PMC2742646_01
Massive gastrointestinal bleeding from an ArterioVenous malformation within a jejunal diverticulum. Superior Mesenteric Angiography (a)-(c) revealed active extravasation (arrow) of the contrast material in the proximal jejunum and pooling of the same (arrow) in the jejunum (c). Intraoperative plain film X-ray obtained during segmental resection of the proximal jejunum (d, e) revealed the presence of two diverticula (stars), located on the mesenteric side. The arrow marks the diverticulum that was the source of hemorrhage, as determined by the presence of the radio opaque angiographic coil which was previously deployed during angiographic intervention. The specimen from segmental jejunal resection (f, g) shows blood clot within the diverticula.
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fig1
Selective splanchnic arterial angiography showed extravasation of contrast from the mid-jejunal branch of the superior mesenteric artery (Figures 1(a), 1(b), and 1(c)). Intraoperatively, two jejunal diverticula were identified on the mesenteric border (Figures 1(d) and 1(e)); one of them with previously placed endovascular coil (arrow) implicated as the source of bleeding. A curative resection of the segment of jejunum containing the two diverticula was performed (Figures 1(f) and 1(g)).
Histopathologic examination by a low power microscopy and hematoxylin and eosin staining confirmed that both diverticula were composed of all layers of the intestinal wall: mucosa, muscularis mucosa, and muscularis propria (a), which is characteristic of true diverticula. A thorough examination of sections through the base of the culprit diverticulum revealed the presence of cavernous spaces (stars) lined by endothelium, interspersed by loose connective tissue (arrowhead), but often communicating with each other (b,c), consistent with the presence of submucosal ArterioVenous malformation.
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fig2
Histopathologic examination confirmed this as true diverticula (Figure 2(a)) with a submucosal Dieulafoy-like AVM surrounded by normal mucosa as the source of bleeding (Figures 2(b) and 2(c)).