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Keywords
Upper gastrointestinal bleeding, hemosuccus, arteriovenous malformations
Introduction
Duodenal AVMs are an uncommon source of upper gastrointestinal bleeding. We present a case mis-diagnosed as hemosuccus entericus.
Methods for image capture: We captured images using an Olympus Endoscope (GIF 160) and processors.
A 51 year-old female smoker with a past medical history of hypertension, and type 2 diabetes mellitus was transferred from an outside hospital for evaluation of recurrent melena and hematochezia.
Five days prior to admission, she had new onset malaise and fatigue, progressively becoming lethargic the following day. She then had four bowel movements described as black, tar-like stool with a ring of bright red blood around the stool. She denied using non-steroidal anti-inflammatory drugs. She was admitted to the intensive care unit of the outside hospital, stabilized with transfusions (four units of packed red blood cells), and underwent upper gastrointestinal endoscopy that showed a questionable small duodenal ulcer. After the endoscopy, patient had bloody bowel movements and coffee-ground emesis and required further transfusion. She had another upper endoscopy that suggested oozing from the ampulla of Vater (Figure 1).
The patient was transferred to our institution for evaluation of hemosuccus entericus. On arrival, she was afebrile. Her orthostatic vital signs were unchanged from those obtained while supine. Her physical exam was otherwise unremarkable. Her blood work was remarkable for an INR of 5, with a PT of 49 and a PTT of 49. Coagulation parameters had not been checked at the outside hospital. Her liver function tests were normal, and an abdominal ultrasound showed no evidence of cirrhosis. A repeat upper endoscopy was performed with both forward and side-viewing endoscopes and revealed a small, flat, fern-like vascular ectasia on the duodenal wall immediately inferior to the ampulla (Figure 2). This area was successfully treated with a 7-french heater probe (Olympus Corporation - Figures 3 & 4). To evaluate her coagulopathy, a mixing study was performed that normalized her PT, and factor levels showed vitamin K-dependent factors II, VII, IX, X were low. A single oral dose of vitamin K improved her INR from 5.0 to 2.0.
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Figure 2 |
Figure 3 |
Figure 4 |
Acquired vitamin K deficiency is uncommon and may occur in cases of prolonged starvation, protracted antibiotic use, poor absorption secondary to pancreatic/biliary disease or resection/disease of the small intestine as in celiac disease or Crohn’s, and the use of vitamin K antagonists such as warfarin or rat poison. In this case, the patient had no prior history of malnutrition, antibiotic use, use of warfarin/rat poison or any other medical disease that would cause deficiency. An empiric oral dose of vitamin K promptly reduced the INR suggesting that patient was absorbing vitamin K enterally. This patient appeared to be vitamin K deficient based on the mixing studies, and a prompt response to oral vitamin K. A specific etiology for her deficiency has not been uncovered. Dietary lack is possible in our patient, although this is uncommon in healthy adults.
The patient had no further bleeding in the hospital or on telephone follow-up.
Summary
Side-viewing endoscopy should be considered for diagnosis and therapy of AVMs in the proximal small intestine.
References
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