S4801 AVMs Reloaded: The Sequel Nobody Wanted

Introduction: Gastrointestinal arteriovenous malformations (AVMs), or angiodysplasias, are a common yet elusive cause of lower GI bleeding in elderly patients. They are often associated with comorbidities such as chronic kidney disease, aortic stenosis (Heyde’s syndrome), and anticoagulant use. Management becomes incredibly challenging when AVMs coexist with inflammatory bowel disease (IBD), prior surgeries, and poor surgical candidacy. Despite advances in endoscopic therapy, many patients experience recurrent bleeding requiring multimodal strategies. Case Description/Methods: Our patient is an 82-year-old woman with a complex medical history, including Crohn’s ileocolitis status post ileocolectomy, complicated by fistulizing disease and 7 bowel resections, end-stage renal disease on hemodialysis, moderate aortic stenosis, and recurrent colonic AVMs. She is a longstanding patient on Vedolizumab and oral Vancomycin for recurrent Clostridioides difficile colitis. Her gastrointestinal history is notable for 7 colonoscopies since 2022, all demonstrating active or recent colonic bleeding. AVMs were repeatedly identified throughout the colon, particularly in the splenic flexure, descending, and ascending segments, and were managed with argon plasma coagulation (APC), endoscopic clipping, and epinephrine injection. Despite these interventions, she experienced recurrent bleeding requiring transfusions. Multiple push enteroscopies and ileoscopy failed to identify a small bowel source. Given the refractory nature of her bleeding, she was initiated on monthly octreotide injections, resulting in stabilization of hemoglobin levels, reduced transfusion requirements, and improved functional status. Discussion: This case illustrates the diagnostic and therapeutic complexities of managing recurrent AVMs in a high-risk host with inflammatory bowel disease, end-stage renal disease, and aortic stenosis. Repeated colonoscopies may achieve temporary hemostasis but do not prevent recurrence. Endoscopic fatigue in AVM management is well described and warrants timely consideration of adjunctive pharmacologic therapies. Somatostatin analogs like octreotide reduce splanchnic blood flow and may suppress angiogenesis, providing durable bleeding control in medically fragile patients. In this case, octreotide was associated with clinical stabilization and transfusion independence. A multidisciplinary approach integrating gastroenterology, hematology, nephrology, and cardiology is essential for optimizing outcomes in patients with multifactorial anemia and AVM recurrence.