Pericardial cyst presented in an unusual location

A 75-year-old man was referred in February 2007 for push enteroscopy, for the management of angiodysplasia. Between 2005 and 2007, he required transfusion of 43 units of packed cells. There was history of moderate chronic obstructive airway disease, but no history of valvular heart disease, antiplatelet therapy or warfarin. Previous gastroscopy confirmed duodenal angiodysplasia, colonoscopy was normal and capsule endoscopy showed tiny red spots in the proximal duodenum. Push enteroscopy was undertaken and angiodysplasia was treated in the second part of the duodenum using argon plasma coagulation (APC) at 50 W. The patient was readmitted every 1–2 months with melaena. Each time endoscopy confirmed bleeding from the duodenum. Each time, the bleeding area was treated with APC, adrenaline, electrocautery or clipping, with control of bleeding by the end of the procedure. In September 2008, tranexamic acid was commenced for persistent bleeding. By May 2009, he required 100 units of packed cells despite treatment and was readmitted with further bleeding. At gastroscopy, the duodenal bleeding site was marked using endoscopic clips and the patient underwent angiography. Angiography confirmed increased vascularity between the two clips (Fig. 1); the vessel of interest was catheterized and coiled. The patient was discharged 2 days later and has maintained normal haemoglobin for the last 4 months. Angiodysplasias are dilated capillaries and may occur anywhere in the gastrointestinal tract. They are more common with increasing age, in patients with aortic stenosis, end-stage renal failure and Von Willebrand’s disease. Angiodysplasia is a common cause of obscure gastrointestinal bleeding. First-line therapy is endoscopy with APC or electrocautery. Medical therapies including oestrogen/ progesterone, tranexamic acid, and thalidomide have been used with variable efficacy. Surgical resection is sometimes helpful especially for colonic angiodysplasia. In this case, clip-guided angiography with coiling was beneficial. Clip-guided angiography should be considered as part of the treatment algorithm for treatment-resistant angiodysplasia.