Demented Patient with Melena for 2 Days - Where is the Source? AVM

87 yo AAM with a PMH of CVA, Dementia and HTN is admitted to the hospital after his wife called his primary care physician and told him that her husband was having tarry black stools for the last 2 days.

PMH:
CVA, dementia, HTN, bowel and bladder incontinence, colonoscopy one month ago which showed diverticulosis.

Medications:
HCTZ, ACEi, Namenda, Aricept, Plavix (for CVA history). Not on ASA.

Physical Examination:
Pleasant gentleman looking comfortable, in NAD
VS stable
Abdomen: benign
Rectal exam: Brown stool, FOBT+

What do you think is going on?
PUD?
Gastritis?
Lower GI bleed is less likely, especially with the history of melena

What to do?
EGD?

First, you have to check the orthostatics, and if the patient is orthostatic (remember the "20-10-20" rule, i.e. changes in SBP-DBP-HR), he needs a NS bolus.

In addition, type and screen 2U PRBC and check H&H STAT.

What happened?
The patient went straight to the GI lab and had an EGD early the same morning. He was not orthostatic and had no complaints.


EGD (click to enlarge)

The EGD "on entry" showed a Schatzki ring in the esophagus, and when we entered the stomach there was a mild gastric erythema.

A careful lookup revealed the source -- a flat AVM on the stomach wall. There was a small clot which was washed away with a NS flush and there was no further bleeding. The AVM was 3 mm in size, visible as a bright red spot on the close-up view.

Next, we took a look at the duodenum "pushing" through the antrum "door" and it was normal.

Final diagnosis:
AVM of the stomach.

The bleeding was due in part to Plavix. No cauterization was done because there was no active bleeding and the procedure itself may precipitate bleeding in patients on Plavix.

What happened?


Labs (click to enlarge)

Hgb showed a drop of 1.5 gm as compared to one month ago and patient was admitted to 23 hour observation service.

Plavix was held.

Repeated H&H q 8 hr did not show any further drop in the Hgb and the patient was discharged home the next day.

When we showed his wife the EGD pictures, she remembered that her husband had a similar bleeding 2 years ago and it was due to an AVM which was cauterized.

She was the same age as the patient and probably had a mild cognitive deficit as well.

What did we learn from this case?
Remember that that dementia may affect not only the patient but also the caregiver.
Plavix may lead to upper GI bleed.
Think about AVM as cause of upper and lower GI bleeds.

References:
Arteriovenous Malformations - The Merck Manual of Diagnosis and Therapy