Bleeding angiodysplasia of the major duodenal papilla: how should it be handled?

Angiodysplasia is characterized by degenerative vascu-lar dilation of the capillary net in the absence of dysplas-tic tissue. On endoscopy, flat or slightly elevated, reddish, roundish or starry lesions are observed, measuring normally between 2 and 10 mm. Angiodysplasia is a frequent cause of unexplained upper gastrointestinal bleeding with significant morbidity. 1 It often occurs in the gastric antrum but may also occur in the duodenum and rarely in the esophagus. In the small bowel, it is the cause of unclear gastrointestinal bleeding in 30% to 40 % of the cases. The incidence of this lesion increases with age. Diagnosis may be established by upper digestive endoscopy, scin-tigraphy with marked erythrocytes, selective angiography, and also by wireless endoscopy. We report a rare case of angiodysplasia of the major duodenal papilla in a patient with chronic iron deficiency anemia of unexplained etiology. A 76-year-old woman, Caucasian, with a history of weakness, asthenia, and myalgia, was investigated for chronic iron deficiency anemia. On physical examination she presented discolored mucosae, without other abnormalities. On a previously performed colonoscopy and upper digestive endoscopy, no lesions that might have caused anemia were seen. Scintigraphy with labelled red blood cells and arteriography did not show a hemorrhagic source of bleeding. Capsule endoscopy was performed, but no abnormality was found. Laboratory test results were as fol-100% with INR equal to 1. Another upper digestive endoscopy was performed and showed a lesion with blood seepage in the second portion of the duodenum. Using a duodenoscope with lateral vision, a flat, roundish, reddish lesion of approximately 10 mm was observed on the major duodenal papilla, showing active oozing of blood, suggestive of a vascular lesion (Figure 1). Because the le-sion occupied the apical third of the major duodenal pa-pilla, endoscopic resection was elected (Figure 1). By means of papillectomy employing a 20-mm mono-filament polypectomy snare, a cutting current of 45 W was used, followed by biliary papillotomy and placement of a 5Fr X 7 cm pancreatic plastic stent under fluoroscopic control , which was removed 3 weeks later. There were no complications from this procedure, and the patient was discharged within 2 days. Duodenoscopy, performed 60 days later, showed retraction of the resection bed with spontaneous drainage of clear bile. Histology revealed an angiodysplastic vascular lesion with predominance of duodenal papilla arteriolar vessels. Figure 1-Endoscopic image of the vascular lesion on the major duodenal papilla with complete involvement of the …