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Diagnostic Dilemma

Diagnostic Dilemma

Colonoscopy was performed on this asymptomatic 72-year-old man with colonic adenomatous polyps.

  1. The photograph reveals:
    a. An adenomatous polyp
    b. A lipoma
    c. An arteriovenous malformation
  2. The most appropriate treatment in this patient is:
    a. Observation
    b. Surgical resection
    c. Medical therapy with estrogens
    d. Endoscopic therapy with laser, cautery, or heater probe

The correct answer to question 1 is c. The photograph obtained during colonoscopy illustrates a dramatic example of a coincidentally detected arteriovenous malformation (AVM), a relatively common finding in people over 60 years old.

AVMs are also referred to as angiodysplasias and vascular ectasias. They are generally flat or slightly raised. Rarely, they can present as polypoid lesions. The delicate vascular network can be appreciated in this photograph. The pattern has been described as a coral reef.

AVMs can cause gastrointestinal bleeding and are among the most common causes of lower gastrointestinal bleeding in the elderly. The bleeding is usually self-limited or occult but can be massive. Patients with AVMs may present with iron deficiency anemia, melena, or hematochezia.

The correct answer to question 2 is a. The most appropriate treatment in this asymptomatic patient is observation. Surgical resection should be avoided since these lesions can be multifocal and less invasive options exist when therapy is indicated. Various forms of endoscopic therapy—including cautery, laser, and heater probe—appear to be of benefit.

Although hormonal therapy is used in some patients with multiple arteriovenous malformations and intractable bleeding, the benefit of such therapy has not been proven.

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