When embolization fails to control GIH, angiography can guide surgical resection of the appropriate segment of bowel . However, the use of angiography has also been reported to misdirect surgical resection, leading to the removal of normal bowel . Catheter injection of methylene blue can be useful to stain involved regions of bowel for resection. Refractory cases in HHT and non-HHT patients often require eventual surgical management.
In the present patient, endoscopic treatment was not possible because the culprit lesion was not identified from within the lumen of the bowel. This is most likely due to the submucosal location of the lesion, anemia and the absence of active bleeding during investigation. In light of the nature of the lesion identified by angiography, medical therapy would not have been appropriate and did not offer a definitive solution. Furthermore, estrogen-progesterone was considered unacceptable to this patient due to the potential adverse effects. Surgery, although a potentially definitive therapy, is far more invasive than transcatheter embolization.
In this patient with a single AVM as the source of recurrent GIH, embolotherapy offered a relatively noninvasive and potentially permanent treatment. Embolization is used for treatment of pulmonary and cerebral AVMs in HHT patients ; however, to our knowledge, this is the first report of a successful embolization of a duodenal AVM in a patient with HHT. Diagnostic angiography should be considered in HHT patients with sudden, massive or refractory GIH and embolization should be considered in the management of AVMs within the duodenum.
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