No Gastrointestinal Bleed too Obscure: A Case Series Report of Small Bowel Phlebectasias

Abstract

Phlebectasias are rare benign venous varicosities of the gastrointestinal (GI) tract. They are frequently found in the jejunum but can occur anywhere in the GI tract. They usually are asymptomatic, but can present with acute gastrointestinal bleeding or chronic anemia. We describe a case series of two patients who presented to the hospital with melena and were found to have small bowel phlebectasias on video capsule endoscopy (VCE). An 82-year-old male with history of gastric ulcer was admitted for evaluation of melena. Esophagogastroduodenoscopy (EGD) was suggestive of healing gastric ulcer and colonoscopy was negative for an active source of bleeding. He was admitted again after three months for evaluation of melena with worsened hemoglobin drop. EGD showed healed gastric ulcer. VCE showed multiple diffuse nodular black lesions in the small bowel. Double Balloon Enteroscopy (DBE) showed numerous vascular-appearing black/blue nodular lesions in the duodenum and jejunum consistent with phlebectasias. The patient is currently being monitored as an outpatient with regular hemoglobin measurements. A 78-year-old male was admitted for evaluation of melena. EGD showed gastritis and a small hiatal hernia. Colonoscopy showed 8mm polyp which was removed and histopathology showed tubular adenoma. Given persistent and worsening anemia, further evaluation with VCE was performed. It showed multiple phlebectasias throughout the small bowel with active bleeding noted from one lesion. Patient was treated supportively. Since diagnosis, patient is being closely followed up with serial hemoglobin measurements. Gastrointestinal vascular anomalies account for 2-8% of all cases of bleeding, and 30-40% of all obscure hemorrhages. They are the most frequent cause of occult bleeding in elderly population. Phelebectasias are usually multiple small discrete blue-black lesions that are located in the submucosa or the serosa and found incidentally during surgery or at autopsy. The mainstay of treatment of intestinal phlebectasias is surgical resection of the involved segment. However, the advent of VCE and DBE has opened doors for diagnostic and potential therapeutic interventions in management of obscure GI bleeds. Our case series illustrates the importance of continued evaluation in obscure GI bleeding and highlights the utility of VCE in diagnosing phlebectasia as a source of GI bleeding and chronic anemia.