Melena Secondary to Phlebectasia of the Small Bowel

Abstract

Background: Phlebectasias are benign venous malformations that may rarely be found in the small intestine. They are bluish-red appearing lesions, millimeters to centimeters in diameter, thought to be congenital in nature. Though typically asymptomatic, they can manifest as minor and major overt GI bleeds. Case Report: The patient is a 69-year-old woman with a history of coronary artery disease, diabetes, pulmonary hypertension, chronic kidney disease, iron deficiency anemia, and a recent provoked DVT on Xarelto. She presented to our clinic for evaluation of her anemia. At that time she endorsed worsening of fatigue and light-headedness in addition to new onset melanotic stools. Decision was made to admit the patient and she was found to have a hemoglobin of 4.4 g/dL, down from her baseline value of 8-10 g/dL. Her anticoagulation was held and she underwent an EGD and colonoscopy which were unrevealing for source of bleeding. A capsule endoscopy was performed revealing several phlebectasisas localized around the distal duodenum and proximal jejunum. They were not actively bleeding. By the time of discharge, she had received a total of 4 units of pRBC. She was discharged on oral iron supplementation with outpatient laboratory follow up to monitor the status of her anemia.FigureFigureFigureDiscussion: Phlebectasias of the small intestine represent a rare and possibly under-recognized cause of occult and overt GI blood loss. The increasing prevalence capsule endoscopy in clinical practice in addition to an improved understanding of phlebectasias and other vascular ectasias will aid in diagnosis of GI bleeding sources. Current treatment is primarily supportive such as with iron supplementation. Other options employ the use of double-balloon endoscopy with subsequent cyanoacrylate injection or endoscopic injection sclerotherapy. More aggressive routes such as small bowel resection may also be considered in extreme or refractory cases.