61-year-old woman with multiple previous hospitalizations for gastrointestinal bleeding episodes, with a history of mitral valvulopathy with protuberty valve replacement and woman receiving acenocoumarol.
In April 2011, the patient was admitted for intestinal bleeding of unknown origin and severe iron deficiency anemia. Gastroscopy and capsule endoscopy were performed without significant findings. After this, the INR range was reduced to 2.5-3.
Two months later, an episode of intestinal bleeding was observed, after which a capsule endoscopy was again performed, showing intestinal dysplasias of the duodenum and another without evidence of a new cause of ileum bleeding due to terminal ileum.
He later presented three admissions for the same reason, requiring multiple units of concentrates.
Up to and midfoot enteroscopy was performed during which there was no evidence of angiodysplasia, making it impossible to assess the existence of ileal angiodysplasia.
At the last admission he had a hemoglobin of 10.5 g, with a hematocrit of 0.340 L/L and a mean corpuscular volume of 25.7 pg.
After this new episode, and persisting bleeding episodes, without finding clear lesions in which to perform other measures such as electrofulguration or surgery, it was decided to use thalidomide, in a 50 mg daily dose.
During three months the patient was asymptomatic, with hemoglobin levels of 124 g/L and negative fecal occult blood test maintained over time.
After this period, she was admitted for presenting a significant deterioration of her general condition, with dyspnea on minimal exertion, apnea, male-to-female edema and no chest pain.
Urgent echocardiography was requested, which was reported as severe pulmonary hypertension with a PSAP (pressure itself as a pulmonary artery ultrasound) of 100mmHg (previously at the beginning of treatment with thalidomide, pulmonary embolism was ruled out)
There was no evidence of other causes justifying the increase in PSAP, so its discontinuation and treatment with monthly lanreotide was initiated.
