Life Threatening Obscure Lower Gastrointestinal Bleeding, Secondary to Isolated Proximal Ileal AV Malformation Management with Intraoperative Enteroscopy and Resection

Abstract

Obscure gastrointestinal (GI) bleeding refers to intermittent or continuous loss of blood where the source is not identified after upper endoscopy and colonoscopy. It may be occult or overt. Obscure GI bleeding accounts for 10% of total GI bleeding cases. The small intestine is the least common site of GI bleeding (5%).Vascular etiologies like arteriovenous malformations (AVM) are a common cause of obscure bleeding, commonly found in jejunum or right colon (80–90%) and rarely in ileum (8%). AVMs are usually seen in patients over 60 years of age and present as recurrent spontaneous bleeding or anaemia or remain asymptomatic; very rarely, they present as life threatening bleeding. Diagnosis of AVMs is challenging as they are often missed on endoscopies as well as during laparotomies. This makes massive, life-threatening obscure bleeding secondary to AVM a therapeutic challenge, as AVMs tend to rebleed spontaneously, if left untreated. We present a case of middle aged man with no previous comorbidities or GI bleeding, presenting acutely with massive, life-threatening obscure lower GI bleeding. Due to rapidly developing shock and acidosis, surgical management was undertaken. On emergency exploration, with on-table enteroscopy, a single AVM was detected in proximal ileum. It was successfully managed with localised resection.