An unusual superior mesenteric arteriovenous malformation causing obscure gastrointestinal bleeding: a case report

Lower gastrointestinal bleeding (LGIB) frequently presents a diagnostic challenge, particularly in liver cirrhosis and portal hypertension patients, as it accounts for about 20-25% of major gastrointestinal bleeding cases. The presence of multiple possible sources of bleeding, among which vascular abnormalities, increases the risk of recurrent bleeding, and clinically significant anemia. Mesenteric arteriovenous malformations (AVMs) are one of the rare high-flow vascular lesions that may lead to gastrointestinal bleeding through arterial blood being diverted to the veins and venous hypertension. As the findings of an endoscopic examination can be unclear, cross-sectional angiographic imaging is indispensable for diagnosis and treatment planning.

A 71-year-old man with decompensated alcoholic liver cirrhosis and a history of recurrent gastrointestinal bleeding presented with two days of hematochezia and worsening anemia. Despite prior endoscopic treatment of esophageal varices, gastric antral vascular ectasia, and colonic AVMs, no active bleeding source was identified on repeat endoscopy. Contrast- enhanced computed tomography angiography demonstrated a high-flow mesenteric vascular nidus supplied by the superior mesenteric artery, with early venous drainage into the right renal vein, consistent with a mesenteric arteriovenous malformation. The patient was successfully managed with endovascular embolization, resulting in stabilization of hemoglobin levels and cessation of overt gastrointestinal bleeding.

In patients with liver cirrhosis having various sites of possible bleeding, mesenteric arteriovenous malformations must be included in the differential diagnosis of obscure or recurrent lower gastrointestinal bleeding. This case highlights an exceptionally rare vascular configuration, with arterial supply from the superior mesenteric artery and anomalous systemic venous drainage into the right renal vein. Comprehensive angiographic imaging is essential for accurate diagnosis, anatomical characterization, and appropriate management of these complex vascular lesions.