When Angiography Makes a Difference - Polyarteritis Nodosa- A Rare Cause of Mid- Gastrointestinal Bleeding
Journal Title: Biomedical Journal of Scientific & Technical Research (BJSTR) - Year 2017, Vol 1, Issue 2
Abstract
We present a case of overt and recurrent mid-gastrointestinal bleeding with hemodynamic repercussion and severe limitation to the patients’ quality of life, followed in our department for the last 6 years. The final diagnosis of isolated gastrointestinal involvement of Polyarteritis Nodosa was only reached after multiple hospital admissions, imaging and gastroenterological examinations. A subtle finding of micro aneurysms in the mesenteric circulation opened the way to effective treatment when endoscopic treatment had failed to prevent recurrences. Mid gastrointestinal bleeding (MGIB) is uncommon but represents the majority of cases of recurrent GI bleeding without an obvious source, even after endoscopic and imaging evaluation [1]. Overt MGIB manifestations depend on the rate of bleeding and when associated with hemodynamic instability may present with haematemesis, melaena and/or haematochezia. Five to ten percent of patients with GI bleeding will not have an identifiable source of bleeding after initial endoscopic and imaging evaluation [2]. The advent of push-and-pull enteroscopy, intraoperative enteroscopy and wireless video capsule enteroscopy has shed light on cases which previously could only be diagnosed as occult GI bleeding, allowing for the identification of a bleeding source in the small bowel in up to 75 percent of these patients [3]. MGIB may be caused by multiples aetiologies such as inflammatory bowel disease (IBD), angiodysplasia, Dieulafoy lesions, Henoch-Schöenlein purpura to name but a small subset (Table 1). Their relative frequencies in MGIB are not well established but appear to be age-dependent [4]. We present an elusive case of recurrent GI bleeding with severe hemodynamic repercussion where imaging proved essential to elicit a rare diagnosis when all other investigations had failed. We report the case of a 58-year-old male patient of black race with recurrent overt gastro- intestinal (GI) bleeding since 2010. The patient has a previous medical history of ischemic heart disease (medicated with acetylsalicylic acid and clopidogrel), essential hypertension (medicated with perindopril and amlodipine), chronic hepatitis B infection without evidence of cirrhosis and latent syphilis (previous treatment). He also had a previous medial laparotomy for unconfirmed suspicion of gastrointestinal stromal tumour. There was no personal or family history of cancer. Since 2010, the patient had multiple hospital admissions with recurrent episodes of GI bleeding characterized by haematemesis, haematochezia and melaena, with hemodynamic repercussion and severely diminishing the patient’s quality of life. During these hospital admissions, multiple and extensive endoscopic and imaging examinations were performed. Between 2010 and 2012, endoscopic examinations including upper GI endoscopy, push-and-pull enteroscopy and colonoscopy, were all interpreted as normal. Conventional and CT-angiography (CTA) only documented high-density intra-luminal content of the proximal jejunum, interpreted in the context of recent upper GI bleeding, but no evidence of active bleeding. Capsule enteroscopy suggested the presence of a possible sub-mucosal lesion at the level of the proximal jejunum. In 2013, both upper GI endoscopy and push-and-pull enteroscopy reported a likely Dieulafoy lesion in the proximal jejunum. The lesion was treated with 1:10,000 epinephrine, four haemostatic clips and the mucosa was tattooed. In 2013, the patient was admitted with a myocardial acute infarction for which he was submitted to percutaneous coronary angiography and stented, starting dual anti platelet therapy. In early 2014, the patient was again admitted on three more separate occasions for episodes of haematochezia, with active bleeding being identified from a Dieulafoy lesion in a previously tattooed zone of the proximal jejunum. Two more haemostatic clips were used to treat the acute bleeding. In October of 2014, the patient was again admitted to our hospital for haematochezia with hemodynamic instability. Blood tests showed microcytic anemia with 5.9g/dL of hemoglobin (Hb). Upper GI endoscopy and colonography failed to identify relevant changes. Complete intraoperative enteroscopy was performed showing blood in the distal ileum but again no lesions. Biopsies performed at the time failed to document microscopic criteria of vasculitis. During this hospital admission, mesenteric angiography revealed “tortuous parietal gastric arterial branches with reduced calibre and millimetric aneurysmatic focal dilatations with similar changes along the vasa recta of the marginal artery of the colon.” (Figure 1). CTA performed after the angiography (Figure 2) confirmed active bleeding with evidence of intraluminal contrast medium (no contrast medium given per mouth) and focal dilatations of the mesenteric circulation. No changes were identified in the renal vessels. A retrospective review of the previous angiographies allowed for the identification of subtle calibre irregularities along the mesenteric vessels with topographic correlation with the aneurysmal dilatations seen in the later scan.
Authors and Affiliations
Erique Guedes Pinto, Diana Penha, Belarmino Gonçalves, David Orta, Ana Costa
Keywords
Related Articles
- EP ID EP569194
- DOI 10.26717/BJSTR.2017.01.000229
- Views 164
- Downloads 0
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