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ArterioVenous Malformation within Jejunal Diverticulum: an unusual cause of massive gastrointestinal bleeding.

Lee JK, Carethers JM, Ghosh P - Gastroenterol Res Pract (2009)

Bottom Line: However, significant bleeding in the setting of few diverticulae is very unusual and rare.The coexistence of jejunal diverticulum and AVM is rare and massive bleeding from an acquired Dieulafoy-like AVM within a diverticulum has never previously been described.Awareness of Dieulafoy-like AVM within jejunoileal diverticulosis is useful in preventing delay in treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Division of Gastroenterology, University of California, San Diego, CA 92103, USA.

ABSTRACT
Massive gastrointestinal (GI) bleeding can occur with multiple jejunal diverticulosis. However, significant bleeding in the setting of few diverticulae is very unusual and rare. We report a case of massive gastrointestinal bleeding from an arteriovenous malformation (AVM) within a jejunal diverticulum to underscore the significance of such coexisting pathologies. Mesenteric angiogram was chosen to help identify the source of bleeding and to offer an intervention. Despite endovascular coiling, emergent intestinal resection of the bleeding jejunal segment was warranted to ensure definitive treatment. However several reports have shown jejunal diverticulosis as a rare cause of massive GI bleeding. The coexistence of jejunal diverticulum and AVM is rare and massive bleeding from an acquired Dieulafoy-like AVM within a diverticulum has never previously been described. Awareness of Dieulafoy-like AVM within jejunoileal diverticulosis is useful in preventing delay in treatment.

No MeSH data available.


Related in: MedlinePlus

Massive gastrointestinal bleeding from an ArterioVenous malformation within a jejunal diverticulum. Superior Mesenteric Angiography (a)–(c) revealed active extravasation (arrow) of the contrast material in the proximal jejunum and pooling of the same (arrow) in the jejunum (c).  Intraoperative plain film X-ray obtained during segmental resection of the proximal jejunum (d, e) revealed the presence of two diverticula (stars), located on the mesenteric side. The arrow marks the diverticulum that was the source of hemorrhage, as determined by the presence of the radio opaque angiographic coil which was previously deployed during angiographic intervention. The specimen from segmental jejunal resection (f, g) shows blood clot within the diverticula.
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fig1: Massive gastrointestinal bleeding from an ArterioVenous malformation within a jejunal diverticulum. Superior Mesenteric Angiography (a)–(c) revealed active extravasation (arrow) of the contrast material in the proximal jejunum and pooling of the same (arrow) in the jejunum (c). Intraoperative plain film X-ray obtained during segmental resection of the proximal jejunum (d, e) revealed the presence of two diverticula (stars), located on the mesenteric side. The arrow marks the diverticulum that was the source of hemorrhage, as determined by the presence of the radio opaque angiographic coil which was previously deployed during angiographic intervention. The specimen from segmental jejunal resection (f, g) shows blood clot within the diverticula.

Mentions: A 91-year-old previously healthy woman presented with hematochezia and hypotension. Esophagogastroduodenoscopy with push enteroscopy and colonoscopy revealed fresh bleeding from an inaccessible segment of small bowel between the mid jejunum and terminal ileum. Selective splanchnic arterial angiography showed extravasation of contrast from the mid-jejunal branch of the superior mesenteric artery (Figures 1(a), 1(b), and 1(c)). Endovascular coiling of the bleeding artery at angiography only achieved short-lived hemostasis, necessitating surgical intervention. Intraoperatively, two jejunal diverticula were identified on the mesenteric border (Figures 1(d) and 1(e)); one of them with previously placed endovascular coil (arrow) implicated as the source of bleeding. A curative resection of the segment of jejunum containing the two diverticula was performed (Figures 1(f) and 1(g)). Histopathologic examination confirmed this as true diverticula (Figure 2(a)) with a submucosal Dieulafoy-like AVM surrounded by normal mucosa as the source of bleeding (Figures 2(b) and 2(c)). Calcified atherosclerosis within the small mesenteric artery feeding this malformation was appreciated, likely contributing towards the pathogenesis of the Dieulafoy-like AVM. The postoperative course was uneventful and the patient remained free of GI bleeding on her 2-month followup.


