The Journal of the Arkansas Medical Society Med Journal April 2020 | Page 18

the proximal-to-mid small bowel. Repeat push
enteroscopy was performed and showed multiple
jejunal AVMs but could not rule out distal small
bowel AVMs. General surgery was consulted to
evaluate for possible bowel resection but felt that
it was not feasible due to the extensive nature of
the patient’s AVMs, and they agreed with GI’s
recommendation to start octreotide.
Hematology was consulted for assistance for re-
fractory GI bleed secondary to extensive AVMs,
and they recommended a trial of thalidomide 100
mg PO daily for four months. Due to continued GI
bleeding, the patient required a total of 12 units
of packed red blood cells during her first month
of her hospitalization prior to approval and com-
mencement of thalidomide. GI continued to fol-
low due to continued bleeding, and they did not
feel that the patient would benefit from further
endoscopic investigation or therapy. They rec-
ommended continuing medical management and
suggested a three-week trial of estrogen therapy
as a possibility. The patient required a total of 19
units of packed red blood cells during her 49-day
hospital course. Her last transfusion was 12 days
following initiation of thalidomide treatment, and
patient subsequently had complete resolution of
her melena.
Discussion
Effective treatment options beyond hormon-
al agents were quite elusive in the treatment of
gastrointestinal angiodysplasias until thalidomide
came into the picture, especially considering the
risk of recurrent bleeding and hospitalizations
and the associated cost of morbidity and mortali-
ty resulting from this condition [1-2] . of risks and benefits gives many patients the op-
tion of outpatient therapy with marked reduction
in the number of transfusions and hospital stays.
Thalidomide is a known teratogenic drug with
suppressive action on tumor necrosis factor
alpha and an effective inhibitor of angiogene-
sis, which was shown to be efficacious in the
treatment of severe intestinal bleeding as early
as 2002 in patients with other chronic intestinal
bleeding such as from Crohn’s disease [3] . Later it
was shown to be effective for bleeding angiodys-
plasias [4] and is now a viable option beyond rou-
tine endoscopic care in many hospitals. Of note
in our case, the patient became discouraged by
her continued melena one week into treatment
with thalidomide and wished to discuss starting
estrogen therapy in addition to continuing trial of
thalidomide. Risks were discussed extensively
with the patient regarding treatment with thalid-
omide and estrogen therapy concurrently. It was
explained at length to the patient that concurrent
treatment with thalidomide and estrogen ther-
apy would present a likely unprecedented and
uncharacterized risk for deep vein thrombosis.
Additionally, it was explained to the patient that
because she still had her uterus, she would be at
risk for endometrial hyperplasia and subsequent
malignancy. Ultimately, the patient elected to de-
fer trial of estrogen therapy. Use with caution, as
with any chemotherapeutic agent, and awareness 1. Junquera F, Feu F, Papo M et al. A multicenter
randomized, clinical trial of hormonal therapy in
the prevention of re bleeding from gastrointesti-
nal angiodysplasia. Gastroenterology 2001 Nov;
121(5):1073-1079 [PMID: 11677198]
References
2. Ge ZZ, Chen HM, Gao YJ et al. Efficacy of
thalidomide for refractory gastrointestinal bleed-
ing from vascular malformation. Gastroenter-
ology 2011 Nov 14; 141(5):1629-1637 [PMID:
21784047]
3. Bauditz J, Schachschnal G, Wdel S, Lochs H.
Thalidomide for treatment of severe intestinal
bleeding. Gastroenterology 2002; 122:A194.
4. Shurafa M, Kamboj G. Thalidomide for the
treatment of bleeding angiodysplasias. Am J
Gastroenterol 2003 Jan; 98: 221-222[ PMID
12526972]
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