An Uncommon Cause of Recurrent Upper Gastrointestinal Bleeding

Abstract

Question: A 28-year-old man was admitted to the emergency department with sudden hematemesis and melena. He reported 2 episodes of upper gastrointestinal bleeding in the last 2 years. In the first one, an erosive bulbitis was diagnosed and, 2 years later, a Dieulafoy lesion was identified adjacent to the cardia in the gastric lesser curvature that was treated with epinephrine injection, polidocanol, and application of 1 through-the-scope clip. On admission he was hypotensive and tachycardic with a hemoglobin level of 11 g/dL. Upper digestive endoscopy showed a vascular stump with a small adherent clot at the fundus/body transition of the gastric greater curvature, without active bleeding (Figure A), and endoscopic therapy with epinephrine injection and through-the-scope clip application was performed. Concomitantly, involving the described lesion and throughout the gastric fundus, exuberant protrusions suspicious of vascular origin were observed (Figures B and C). What might be the diagnosis and how should it be managed? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Due to the exuberant vascular protrusions in the gastric fundus, an abdominal computed tomography angiography was performed that identified numerous intraparietal vascular structures in the gastric fundus, with opacification in the arterial phase, suggestive of arteriovenous malformation (AVM) emerging from the splenic and left gastric arteries (Figure D). On the second day after the procedure, he presented recurrent bleeding, with hematemesis, hemodynamic instability, and a decrease of 2 g of hemoglobin. An upper digestive endoscopy was performed, identifying previously placed clips with a vascular stump visible in the middle and endoscopic therapy was repeated with over-the-scope clip application (Figure E). After the procedure the patient remained under therapy with proton pump inhibitors, without recurrence of bleeding. After multidisciplinary decision, angiography was performed with selective catheterization of the splenic artery and embolization of 2 short engorged branches vascularizing the AVM with multiple microcoils (Figure F). It was not possible to selectively catheterize one of the branches of the splenic artery as well as one of the branches of the left gastric artery. A second procedure was scheduled, but the patient refused another intervention and was lost to follow-up. AVMs are congenital lesions with persistent connections between their arterial and venous components, which result from a failure of the embryonic vascular plexus to fully differentiate and develop a mature capillary bed.1Schimmel K. Ali M.K. Tan S.Y. et al.Arteriovenous malformations-current understanding of the pathogenesis with implications for treatment.Int J Mol Sci. 2021; 22: 9037Crossref PubMed Scopus (10) Google Scholar Gastric AVMs are a rare cause of upper gastrointestinal bleeding, with few cases described in the literature, and the best therapeutic strategy remains to be defined.2Hirayama Y. Takai C. Korekawa K. et al.Gastric arteriovenous malformation with characteristic endoscopic findings.Intern Med. 2018; 57: 2341-2345Crossref PubMed Scopus (2) Google Scholar,3Latar N.H. Phang K.S. Yaakub J.A. Muhammad R. Arteriovenous malformation of the stomach: a rare cause of upper gastrointestinal bleeding.Med J Malaysia. 2011; 66: 142-143PubMed Google Scholar This case demonstrates the complexity of its diagnosis and treatment and illustrates the potential complementary role of endoscopy and selective angiography in the management of this pathology.