METHODS
UGI endoscopy revealed multiple angiodysplastic lesions on the second part of the duodenum and jejunum. Coagulation for bleeding prevention using Argon Plasma was done. Enteroscopy revealed single bleeding angiodysplstic lesion in the third portion of the duodenum. A colonoscopy revealed multiple diverticulosis and polyps, however, angiodysplasia was not visible. Nuclear Medicine examination of Gastrointestinal Blood Loss was done and no scintigraph evidence of active bleeding was detected. CECT Abdomen and Pelvis were obtained which shows no active bleeding, no free or loculated collection and metastasis was detected. Transthoracic Echocardiography showed a prosthetic pericardial valve in situ with an Ejection fraction: of 55-60 %. The rest of the findings were unremarkable. Lab investigation revealed low hemoglobin (7.5 gm/dl), Low Hematocrit (24.5%), low MCH, MCHC and high RDW. Haptoglobin and Ferritin were also found to be decreased. Peripheral Blood flow cytometry was normal. The fecal Occult Blood Test was positive. Von Willebrand Factor analysis revealed an absence of the highest molecular weight multimers suggestive of acquired deficiency (Type 1)
On a recent transesophageal echocardiogram, the patient was found to have developed a fistula between the aorta and the left atrium, and there was also the presence of moderate paravalvular leak with hemolytic anemia and symptoms of dyspnea on exertion.