Cause Of Recurrent Gastrointestinal Bleeding Research Articles

A155 METASTATIC EPITHELIOID ANGIOSARCOMA AND RECURRENT GASTROINTESTINAL BLEEDING: A CASE REPORT

Abstract Background Angiosarcomas are aggressive tumors of the vascular endothelium that represent less than 3% of all sarcomas. Epithelioid angiosarcomas are a distinct subtype, and in exceedingly rare circumstances can involve the gastrointestinal tract leading to significant bleeding. Aims Report a case of metastatic epithelioid angiosarcoma as a cause of recurrent gastrointestinal bleeding and the utility of endoscopy in obtaining a diagnosis. Methods A retrospective case report. Results A 71 year old female with a history of type two diabetes and coronary artery disease presented to a peripheral hospital with a two week history of fatigue, abdominal pain, and intermittent fevers for which she was diagnosed with pyelonephritis. Computed tomography (CT) scan of the abdomen/pelvis was unremarkable on admission. Her stay was complicated by cardiac ischemia prompting the initiation of dual antiplatelet therapy and anticoagulation. After a few days she developed melena and an acute hemoglobin drop requiring red blood cell (RBC) transfusion. Gastroscopy revealed a few superficial erosions in the stomach and duodenum. She went on to develop hypercalcemia prompting a repeat CT abdomen/pelvis which showed multiple lytic bone lesions, innumerable small lung nodules, and areas of hypoattenuation in the liver. Contrast enhanced MRI abdomen was performed to better assess the liver, showing a geographic area of signal abnormality without mass like features. The patient was transferred to a tertiary centre for ongoing work-up and management. Shortly after arrival, a bone biopsy from a lytic lesion of the iliac crest was taken. Initial histopathology was inconclusive for malignancy. During this time, she had ongoing melena and need for intermittent RBC transfusions. Enteroscopy revealed multiple centrally ulcerated, hemorrhagic, erythematous/purpuric lesions throughout the stomach and proximal small bowel (Figure 1a). A duodenal lesion with fresh clot was clipped and multiple biopsies were taken from the stomach and duodenum. Histopathology from a gastric biopsy confirmed the diagnosis of epithelioid angiosarcoma (Figure 1b). PET scan revealed uptake in bone, lungs, and liver. The patient received 1 cycle of palliative chemoradiation, however this was discontinued due to frailty. Overt bleeding and intermittent RBC transfusions continued. The patient was transferred to full comfort care and died within 4 months of initial presentation to hospital. Conclusions Epithelioid angiosarcoma involving the gastrointestinal tract should be considered as a cause for upper gastrointestinal bleeding. Our case highlights the endoscopic characteristics and the importance of endoscopic biopsy in obtaining a histopathologic diagnosis. Figure 1a. Enteroscopy showing metastatic angiosarcoma to the stomach and small bowel. A. Gastroesophageal junction; B. Cardia and fundus; C. Duodenal bulb; D. Second portion of duodenum. Figure 1b. Metastatic epithelioid angiosarcoma to the stomach. A-B. Low and medium power H&E; C. Cytokeratin AE1/3; D. Ber-EP4; E. CD31; F. ERG. Funding Agencies None

Transcatheter aortic valve implantation in patient with Heyde’s syndrome

Clinical case of an 85-year-old patient with Heid’s syndrome is being reported: recurrent gastrointestinal bleeding due to angiodysplasia of the stomach and intestines in combination with acquired destruction of large von Willebrand factor multimers in severe aortic stenosis. Actually it remains difficult to make a diagnosis in these patients and perform timely surgical intervention. Considering the age of the patient, severity of manifestations of heart failure and high risk of surgical complications, transcatheter aortic valve implantation (TAVI) was the method of choice. Surgical correction of heart disease in this case is aimed not only at treating its clinical manifestations, but also at eliminating the cause of recurrent gastrointestinal bleeding in Hyde’s syndrome.

Typhoid ulcer causing life-threatening bleeding from Dieulafoy's lesion of the ileum in a seven-year-old child: a case report

IntroductionWe describe a case of rare complication of typhoid fever in a seven-year-old child and review the literature with regard to other rare causes of bleeding per rectum. Dieulafoy's lesion is an uncommon but important cause of recurrent gastrointestinal bleeding. Dieulafoy's lesion located extragastrically is rare. We report a case of typhoid ulcer with Dieulafoy's lesion of the ileum causing severe life-threatening bleeding and discuss the management of this extremely uncommon entity.Case presentationAs a complication of typhoid fever, a seven-year-old Kurdish girl from Northern Iraq developed massive fresh bleeding per rectum. During colonoscopy and laparotomy, she was discovered to have multiple bleeding ulcers within the Dieulafoy's lesion in the terminal ileum and ileocecal region.ConclusionAlthough there is no practical way of predicting the occurrence of such rare complications, we emphasize in this case report the wide array of pathologies that can result from typhoid fever.

