1. What Does Aortic Stenosis Have to Do With Heme Positive Stool? COPYRIGHT © 2014, ALL RIGHTS RESERVED From the Publishers of

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3. Copyright © 2014 An 80 year old man presents for evaluation prior to laparoscopic hernia repair Known severe aortic stenosis (no angina, syncope, CHF) No prior history of abnormal bleeding, or clotting disorder Bp 120/70 HR 90 sinus III/VI mid peaking crescendo-decrescendo murmur of aortic stenosis heard in aortic area and radiating to carotids and precordium Stool heme positive Case

4. Copyright © 2014 Case Echo: Severe aortic stenosis, normal left ventricular function  No change from echo performed one year ago Hbg 7.5  Hbg was 14.0 six months ago, microcytic hypochromic Colonoscopy

5. Copyright © 2014 Colonoscopy

6. Copyright © 2014 Case Which of the following, in addition to the finding noted at colonoscopy, best explains the cause of his anemia? A. Acquired disorder impairing platelet adhesion B. Inherited disorder impairing platelet adhesion C. Acquired disorder of thrombin generation D. Inherited disorder of thrombin generation

7. Copyright © 2014 Case 80 year old man Severe aortic stenosis GI bleed Colonic A-V malformation

8. Copyright © 2014 Letter to the Editor, Heyde EC, N Engl J Med 1958;259:196 10 cases Aortic stenosis GI bleed Elderly

9. Copyright © 2014 Von Willebrand Factor Gigantic multimeric protein Mediates adhesion of platelets to sites of vascular damage Large multimers cleaved by plasma metalloprotease under conditions of high shear stress Absence of large multimers of vWF cause bleeding from gastrointestinal angiodysplasia

10. Copyright © 2014 Von Willebrand Factor

11. Copyright © 2014 Warkentin TE, Moore JC, Anand SS, et al.: Gastrointestinal bleeding, anngiodysplasia, cardiovascular disease and acquired von Willebrand syndrome. Transfus Med Rev 2003; 17:272-86.

12. Copyright © 2014

13. Case Which of the following, in addition to the finding noted at colonoscopy, best explains the cause of his anemia? A. Acquired disorder impairing platelet adhesion B. Inherited disorder impairing platelet adhesion C. Acquired disorder of thrombin generation D. Inherited disorder of thrombin generation

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