In a landmark paper in 1978, Fogler and Golembe described the injection of methylene blue through direct cannulation of the superior mesenteric artery in the

operating theater, guided by preoperative angiographic findings of an arteriovenous malformation (AVM) in the proximal jejunum. A segment of small bowel measuring 10 cm which cleared the blue dye rapidly while the color remained in proximal and distal segments was presumed buy BTSA1 to contain the pathological AVM. Though this was not demonstrated on pathology, the patient remained free of GI bleeding on 6 month follow-up [2]. From this highly invasive and non-selective approach, several refinements on this technique have been pioneered over the years to result in a less invasive and more focused surgical resection in the treatment of GI bleeding from the small intestine [3–8]. In this report, we describe how pathological findings on CTA in a non-actively, obscure GIB patient prompted super-selective angiographic catheter placement and, ultimately, limited enterectomy directed by intra-operative methylene

blue injection. Case report The patient is a 52 year-old male with past medical history significant for coronary artery disease, hyperlipidemia, gout and obesity. He had undergone cardiac catheterization and stent placement 4 years ago and continued on anti-platelet therapy with aspirin and Cilengitide ic50 Plavix. Two years prior to current presentation, he underwent work-up for melanotic stools with upper, lower and capsule endoscopy. He was diagnosed at that time with duodenitis, attributed to Arcoxia, a COX-2 inhibitor he had been prescribed for aminophylline treatment

of gouty arthritis, with likely synergistic effect due to concomitant aspirin intake. Past surgical history was notable for laparoscopic sleeve gastrectomy earlier this year with resultant 35 kilogram weight loss. His current presentation was marked by intermittent melanotic stools, fall in hemoglobin to a low of 7.3 g/dl and orthostatic symptoms. He was resuscitated and required a blood transfusion. Nasogastric tube placement did not reveal evidence of bleeding. Further work-up included upper and lower endoscopy which failed to reveal the source of bleeding. Capsule endoscopy, however, showed active bleeding localized to the jejunum, which prompted small bowel enteroscopy, which failed to show pathology to a depth of 160 cm. This was followed by double balloon enterosopy to a depth of 2m reaching the ileum. Again, this was negative for any responsible lesions. At this time, we elected to perform CTA of the abdomen both to exclude a mass lesion and attempt to localize a possible AVM. Of note, the patient was not experiencing any active bleeding at this time.