This 73 year old man was referred for evaluation of recurrent bleeding over the past year and a half requiring over 25 units of packed RBCs. His prior negative studies included 3 EGDs, 2 colonoscopies, and a SBFT. A recent Capsule study revealed a right colonic bleeding source. Colonoscopy was then performed. In the base of the cecum this faint angiodysplastic lesion was seen. This lesion could easily have been missed on prior studies especially if the preparation had been marginal as was noted on the prior colonoscopy reports.
To enhance the flow through the lesion, 0.2 mg of IV Nalaxone is given. Within 60 seconds, the lesion fills and becomes more intense, better defining its borders. Bicap cautery is then performed with setting of 15 joules and pulses of 2-4 seconds. The lesion is completely ablated.
Twelve days later he passes large amounts of clots and his hematocrit drops to 24%. He is transfused and a repeat colonoscopy is performed. This fresh post cautery ulcer is seen in the cecum at the site of the AVM. A clot had just been aspirated from the surface of this lesion. No therapy is applied and he does not rebleed.
Six weeks later, his hct has risen to the mid 30s, he has required no further transfusions, and the site has completely healed leaving only this stellate scar.
Peter B. Kelsey, M.D., Harvard Medical School, Massachusetts General Hospital