Case 189 -- Gastrointestinal Bleeding and a History of Rheumatoid Arthritis

Contributed by Kevin D Horn, MD, Jawad Ahmad, MD* and Sydney Finkelstein, MD
    *Department of Gastroenterology, University of Pittsburgh Medical Center.
Published on line in April 1999


The patient is a 52 year old woman with a recent history of myocardial infarction, and a long standing history of rheumatoid arthritis with severe joint deformities in both hands, including a gangrenous left fifth digit. She also has a history of multiple deep venous thromboses of the lower extremities. A vague history of possible systemic lupus erythematosus is also reported (constituting a possible mixed connective tissue disorder). She is on multiple medications, including Coumadin and hydrocortisone (100 mg every 8 hours) for her joint disease. The patient has a long history of borderline adrenal gland insufficiency, which is likely a result of the chronic administration of systemic steroids. She presents to the hospital with complaints of fatigue and is noted to be anemic on complete blood count, which reveals a hemoglobin of 8.1 with a hematocrit of 23.9. A rectal exam is guaiac positive for blood. The patient is scheduled for colonoscopy to evaluate the source of the gastrointestinal bleeding.


Colonoscopy demonstrates diffuse vascular ectatic lesions from the level of the mid-transverse colon to the cecum. Multiple diffuse vascular lesions are noted in the right hemicolon, including the cecum, ascending colon and proximal transverse colon. Although no active bleeding is noted at the time of colonoscopy, these lesions are thought to represent the most probable source of the heme positivity in the stool. Etiologies which are considered for the lesions evaluated endoscopically include vasculitis, arteriovenous malformations, angiodysplasia, or lesions of cytomegalovirus infection. Two biopsies are procured from the right colon; one is sent for histopathologic study, and the second is sent for CMV studies. CMV is not detected in these subsequent studies.


The specimen is received in formalin and consists of an irregularly shaped fragment of tan-pink mucosal tissue measuring 0.1 cm in greatest dimension.



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