Life-Threatening Melena from Deep Ileal Angiodysplasia Successfully Treated by Intraoperative Enteroscopy-Guided Segmental Resection: A Case Report.

INTRODUCTION: Small bowel angiodysplasia (AGD) is a common yet diagnostically challenging cause of gastrointestinal (GI) bleeding in older patients, particularly in those receiving anticoagulants. In hemodynamically unstable cases where conventional modalities fail, intraoperative enteroscopy (IOE) remains an important rescue modality. CASE PRESENTATION: An 85-year-old man receiving apixaban presented with life-threatening melena and hemorrhagic shock (hemoglobin nadir 5.5 g/dL). Esophagogastroduodenoscopy, colonoscopy, and selective mesenteric angiography were all non-diagnostic. Dynamic contrast-enhanced CTA demonstrated active contrast extravasation in the deep ileum. An emergency laparotomy with IOE was performed: a sterile upper GI endoscope was introduced through a mid-intestinal enterotomy and advanced bi-directionally; systematic intraluminal irrigation with warmed saline via a water-jet system restored clear visualization of the small bowel mucosa; and a minute, actively spurting vascular lesion was identified in the deep ileum. A targeted 10-cm segmental resection with primary anastomosis was performed. No gross abnormalities were evident in the resected specimen; however, histopathology confirmed AGD with dilated, tortuous submucosal vessels. No recurrent bleeding was observed over 1 year of follow-up. CONCLUSIONS: IOE-guided surgery is a definitive diagnostic and therapeutic option in life-threatening small bowel bleeding when standard modalities fail. Early multidisciplinary decision-making and prompt surgical intervention are essential in such high-risk older patients receiving anticoagulation therapy.