[Intestinal angiodysplasias as initially unrecognizable cause of recurrent gastrointestinal hemorrhage].

HISTORY AND CLINICAL FINDINGS

Five years before hospitalization a 72-year-old woman was first found to have anaemia. Shortly thereafter she had noticed blood on her stool, but endoscopy had failed to find the origin of the bleeding. Selective mesenteric angiographies, diagnostic laparoscopy and contrast radiography of the small intestine (after Sellink) as well as scintigraphy during the subsequent years had all been negative, although there had been several severe bleedings. Admission was prompted by renewed severe peranal blood loss. The patient was found to be obese but in a poor general state. Her skin was pale, blood pressure was 80/60 mmHg, heart rate 130/min. The abdomen was soft and without resistance on palpation.

INVESTIGATIONS

Haemoglobin was 5.7 g/dl, haematocrit 26%. Quick value, partial thromboplastin time and prothrombin time were normal. Emergency esophagogastroduodenoscopy and coloscopy as well as angiography again failed to find the source of bleeding.

TREATMENT AND COURSE

The circulation was stabilized with infusion of 4 units of erythrocyte concentrate and 2000 ml 10% hydroxyethylstarch. The blood pressure again dropped 2 days later. In parallel to renewed volume substitution another angiography was performed. This revealed arteriovenous shunts with ectasias in the terminal ileum. A right hemicolectomy was performed. The resected specimen showed intestinal angiodysplasia. At follow-up 6 months later the patient was symptom-free and there had been no further bleeding.

CONCLUSION

Even selective angiography of the superior mesenteric artery sometimes fails to demonstrate intestinal angiodysplasia. The diagnosis may then be made by repeat angiography during the phase of acute bleeding.