Locating the Site of Obscure Bleeding
An 81-year-old woman presented to her local hospital with melena, chest pain, and fatigue. An initial upper endoscopy and colonoscopy failed to reveal the source of bleeding, but her hemoglobin continued to drop, and she required repeated blood transfusions.
During the ensuing 6 weeks, she was repeatedly admitted to the hospital and underwent multiple additional tests. Repeat upper endoscopy showed what appeared to be a small arteriovenous malformation, but she continued to bleed, even after it was treated. A tagged red blood cell scan revealed active bleeding, prompting 2 angiographies with coil embolization. Still, the bleeding persisted.
Finally, video capsule endoscopy showed active bleeding in her mid to distal small bowel. She was transferred to Duke for further management.
Question: How was the source of the bleeding identified and accessed?