Case Study - An Unusual Case of Bleeding

Abstract

A 26 yo Maori man, born in New Zealand, presented to a regional hospital in Australia with 5 episodes of large volume PR bleeding associated with clots in the preceding 24 hours, associated with lethargy and exertional dyspnoea. This was in the setting of a longstanding history of unexplained intermittent PR bleeding and symptomatic anaemia. There was a past medical history of Gastroschisis complicated by recurrent bowel obstructions requiring multiple bowel resections. He was parentally fed via a porthacath as a child before being transitioned to enteral feeding via a gastrostomy tube. He reported having been investigated with several gastroscopies and colonoscopies by the time of presentation to us, without a bleeding source identified, both in Australia and in New Zealand. In each of these instances the bleeding spontaneously settled and no cause was found. On examination he was hypotensive with a blood pressure of 90/56mmHg but not tachycardic. His hypotension was fluid responsive. His abdomen was noted to be soft non tender, prior scars from his surgery and gastrostomy tubes were noted. In addition there were several distended abdominal veins (see Fig 1) but no stigmata of chronic liver disease nor of ascites. A per rectal examination revealed fresh blood. Laboratory tests revealed a haemoglobin of 120 g/L, Urea 6.0 mmol/L, Creatinine 128 μmol/L. There was no coagulopathy with an INR 1.0 and platelets of 242 x10ˆ9/L. The bleeding had settled completely within the first 24 hours of admission and the haemoglobin dropped to 91g/L. A CT mesenteric angiogram(CTMA) was undertaken. This revealed large submucousal varices at the rectosigmoid junction which were presumed to be the cause of his bleeding. There was also extensive subcutaneous venous collaterals shunting blood from the thorax to the abdomen via multiple systemic pathways. There was no clear cause for these venous collaterals but the picture did not appear to be secondary to portal hypertension. A CT scan of the chest showed complete occlusion of the left brachiocephalic vein and a stenosis of the superior vena cava (see Fig 2). The patient was subsequently referred to a vascular surgeon for opinion on management of the venous obstruction. The patient did not attend. This is an unusual case of PR bleeding due historical iatrogenic cause, in which a CTMA was helpful in clarifying the aetiology of the bleeding.2015_A Figure 1. Clinical examination showing abnormal abdominal vessels2015_B Figure 2. CT mesenteric angiogram showing extensive collaterals including within abdominal wall2015_C Figure 3. CT chest showing superior vena cava stenosis