ArterioVenous Malformation within Jejunal Diverticulum: an unusual cause of massive gastrointestinal bleeding.

Lee JK, Carethers JM, Ghosh P - Gastroenterol Res Pract (2009)

Massive gastrointestinal bleeding from an ArterioVenous malformation within a jejunal diverticulum. Superior Mesenteric Angiography (a)–(c) revealed active extravasation (arrow) of the contrast material in the proximal jejunum and pooling of the same (arrow) in the jejunum (c).  Intraoperative plain film X-ray obtained during segmental resection of the proximal jejunum (d, e) revealed the presence of two diverticula (stars), located on the mesenteric side. The arrow marks the diverticulum that was the source of hemorrhage, as determined by the presence of the radio opaque angiographic coil which was previously deployed during angiographic intervention. The specimen from segmental jejunal resection (f, g) shows blood clot within the diverticula.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2742646&req=5

fig1: Massive gastrointestinal bleeding from an ArterioVenous malformation within a jejunal diverticulum. Superior Mesenteric Angiography (a)–(c) revealed active extravasation (arrow) of the contrast material in the proximal jejunum and pooling of the same (arrow) in the jejunum (c). Intraoperative plain film X-ray obtained during segmental resection of the proximal jejunum (d, e) revealed the presence of two diverticula (stars), located on the mesenteric side. The arrow marks the diverticulum that was the source of hemorrhage, as determined by the presence of the radio opaque angiographic coil which was previously deployed during angiographic intervention. The specimen from segmental jejunal resection (f, g) shows blood clot within the diverticula.
Mentions: A 91-year-old previously healthy woman presented with hematochezia and hypotension. Esophagogastroduodenoscopy with push enteroscopy and colonoscopy revealed fresh bleeding from an inaccessible segment of small bowel between the mid jejunum and terminal ileum. Selective splanchnic arterial angiography showed extravasation of contrast from the mid-jejunal branch of the superior mesenteric artery (Figures 1(a), 1(b), and 1(c)). Endovascular coiling of the bleeding artery at angiography only achieved short-lived hemostasis, necessitating surgical intervention. Intraoperatively, two jejunal diverticula were identified on the mesenteric border (Figures 1(d) and 1(e)); one of them with previously placed endovascular coil (arrow) implicated as the source of bleeding. A curative resection of the segment of jejunum containing the two diverticula was performed (Figures 1(f) and 1(g)). Histopathologic examination confirmed this as true diverticula (Figure 2(a)) with a submucosal Dieulafoy-like AVM surrounded by normal mucosa as the source of bleeding (Figures 2(b) and 2(c)). Calcified atherosclerosis within the small mesenteric artery feeding this malformation was appreciated, likely contributing towards the pathogenesis of the Dieulafoy-like AVM. The postoperative course was uneventful and the patient remained free of GI bleeding on her 2-month followup.

Bottom Line: However, significant bleeding in the setting of few diverticulae is very unusual and rare.The coexistence of jejunal diverticulum and AVM is rare and massive bleeding from an acquired Dieulafoy-like AVM within a diverticulum has never previously been described.Awareness of Dieulafoy-like AVM within jejunoileal diverticulosis is useful in preventing delay in treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Division of Gastroenterology, University of California, San Diego, CA 92103, USA.

ABSTRACT
Massive gastrointestinal (GI) bleeding can occur with multiple jejunal diverticulosis. However, significant bleeding in the setting of few diverticulae is very unusual and rare. We report a case of massive gastrointestinal bleeding from an arteriovenous malformation (AVM) within a jejunal diverticulum to underscore the significance of such coexisting pathologies. Mesenteric angiogram was chosen to help identify the source of bleeding and to offer an intervention. Despite endovascular coiling, emergent intestinal resection of the bleeding jejunal segment was warranted to ensure definitive treatment. However several reports have shown jejunal diverticulosis as a rare cause of massive GI bleeding. The coexistence of jejunal diverticulum and AVM is rare and massive bleeding from an acquired Dieulafoy-like AVM within a diverticulum has never previously been described. Awareness of Dieulafoy-like AVM within jejunoileal diverticulosis is useful in preventing delay in treatment.

No MeSH data available.


Related in: MedlinePlus