S2146 Rare Presentation of a Bleeding Arteriovenous Malformation Within a Periampullary Duodenal Diverticulum

Abstract

INTRODUCTION: The incidence of duodenal diverticula (DD) is reported between 0.16% and 23% in the literature, depending on the method of diagnosis, with more than 60% arising in the second part of the duodenum. Though typically asymptomatic, various complications including pancreatitis, diverticulitis, duodenal obstruction, and bleeding have rarely been reported in the literature. We present a case of melena that was initially thought to be due to epistaxis in the setting of a supra-therapeutic INR, and was later found to be secondary to an arteriovenous malformation (AVM) within a periampullary DD. CASE DESCRIPTION/METHODS: A 72-year-old male with a history of metastatic renal cell carcinoma status-post nephrectomy, aortic stenosis, end-stage renal disease on peritoneal dialysis, and atrial fibrillation on Coumadin presented with subacute epistaxis and melena. Abdominal exam was unremarkable, and labs were notable for a hemoglobin 7.1 g/dL, platelet 76 k/uL, sodium 121 mmol/L, and INR 4.5. Given a history of epistaxis requiring otolaryngology intervention on admission that could explain his melena, a gastroenterology consult was not at first pursued. However, 12 days into the hospitalization, he continued to have melena with blood transfusion requirements, despite no evidence of recurrent epistaxis. An EGD was then done and showed a 4-mm non-bleeding ulcer in the duodenal bulb, a bleeding 5-mm AVM in a large DD treated with argon plasma coagulation (APC) and clipping, and a bleeding AVM in the posterior duodenal bulb. Ongoing melena and persistent anemia later prompted an additional push enteroscopy, colonoscopy and capsule endoscopy, which showed no evidence of ongoing bleeding at the previously treated sites or new lesions with bleeding. To reduce the risk of rebleeding, the patient's medications were adjusted (Coumadin switched to Apixaban and his VEGF inhibitor was discontinued). DISCUSSION: Definitive treatment for bleeding arising from DD traditionally involves surgical removal, though there have been increasing reports of successful endoscopic therapy. In this case, we showed that APC and clipping of a bleeding AVM within a periampullary DD was a safe and effective approach. We also highlight the need to avoid the premature assumption that persistent melena in the setting of recent recurrent epistaxis precludes coexistent gastrointestinal bleeding.Figure 1.: Bleeding AVM within duodenal diverticulum, prior to treatment.Figure 2.: AVM within duodenal diverticulum after treatment with APC and clip.Figure 3.: A CT of the abdomen/pelvis demonstrating an air-filled diverticulum of the second portion of the duodenum.