1. David J. Hass, MD Assistant Clinical Professor of Medicine Yale University School of Medicine Gastroenterology Center of Connecticut, P.C.

2. Case # 1 63 year old woman Recurrent overt obscure gastrointestinal bleeding Feels well most days, but with painless recurrent melena

3. Case # 1 PE: Appears well, but fatigued, Slight tachypnea Lungs clear to auscultation. II/VI systolic ejection murmur Gross melena noted on rectal examination Exam otherwise normal

4. Case # 1 CBC WBC4.5 Hgb5.1 HCT15.6 Platlets244,000 MCV64 Ferritin 6, Iron saturation 4% Serum electrolytes Normal Coagulation profile normal Liver tests unremarkable

5. Case # 1 EGD and Colonoscopy with ileal intubation -- negative for overt pathology Meckel’s scan -- negative Tagged RBC scan -- negative Upper GI with Small Bowel Examination -- negative

6. Case # 1 Small bowel capsule endoscopy performed…….

10. Case # 1 Diagnosis: Small bowel angioectasias causing obscure overt gastrointestinal bleeding and anemia.

11. Angioectasias Most common vascular abnormality of the GI tract Most frequent cause of recurrent gastrointestinal bleeding Commonly located in the colon, but can be seen throughout the entire gastrointestinal tract Bleeding from angioectasias is usually recurrent and low grade, though 15% of patients present with massive hemorrhage

12. Angioectasias Treatment options: Hormonal therapy Angioembolization Endoscopic evaluation with push enteroscopy, double balloon enteroscopy coupled with BICAP cauterization or argon plasma coagulation

13. References Boley SJ, Brandt LJ. Dig Dis Sci 1986;31: 26S-42S. “Vascular Lesions of the Gastrointestinal Tract” In: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 9 th edition.