SHM Converge Scientific Abstract ePoster Gallery-Scope, Scope, Pill, Scope: Where Is the Bleed?

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This case report describes a 51-year-old man with end-stage renal disease (ESRD) on hemodialysis, diabetes, peripheral arterial disease, coronary artery disease, and other comorbidities who developed severe gastrointestinal bleeding after admission for altered mental status related to missed dialysis.<br /><br />Because the patient had recurrent large bloody bowel movements and worsening anemia, he underwent an extensive diagnostic workup. Initial colonoscopy showed blood but no clear bleeding source. An esophagogastroduodenoscopy was normal, and a PillCam study also failed to localize the bleed. A tagged red blood cell scan suggested active bleeding near the hepatic flexure/right upper quadrant. Interventional radiology attempted embolization, but no angiographic source was found. A repeat colonoscopy was again unsuccessful.<br /><br />The bleeding source was ultimately identified by a large bowel capsule, which revealed an oozing arteriovenous malformation (AVM) in the ascending colon. Three hemoclips were placed, but bleeding persisted, so a hot snare was used over the clips to achieve hemostasis. After this intervention, the patient’s stools became non-bloody and his hemoglobin stabilized without further transfusions.<br /><br />The report emphasizes several key points: AVMs and angiodysplasia are more common in patients with ESRD, who are also at increased risk of bleeding due to platelet dysfunction and anemia. It also highlights the technical difficulty of locating and treating GI bleeding in such patients, often requiring multiple procedures and modalities. In this case, combined use of hemoclips and hot snare successfully controlled a difficult bleed, suggesting that this approach may be useful when clips alone are insufficient.

Asset Subtitle

Daniel H. Wang

Meta Tag

Author List Daniel H. Wang, David Chung, Jin Sun Kim, Patrick Chang

Category Clinical Vignettes

Concept End-stage Kidney Disease

Concept Gastrointestinal Bleeding

Concept Angiodysplasia

Concept Obscure Gastrointestinal Bleeding

Concept Vascular abnormality

Distinguished Non-Finalist

Presenter Organization University of Southern California

Presenting Author Daniel H. Wang

Track Adult

Keywords

end-stage renal disease

hemodialysis

gastrointestinal bleeding

ascending colon AVM

angiodysplasia

hemoclips

hot snare

colonoscopy

capsule endoscopy

hemostasis

End-stage Kidney Disease

Gastrointestinal Bleeding

Angiodysplasia

Obscure Gastrointestinal Bleeding

Vascular abnormality