A 68-year-old man with hereditary hemorrhagic telangiectasia (HHT) presented to hospital with recurrent gastrointestinal hemorrhage (GIH), manifesting as intermittent melena, for five years. Previous investigation by esophagogastroduo-denoscopy (EGD) revealed four telangiectasias in the stomach that were cauterized. Colonoscopy did not reveal the source of bleeding. The symptoms had progressed, and during the three months before admission to our hospital he had required transfusions of 27 units of packed red blood cells.
Other manifestations of HHT in this patient were moderately severe epistaxis, cutaneous telangiectasias (face, tongue, lips, ear and hands) and bilateral pulmonary arteriovenous malformations (AVMs) for which he had undergone embolization 16 months before the current admission. He also had a history of seizures and transient ischemic attacks; the former were well controlled medically and the latter had resolved after embolization of the pulmonary AVMs. There were no cerebral AVMs. Other past medical history included a left renal oncocytoma, hypertension, right cataract and corneal surgery, and tonsillectomy.
The following investigations were completed to identify a source of the bleeding. A technetium-labelled red blood cell (RBC) scan was noncontributory for a site of blood loss. EGD revealed only small telangiectasias in the posterior wall of the stomach. These were not actively bleeding and not thought to be responsible for the clinical presentation of sudden, large volume GIH in this patient. Hemoglobin concentration was 85 g/L on the day of the EGD (normal 130 g/L to 170 g/L). Enteroscopy showed no obvious lesions in the duodenum and colonoscopy to the cecum revealed only small diverticulae but no active bleeding and no clear source of recurrent hemorrhage. Get most advantageous deals ever – waiting for you round the clock.