An 82-year-old woman is brought to the emergency department after 2 episodes of large bloody bowel movements. She has no abdominal pain or vomiting. Her past medical history is significant for paroxysmal atrial fibrillation and hypertension. She takes daily low-dose aspirin.
Her blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 14/min. Abdominal examination reveals no tenderness or organomegaly.
Laboratory results are as follows:

While in the emergency department, the patient has another bloody bowel movement accompanied by transient dizziness and diaphoresis. Upper gastrointestinal endoscopy and colonoscopy reveal no source of bleeding.
Which of the following is the most likely additional physical finding on chest examination?

Question

An 82-year-old woman is brought to the emergency department after 2 episodes of large bloody bowel movements.  She has no abdominal pain or vomiting.  Her past medical history is significant for paroxysmal atrial fibrillation and hypertension.  She takes daily low-dose aspirin.
Her blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 14/min.  Abdominal examination reveals no tenderness or organomegaly.
Laboratory results are as follows:

While in the emergency department, the patient has another bloody bowel movement accompanied by transient dizziness and diaphoresis.  Upper gastrointestinal endoscopy and colonoscopy reveal no source of bleeding.
Which of the following is the most likely additional physical finding on chest examination?

Quizplus · Accepted Answer

Lower gastrointestinal bleeding is typically due to anatomic conditions (eg, diverticulosis), vascular causes (eg, arteriovenous malformation [AVM]), inflammatory diseases (eg, inflammatory bowel disease), or malignancy. This patient's normal gastrointestinal endoscopy and colonoscopy make diverticulosis, malignancy, inflammatory bowel disease, and hemorrhoids less likely. She likely has intestinal angiodysplasia or AVM, which are abnormal connections between veins and arteries that can erode through the gastrointestinal mucosa and bleed. Angiodysplasia usually presents in patients age > 60 and can occur in 1 or multiple areas of the gastrointestinal tract. Angiodysplasia is often discovered in patients with underlying aortic stenosis or end-stage renal disease. In aortic stenosis, turbulent blood flow through the valve causes disruption of von Willebrand multimers (acquired von Willebrand disease). This leads to increased risk of bleeding, resulting in identification of angiodysplasia. The bleeding tends to improve with aortic valve replacement, but patients usually require endoscopic treatment for active bleeding. This patient's physical examination would likely indicate a systolic crescendo-decrescendo murmur that radiates to the carotid arteries. Uremic platelet dysfunction in end-stage renal disease also increases bleeding risk, leading to identification of angiodysplasia. (Choices B, C, and D) Holosystolic murmur is due to tricuspid regurgitation, mitral regurgitation, and ventricular septal defect. Aortic regurgitation leads to a diastolic decrescendo murmur. Mitral stenosis presents with a mid-diastolic rumble and is unlikely in this elderly patient. These valvular conditions are usually not associated with angiodysplasia. (Choice E) Pericardial knock is an earlier-than-normal S3 that occurs due to restricted ventricular filling during diastole. It is usually seen in constrictive pericarditis and is usually not associated with angiodysplasia. Educational objective: Arteriovenous malformation can present with significant lower gastrointestinal bleeding and chronic iron deficiency anemia. It is found more commonly in elderly patients with end-stage renal disease and aortic stenosis. __________ References: Diagnosis and management of lower gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/19881516) An epidemiological study of Heyde's syndrome: an association between aortic stenosis and gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/15473467)

An 82-Year-Old Woman Is Brought to the Emergency Department After