Gao Yijun, Lodh Suhrid P, Ahmadi Nima
St George Peritonectomy Unit, St George Public Hospital, Sydney, NSW 2217, Australia; University of New South Wales, St George & Sutherland Clinical School, Sydney, NSW 2217, Australia.
St George Peritonectomy Unit, St George Public Hospital, Sydney, NSW 2217, Australia.
Int J Surg Case Rep. 2024 Feb;115:109291. doi: 10.1016/j.ijscr.2024.109291. Epub 2024 Jan 20.
We present the case of a 17 years old girl with per rectal haemorrhage secondary to pelvic arteriovenous malformations (AVM) and potentially haemorrhoids. Pelvic AVMs are rare and extremely variable in their clinical presentation, size and location and pose a therapeutic challenge. Focus has turned towards interventional radiological procedures with angioembolisation as the main treatment form for pelvic AVMs.
A 17 years old girl presented to a rural hospital with significant per rectal bleeding requiring transfer to a tertiary centre with interventional radiology capabilities. Diagnostic imaging determined the presence of a pelvic AVM as well as haemorrhoid. She had no prior history of haemorrhoids, per rectal bleeding or per vaginal bleeding. Further diagnostic imaging including a digital subtraction angiography and MRI pelvis was performed and her case was discussed at a multidisciplinary meeting where the decision was made for angioembolisation of a large right rectal AVM as well as precautionary banding of haemorrhoids that had developed secondary to outflow obstruction. A repeat CT mesenteric angiogram a month later demonstrated diminished appearances of the rectal AVM.
Pelvic AVMs are a rare entity and are not a common cause for per rectal bleeding. There is currently no direct consensus on the optimum management of complex pelvic AVMs particularly those that present with a second pathology such as haemorrhoids. Surgical management often results in recurrence or rapid progression of the AVM lesion and recruitment of new blood supply further complicates the problem. Selective embolisation allows for control of haemorrhage and utilises chemical agents as well as detachable coils and balloons. However, postoperative pain and swelling can still be expected and multiple transcatheter embolisations may be required.
The treatment of symptomatic pelvic AVMs is complex and requires a multidisciplinary approach with careful radiological planning prior to embolisation. Angioembolisation is becoming increasingly prevalent and multiple embolisation procedures may be required to reach the desired therapeutic effect.
我们报告一例17岁女孩，因盆腔动静脉畸形（AVM）继发直肠出血，可能还合并痔疮。盆腔AVM罕见，临床表现、大小和位置差异极大，给治疗带来挑战。目前，介入放射学方法，尤其是血管栓塞术，已成为盆腔AVM的主要治疗方式。
一名17岁女孩因严重直肠出血就诊于一家乡村医院，后转至具备介入放射学能力的三级中心。诊断性影像学检查发现盆腔存在AVM及痔疮。她既往无痔疮、直肠出血或阴道出血史。进一步进行了包括数字减影血管造影和盆腔MRI在内的诊断性影像学检查，并在多学科会议上讨论了她的病例，决定对右侧较大的直肠AVM进行血管栓塞，并对因流出道梗阻继发的痔疮进行预防性套扎。一个月后重复进行的CT肠系膜血管造影显示直肠AVM的表现有所减轻。
盆腔AVM是一种罕见疾病，并非直肠出血的常见原因。目前对于复杂盆腔AVM，尤其是合并如痔疮等第二种病变的最佳管理尚无直接共识。手术治疗常导致AVM病变复发或快速进展，新血供的形成使问题更加复杂。选择性栓塞可控制出血，使用化学剂以及可脱卸线圈和球囊。然而，术后仍可能出现疼痛和肿胀，可能需要多次经导管栓塞。
有症状的盆腔AVM治疗复杂，需要多学科方法，在栓塞前进行仔细的放射学规划。血管栓塞术越来越普遍，可能需要多次栓塞程序才能达到理想的治疗效果。