Vascular ectasia of the whole intestine as a cause of recurrent gastrointestinal bleeding after high-dose chemotherapy

We present the first case in the literature of vascular ectasia of the whole intestine as a cause of recurrent and profuse gastrointestinal bleeding in a patient with relapsing Hodgkin's disease. The 17-year-old patient experienced early relapse of his Hodgkin's disease after first-line chemotherapy. Salvage chemotherapy was followed by high-dose chemotherapy and autologous stem cell transplantation. Complete remission was achieved after another relapse by means of a second transplant. The patient presented with profuse gastrointestinal bleeding 5 months later, however. Gastric antral vascular ectasia following hematopoietic stem cell transplantation was diagnosed by endoscopy, with histological confirmation. Similar lesions were found in the duodenum, the ileum, and throughout the entire colon. In conclusion, vascular ectasia of the whole intestine should be considered as cause of acute gastrointestinal bleeding after stem cell transplantation. Physicians should be aware of this complication because its onset is typically delayed. Importantly, this disease is not limited to patients who have undergone allogeneic transplantation, but can also occur after autologous transplantation.

4462 Lack of effect of hormonal therapy in the prevention of rebleeding from gastrointestinal angiodysplasia: a multicenter, randomized controlled trial.

Angiodysplasia is a major cause of recurrent gastrointestinal bleeding. Several uncontrolled studies and one small randomized controlled trial with short follow-up have suggested that hormonal therapy may be useful in the prevention of rebleeding from gastrointestinal angiodysplasia. Aim: To investigate the efficacy of the long-term estrogen and progestagen therapy in the prevention of recurrent bleeding from gastrointestinal angiodysplasia. Patients and methods: Seventy-two patients bleeding from gastrointestinal angiodysplasia confirmed by endoscopy or angiography were included in three major teaching hospitals. Patients were randomized to receive, in strict double-blind conditions, continuous treatment with a combination of ethinilestradiol (0.05 mg) plus norethisterone (1mg) at a dose of 1 tab/day, or placebo (1 tab/day). Failure of treatment was defined as any gastrointestinal bleeding or persistence of chronic anemia during 6 months despite continuous iron therapy. Patients were followed up for a minimum period of 1 year(range 1-3 years). Results: No significant differences were found between boths groups regarding demographic, clinical data and severity of bleeding. Four patients were lost to follow-up. Failure of treatment occurred in 14 out of 33 patients (41%) in the treatment group and in 17 of 35 patients (48%) in the placebo group (p=NS). The actuarial probability of remaining free of rebleeding at 1 and 2 years of follow-up was 69% (CI:50-87) and 50% (CI:27-73) for the treatment group, and 55% (CI:36-74) and 36% (CI:14-58) for the placebo group (log-rank test, p=0.6949). In a multivariate analysis, previous bleeding from angiodysplasia, but not treatment received, was an independent predictor for failure (p=0.013). No significant differences between groups were found according to bleeding episodes (treatment: 0.7 ± 1.0 vs. placebo: 0.9 ± 1.5) and transfusional requirements (treatment: 0.9 ± 1.9 units vs. placebo: 0.7 ± 1.5 units). The incidence of metrorrhagia was higher in treatment group (5 of 34, 15%) than in placebo group (0 of 38, 0%)(p=0.02). Two patients in treatment group( pulmonary embolism, stroke) and 1 in placebo group (pulmonary embolism) had severe side-effects. There were no differences in mortality between hormonal and placebo group (0 vs. 1, respectively). Conclusion: Continuous estrogen+progestagen treatment is not useful in the prevention of rebleeding from gastrointestinal angiodysplasia. Angiodysplasia is a major cause of recurrent gastrointestinal bleeding. Several uncontrolled studies and one small randomized controlled trial with short follow-up have suggested that hormonal therapy may be useful in the prevention of rebleeding from gastrointestinal angiodysplasia. Aim: To investigate the efficacy of the long-term estrogen and progestagen therapy in the prevention of recurrent bleeding from gastrointestinal angiodysplasia. Patients and methods: Seventy-two patients bleeding from gastrointestinal angiodysplasia confirmed by endoscopy or angiography were included in three major teaching hospitals. Patients were randomized to receive, in strict double-blind conditions, continuous treatment with a combination of ethinilestradiol (0.05 mg) plus norethisterone (1mg) at a dose of 1 tab/day, or placebo (1 tab/day). Failure of treatment was defined as any gastrointestinal bleeding or persistence of chronic anemia during 6 months despite continuous iron therapy. Patients were followed up for a minimum period of 1 year(range 1-3 years). Results: No significant differences were found between boths groups regarding demographic, clinical data and severity of bleeding. Four patients were lost to follow-up. Failure of treatment occurred in 14 out of 33 patients (41%) in the treatment group and in 17 of 35 patients (48%) in the placebo group (p=NS). The actuarial probability of remaining free of rebleeding at 1 and 2 years of follow-up was 69% (CI:50-87) and 50% (CI:27-73) for the treatment group, and 55% (CI:36-74) and 36% (CI:14-58) for the placebo group (log-rank test, p=0.6949). In a multivariate analysis, previous bleeding from angiodysplasia, but not treatment received, was an independent predictor for failure (p=0.013). No significant differences between groups were found according to bleeding episodes (treatment: 0.7 ± 1.0 vs. placebo: 0.9 ± 1.5) and transfusional requirements (treatment: 0.9 ± 1.9 units vs. placebo: 0.7 ± 1.5 units). The incidence of metrorrhagia was higher in treatment group (5 of 34, 15%) than in placebo group (0 of 38, 0%)(p=0.02). Two patients in treatment group( pulmonary embolism, stroke) and 1 in placebo group (pulmonary embolism) had severe side-effects. There were no differences in mortality between hormonal and placebo group (0 vs. 1, respectively). Conclusion: Continuous estrogen+progestagen treatment is not useful in the prevention of rebleeding from gastrointestinal angiodysplasia.