| Summary: | A 14-year old boy with anemia due to chronic gastrointestinal bleeding required recurrent transfusion. An extensive non-invasive evaluation that included detection of fresh blood in the small bowel followed by laparotomy with on-table pan-endoscopy (including enteroscopy) was unsuccessful in identifying a bleeding source. After repeat capsule endoscopy at our center confirmed bleeding in the distal small bowel, CT angiography identified a 6-mm focal area of enhancement in the ileum communicating with a distal branch of the superior mesenteric artery. Direct visceral angiography with super-selective arteriography identified a fast-flow vascular malformation supplied by terminal branches of the ileal artery.
Diagnostic laparoscopy revealed intra-abdominal adhesions and no clear vascular malformation. Initial careful visual and manual examination of the bowel after conversion to laparotomy failed to identify the lesion. On-table retrograde enteroscopy demonstrated a small, pulsatile lesion without ulceration or adherent clot in the mucosa of the proximal ileum. With endoscopic transillumination, a cluster of serpiginous vessels could be seen within the wall of the small bowel. The lesion was resected and pathology was consistent with angiodysplasia. Angiodysplasia is a rare cause of occult, chronic gastrointestinal bleeding in children. A multidisciplinary approach optimizes the likelihood of therapeutic success.
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