INTESTINAL ANGIODYSPLASIAS - INITIALLY NO T IDENTIFIABLE SOURCE OF RECURRENT GASTROINTESTINAL-BLEEDING

History and clinical findings: Five years before hospitalization a 72- year-old woman was first found to have anaemia. Shortly thereafter she had noticed blood on her stool, but endoscopy had failed to find the origin of the bleeding. Selective mesenteric angiographies, diagnostic laparoscopy and contrast radiography of the small intestine (after Se llink) as well as scintigraphy during the subsequent years had all bee n negative, although there had been several severe bleedings. Admissio n was prompted by renewed severe peranal blood loss. The patient was f ound to be obese but in a poor general state. Her skin was pale, blood pressure was 80/60 mmHg, heart rate 130/min. The abdomen was soft and without resistance on palpation. Investigations: Haemoglobin was 5.7 g/dl, haematocrit 26%. Quick value, partial thromboplastin time and pr othrombin time were normal. Emergency oesophagogastroduodenoscopy and coloscopy as well as angiography again failed to fmd the source of ble eding. Treatment and course: The circulation was stabilized with infus ion of 4 units of erythrocyte concentrate and 2000 ml 10% hydroxyethyl starch. The blood pressure again dropped 2 days later. In parallel to renewed volume substitution another angiography was performed. This re vealed arteriovenous shunts with ectasias in the terminal ileum. A rig ht hemicolectomy was performed. The resected specimen showed intestina l angiodysplasia. At follow-up 6 months later the patient was symptom- free and there had been no further bleeding. Conclusion: Even selectiv e angiography of the superior mesenteric artery sometimes fails to dem onstrate intestinal angiodysplasia. The diagnosis may then be made by repeat angiography during the phase of acute bleeding.