A rare cause of small bowel bleeding
A 57-year-old Caucasian woman presented with lethargy and malaise following an episode of malaena. She was haemodynamically stable. Her haemoglobin was 7.5 g/dL, and the clotting profile was normal. She was transfused with four units of blood. Gastroscopy revealed a 5 mm chronic gastric ulcer, which had no stigmata of recent haemorrhage. Therefore, colonoscopy was also undertaken. This showed two small polyps, which were resected, but no bleeding point was identified. The patient remained stable, so she was discharged home with a follow-up for video capsule endoscopy (VCE).\nHer past medical history included primary angiosarcoma of the right breast two years previously, which was treated with right mastectomy, partial lymph node clearance and an adjuvant course of radical radiotherapy. She also had a history of hypertension. A year later, she had presented with a single metastatic skin deposit, which was treated with surgical excision.\nThe patient was re-admitted two days later with further malaena. Repeat haemoglobin had dropped to 6.6 g/dL and therefore further blood transfusion was given. An urgent VCE was performed which showed an active bleeding in the small bowel (Figure ). Computerized tomography angiogram of the abdomen showed multiple metastatic liver deposits, as well as evidence of a tumour at the jejuno-ileal junction of the small bowel (Figures a and b). Urgent laparotomy was performed and the bleeding lesion was resected. The patient made an uneventful recovery and was discharged home a few days later. The histological features were consistent with metastatic angiosarcoma (Figures a–c).\nFour months later, the patient had required further blood transfusion, although she did not report any malaena. She was referred to a specialist Sarcoma unit and commenced on Abraxane chemotherapy, but had progressive metastatic liver disease for which she was treated palliatively with doxorubicin. The patient died of progressive disease, 11 months after the first episode of small bowel haemorrhage, and 35 months after diagnosis of the primary breast tumour.