An unusual multiplex cause of severe gastrointestinal bleeding in a haemodialysed patient

Gastrointestinal bleeding is a frequent and sometimes life‐threatening complication of end‐stage renal disease. The most important causes of bleeding are vascular malformations, peptic ulcers, erosive gastritis and oesophagitis, colonic and rectal ulcers, and diverticular disease [1]. In the spectrum of these abnormalities, vascular malformations have a very specific place, because diagnosis often is difficult and treatment is frequently frustrating [2,3]. A 77‐year‐old female patient has had a history of hypertension since 1966 and according to past medical history, she had not been treated optimally. End‐stage renal disease was diagnosed in January 1998. Blood pressure was 200/100 mmHg, serum creatinine 441 μmol/l, urea nitrogen 34.7 mmol/l, creatinine clearance 9.8 ml/min, and serum potassium 6.3 mmol/l. The patient had severe metabolic acidosis. The suspected renal diagnosis was hypertensive nephrosclerosis. Chest X‐ray showed cardiac enlargement, ECG showed left ventricular hypertrophy and the patient had evidence of diffuse atherosclerosis. Both kidneys were small (87×29 mm and 94×32 mm). Haemodialysis was started in January of 1998. Since that time, severe anaemic episodes occurred on seven occasions (lowest haematocrit 10.7%, haemoglobin 3.6 g/dl, and serum iron 2.7 μmol/l), which required multiple blood transfusions and was resistant to iron supplementation, human recombinant erythropoietin, and anti‐ulcer drug treatment. She required a total of 29 units of packed red blood cells over a 4‐month period. The investigations excluded any coagulation abnormalities, haematological and gynecological diseases. Although there was no evidence of manifest bleeding, the patient's stool was consistently positive for occult blood.