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well now start our next case we have a
45 year old man seen in the IDI for
three episodes of melena in the last two
days he has not had any abdominal pain
he has no history of bleeding disorders
alcoholism chronic liver disease or
cancer his medical conditions include
hypertension and pre-diabetes this is
his first episode of melena he takes
high dose aspirin for chronic knee pain
his vitals are notable for a heart rate
of 110 blood pressure is 125 over 62
while supine and 95 over 55 while
standing his abdominal exam is
unremarkable and rectal exam identifies
melena lab studies show a hemoglobin of
10 but our otherwise normal so what is
the best next step in management let's
go through some key items in this case
so he has melena he has no significant
past medical history that would place
him at risk for developing melena he
does however have high dose aspirin use
which is a risk factor for GI bleeding
and on his exam this is notable for
resting tachycardia and he has
orthostatic hypotension as you note the
blood pressure change from supine to
standing this indicates that he already
has moderate intravascular volume loss
so before we answer the question let's
go through a differential for him so as
we mentioned in our approach to GI
bleeds there's a very broad differential
for upper GI bleeds in this case and we
think through his risk factors we know
that he has a history of chronic and
said use which puts him at risk for
gastric or duodenal ulcers also he's at
risk for erosive esophagitis gastritis
or do a denied us although this is rare
he could have an arteriovenous
malformation synthesis should always be
on your differential and although he's
fairly young you should always put
malignancy on your differential and make
sure that you have ruled it out the
other causes listed here including
esophageal gastric varices or portal
hypertensive
droppeth II are less likely in him
because he does not have a history of
cirrhosis in addition a mallory-weiss
tear is also pretty unlikely in this
case because it does not describe a
history of frequent vomiting prior to
his bleeding episode so if we return to
our case we know that he is a 45 year
old man with melena no particular
significant past medical history but he
does have high dose and said use so the
best next step in management includes
recognizing that he has moderate
hypovolemia so the first step as always
is to fluid resuscitate and then consult
GI for endoscopy our case now continues
the patient is fluid resuscitated he has
no further episodes of melena he
undergoes an upper endoscopy which does
not visualize a source of bleeding he
then undergoes a video capsule endoscopy
followed by push enter osku P as so
shown here so first this is a video
capsule endoscopy so the patient
swallowed a small capsule that then
allows us to visualize the small bowel
here you see a small amount of bleeding
in the jejunum the next step after doing
a video capsule is to do push enter osku
P which is a method by which we can then
visualize the small bowel which is
otherwise very difficult to access so
here you see an image from his push
enter a skivvy
that shows a small area of
angiodysplasia in the jejunum which
probably corresponds to the area that
was bleeding on the video capsule in the
next step he then undergoes argon plasma
coagulation which is a method of
hemostasis to stop the bleeding and
after this vessel is coagulated he then
has a resolution of his bleeding so
let's talk a bit about angiodysplasia or
arteriovenous malformations while they
are rare they can cause up to 4 to 7% of
GI bleeds and they are caused by a
vascular abnormality so as you can see
here on the right normally a capillary
bed is made by an arteriole
and a venial coming together that's on
top you can see a normal blood vessel on
the bottom on the other hand these blood
vessels may form abnormally and cause an
abnormal collect connection which is an
AVM so patients with AVMs may have
either overt or occult GI bleeding and
usually they're bleeding is unmasked by
things like aspirin and seds or
anticoagulants the diagnosis as with all
GI bleeds is done by endoscopy and with
endoscopy you can also treat so we have
various hemostasis interventions to stop
the vessel from bleeding including
injecting epinephrine doing coagulation
or placing a clip on the bleeding vessel
to stop it from bleeding you might
encounter the term do a voice lesion a
dual avoids lesion is just a particular
type of AVM it refers to a dilated
normal vessel that erodes into the
epithelium without causing an ulcer it
is usually referred to in the proximal
stomach but can really be found anywhere
in the GI tract
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you