Resistive small bowel bleeding secondary to an arteriovenous malformation.

Abstract

A 79 year old patient presented to hospital with nausea and an episode of haematemesis. She was receiving chemotherapy for low volume metastatic transitional cell carcinoma of the bladder. In the subsequent days she developed multiple episodes of both dark and bright red per rectal (PR) bleeding, with a haemoglobin drop to 75 g/L and thrombocytopenia. She was not on any anticoagulation. She was resuscitated with blood products and had two Computed Tomography (CT) angiograms that failed to demonstrate any active bleeding. She proceeded to a Technetium 99 m red cell scan and at the 10 minute mark there was a small focus of increased red cell activity within the left upper quadrant which progressed over the next 15 min. Corresponding single-photon emission computerized tomography (SPECT) images were highly suggestive of a proximal small bowel haemorrhage, possibly in the proximal jejunum (Fig. 1). She proceeded to a gastroscopy and colonoscopy. There was severe reflux oesophagitis and multiple superficial gastric ulcers, with normal proximal jejunum seen. No old or fresh blood was seen in the upper gastrointestinal tract. The colonoscope was only able to be advanced to the splenic flexure due to the presence of blood and clots. She was placed on intravenous proton pump inhibitor and began to improve. A few days later she developed recurrent melaena that was associated with a further haemoglobin drop to 65 g/L. She underwent a repeat gastroscopy which showed improved gastritis thus suggestive of an alternate source of bleeding, and a PillCam was deployed into the duodenum. Review of the images confirmed multiple angioectasia in the proximal third of the small bowel. Active bleeding from an arteriovenous malformation (AVM) was seen at 34% of transit time, and again at 46% (Fig. 2a, b). She underwent double balloon endoscopy and four AVMs in the proximal jejunum were treated with Argon Plasma Coagulation (APC). A resolution clip and tattoo were placed at this site for future localisation if her bleeding did not settle (Fig. 2c, d). Two days later she had further melaena and a haemoglobin drop to 43 g/L, with a repeat CT angiogram demonstrating active bleeding from the proximal small bowel and angiographic embolisation was organized (Fig. 3a). Right common femoral artery puncture was performed with preliminary images demonstrating a small irregular vessel in the region of the clip. A Prograte microcatheter was positioned into the relevant jejunal branch which was successfully coiled with two 4 mm × 8 cm Concerto coils (Fig. 3b, c). Despite the above interventions, as well as multiple transfusions of blood and blood products, she had persistent melaena with an ongoing haemoglobin drop and subsequently altered vital signs. She proceeded to theatre and underwent a midline laparotomy. The affected jejunal segment was identified by the tattoo and a palpable clip. An enterotomy was made in this segment and on table enteroscopy of the proximal and distal jejunum was performed to exclude any other sources of bleeding. A small bowel resection was performed, and histopathology confirmed the presence of multiple AVMs. The patient recovered well and was discharged home. GI bleeding that originates in the small bowel, is uncommon and can be elusive to diagnose, often requiring multiple scans and interventions. Zhang et al. studied obscure GI bleeding and found that vascular malformations comprised 54.35% of bleeding in patients over 65 years old.1 AVMs are typically found in the caecum or right colon, with only 10% of cases occurring in the jejunum.2 Consideration should be given to performing radionuclide imaging in the context of small volume persistent GI bleeding. Bleeding rates as low as 0.1 mL/min can be identified although the accuracy can be variable.3 The era of advanced endoscopy including capsule endoscopy (e.g., PillCam) and double balloon enteroscopy, in conjunction with improved radiological imaging and interventions has facilitated a paradigm shift in our ability to treat small bowel bleeding. This case highlights the armamentarium required to successfully manage persistent GI bleeding. In particular, a multidisciplinary approach that includes collaboration between general surgeons, gastroenterologists, interventional endoscopists and radiologists. Failure to control localized small bowel bleeding with endoscopic or radiological methods should be escalated to definitive surgical treatment. Informed consent was obtained from the patient prior to publication. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians. Bushra Othman: Conceptualization; data curation; investigation; writing – original draft; writing – review and editing. Jonathan Y. C. Tan: Supervision; writing – review and editing. Antony Friedman: Supervision; writing – review and editing. Malcolm Steel: Supervision; writing – review and editing.