoje- junal flexure, consistent with the suspected small intestine vascular lesion (Fig. 1). By using microcatheters (Excelsior with 0.018-in guide- wire; Boston Scientific, Fremont, Calif), the vessels sup- plying the vascular lesion were selectively embolized with microspheres (Embosphere microspheres; BioSphere Med- ical, Rockland, Mass), 300 to 500 lm in size (Fig. 2). Follow- up angiography confirmed that the previously documented vascular blush was no longer present (Fig. 3). Current affiliations: Department of Gastroenterology, Hepatology and General Medicine, Department of Radiology, Royal Adelaide Hospital, Adelaide, South Australia. Reprint requests: Mark Schoeman, MD, Department of Gastroen- terology, Hepatology and General Medicine, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia. Copyright Ó 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 PII:S0016-5107(03)02007-8 VOLUME 58, NO. 5, 2003 GASTROINTESTINAL ENDOSCOPY 797 Embolotherapy for small bowel angiodysplasia N Nguyen, D Croser, D Madigan, et al.