CASE REPORT
Massive lower gastrointestinal bleeding in a young postpartum lady: A management dilemma
 
More details
Hide details
1
Department of Surgery, School of Medical Sciences, University Sains Malaysia, Kelantan, Malaysia
2
Pathology Department, School of Medical Sciences and Hospital, University Sains Malaysia, Kelantan, Malaysia
CORRESPONDING AUTHOR
Michael Pak-Kai Wong   

Department of Surgery, School of Medical Sciences and Hospital, University Sains Malaysia, 16150, Kota Bharu, Kelantan, Malaysia. Tel: +60197676779.
Submission date: 2020-09-27
Final revision date: 2021-03-29
Acceptance date: 2021-03-29
Online publication date: 2021-07-20
 
 
KEYWORDS
TOPICS
ABSTRACT
Introduction:
Lower gastrointestinal (GI) bleeding secondary to bleeding colonic angiodysplasia in a young population is rare. The prevalence of angiodysplasia in healthy asymptomatic adult was 0.8% and increases in elderly population, chronic renal failure, pulmonary disease, aortic stenosis, and von Willebrand disease.

Aim:
We are reporting a case of a young, postpartum woman who presented to us with massive lower GI bleeding secondary to bleeding angiodysplasia. Angiodysplasia is rare in this group of patients, making the detection and treatment challenging.

Case study:
A fit 25-year-old woman presented with type IV hypovolemic shock due to massive lower GI bleeding on postpartum day 15. Emergency colonoscopy was attempted with no evidence of active bleeding detected until splenic flexure. The patient was rushed to the operation theatre for exploratory laparotomy due to unstable condition. Segmental colonic clamping was performed and due to persistent blood pooling at different segments throughout the colon, subtotal colectomy and end ileostomy were performed. Patient recovered well post-operatively.

Results and discussion:
Physiological changes during pregnancy may has aggravated the risk of bleeding in GI angiodysplasia. Following resuscitation, a lesion causing lower GI bleed can be identified and treated with a variety of endoscopic procedures, radiological and surgical interventions. In our case, the role of surgery comes in place due to massive life-threatening lower GI bleeding not responding to resuscitation.

Conclusions:
Postpartum gastrointestinal bleeding from multiple colonic angiodysplasia is rare. It poses a challenge in diagnostic and treatment strategies. A timely individualized intervention either via endoscopy, interventional radiology or surgery is crucial and life-saving.

FUNDING
None declared.
CONFLICT OF INTEREST
None declared.
 
REFERENCES (16)
1.
Beg S, Ragunath K. Review on gastrointestinal angiodysplasia throughout the gastrointestinal tract. Best Pract Res Clin Gastroenterol. 2017;31(1):119–125. https://doi.org/10.1016/j.bpg.....
 
2.
Arribas Anta J, Zaera de la Fuente C, Martín Mateos R, et al. Evaluation of the efficacy of therapeutic endoscopy in gastrointestinal bleeding secondary to angiodysplasias. Rev Gastroenterol México (English Ed). 2017;82(1):26–31. https://doi.org/10.1016/j.rgmx....
 
3.
Kaaroud H, Fatma LB, Beji S, et al. Gastrointestinal angiodysplasia in chronic renal failure. Saudi J Kidney Dis Transpl. 2008;19(5):809–812.
 
4.
Vanagunas A. Gastrointestinal complications in pregnancy. GLOWM. 2008. https://doi.org/10.3843/GLOWM.....
 
5.
Tuşaliu M, Zainea V, Goanţă C-M, Sorică A. Minimally invasive surgical techniques for hemostasis in Osler–Weber–Rendu disease. Pol Ann Med. 2015;22(1):50–54. https://doi.org/10.1016/j.poam....
 
6.
Christian SJ, Lauren BG. Management of gastrointestinal angiodysplasia lesion (GIADs): A systemic review and meta-analysis. Am J Gastroenterol. 2014;109(4):474–483. https://doi.org/10.1038/ajg.20....
 
7.
Chandra S, Tripathi AK, Mishra S, Amzarul M, Vaish AK. Physiological changes in hematological parameters during pregnancy. Indian J Hematol Blood Transfus. 2012;28(3):144–146. https://doi.org/10.1007/s12288....
 
8.
Nardone G, Compare D, Martino A, Rocco A. Pharmacological treatment of gastrointestinal bleeding due to angiodysplasias: A position paper of the Italian Society of Gastroenterology (SIGE). Dig Liver Dis. 2018;50(6):542–548. https://doi.org/10.1016/j.dld.....
 
9.
Frost J, Sheldon F, Kurup A, Disney BR, Latif S, Ishaq S. An approach to acute lower gastrointestinal bleeding. Frontline Gastroenterol. 2017;8(3):174–182. https://doi.org/10.1136/flgast....
 
10.
Kwan V, Bourke MJ, Williams SJ, et al. Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: Experience in 100 consecutive patients with long-term follow-up. Am J Gastroenterol. 2006;101(1):58–63. https://doi.org/10.1111/j.1572....
 
11.
Romagnuolo J, Brock AS, Ranney N. Is endoscopic therapy effective for angioectasia in obscure gastrointestinal bleeding?: A systematic review of the literature. J Clin Gastroenterol. 2015;49(10):823–830. https://doi.org/10.1097/mcg.00....
 
12.
Jackson CS, Strong R. Gastrointestinal angiodysplasia: Diagnosis and management. Gastrointest Endosc Clin N Am. 2017;27(1):51–62. https://doi.org/10.1016/j.giec....
 
13.
Tsai Y-Y, Chen B-C, Chou Y-C, et al. Clinical characteristics and risk factors of active bleeding in colonic angiodysplasia among the Taiwanese. J Formos Med Assoc. 2019;118(5):876–882. https://doi.org/10.1016/j.jfma....
 
14.
Filograna L, Filograna E, D’Onofrio A, Flor N, Haddad Y, Floris R. Colonic angiodysplasia on CT colonography: Case report and characteristic imaging findings. Radiol case reports. 2017;12(4):693–696. https://dx.doi.org/10.1016%2Fj....
 
15.
Junquera F, Quiroga S, Saperas E, et al. Accuracy of helical computed tomographic angiography for the diagnosis of colonic angiodysplasia. Gastroenterology. 2000;119(2):293–299. https://doi.org/10.1053/gast.2....
 
16.
Hara H, Ozawa S, Nabeshima K, Koizumi J. Successful laparoscopic surgery combined with selective arterial embolization for bleeding due to jejunal angiodysplasia: a case report. BMC Surg. 2020;20(1):262. https://doi.org/10.1186/s12893....