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.