P0495 - Life Threatening Hemorrhoidal Bleed Due to Inferior Mesenteric Arteriovenous Malformation

Sikder Hassan, MD, Oluwafemi Ajibola, MD, Nneka Chukwu, MD, Olushola Ogunleye, MD, MPH, Hussain Dalal, MD, Joseph Kuruvilla, DO, Noor UI Ain Qureshi, MD, Uma Medapati, MD, Shazia Choudry, MD, Matthew Apedo, MBChB, FCCP
Vassar Brothers Medical Center, Poughkeepsie, NY

Introduction: Mesenteric Arteriovenous malformations (AVMs) are extremely rare. With few cases reported in the literature, we present a case of massive hemorrhoidal bleed due to inferior mesenteric artery (IMA) AVM.

Case Description/Methods: 52-year-old woman with a history of stroke on clopidogrel, gastric sleeve surgery, and hyperlipidemia presented with persistent lower abdominal pain for 1 month. The vital signs were stable. Exam was remarkable for diffuse abdominal tenderness without guarding or rebound. Labs notable for hypokalemia (2.9 mmol/l). CT abdomen and pelvis showed mural thickening of rectosigmoid with mesenteric and retroperitoneal lymphadenopathy. Patient was admitted for proctocolitis and was started on intravenous ciprofloxacin and metronidazole, and potassium replacement. On Day 3, patient developed large hematochezia and dizziness, and became hemodynamically unstable (BP of 86/74 mmHg and HR of 123 bpm). Fluid resuscitation along with massive transfusion protocol were initiated (received 9 units of PRBC, 4 units of platelet, 2 units of FFP, and 1 unit of cryoprecipitate), and clopidogrel was discontinued. CTA of abdomen and pelvis was negative for bleeding source. An upper endoscopy was unrevealing as well. However, the repeat CTA abdomen and pelvis showed active bleed in the distal rectum. The flexible sigmoidoscopy was limited due to old blood in the rectum. Patient underwent ultrasound and fluoroscopically guided IMA arteriography and embolization. The arteriography demonstrated an AVM arising from branches of the superior rectal and left colic artery, supplying a large bed of rectal hemorrhoids. Coil embolization of the superior rectal artery and left colic artery were performed with resolution of the bleeding.

Discussion: AVMs more often occur in hepatic (40%), splenic (35%), superior mesenteric and gastroduodenal arteries. IMA AVMs are extremely rare and difficult to diagnose because of their low clinical incidence and non-specific symptoms. Commonly presents with lower abdominal pain, portal hypertension, intestinal ischemia, or lower gastrointestinal bleed with risk of hemorrhagic shock and exsanguination, as illustrated by this case. The standard arteriography provides diagnostic and therapeutic option with embolization. If embolization fails, these patients might require surgery.

This case highlights the need to investigate hemorrhoidal bleeds for possible association with an AVM involving branches of IMA, especially when there is severe acute blood loss.



Disclosures:


Sikder Hassan, MD, Oluwafemi Ajibola, MD, Nneka Chukwu, MD, Olushola Ogunleye, MD, MPH, Hussain Dalal, MD, Joseph Kuruvilla, DO, Noor UI Ain Qureshi, MD, Uma Medapati, MD, Shazia Choudry, MD, Matthew Apedo, MBChB, FCCP. P0495 - Life Threatening Hemorrhoidal Bleed Due to Inferior Mesenteric Arteriovenous Malformation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.