Octreotide as an Effective Alternative for Managing Refractory GI Bleeding in Hereditary Hemorrhagic Telangiectasia

Introduction: Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant genetic disorder that affects multiple organs, leading to the development of telangiectasias and arteriovenous malformations (AVMs). Gastrointestinal AVMs, primarily found in the stomach and small bowel, commonly occur in individuals 50-60 years of age, often present with anemia or GI hemorrhage. Managing symptomatic cases can be challenging, especially in patients who have not responded to standard endoscopic therapy and are not suitable candidates for surgery. Here, we present a case where octreotide was successfully utilized, resulting in the resolution of symptoms. Case Description/Methods: A 59-year-old man with a history of HHT, epistaxis, COPD and pulmonary hypertension presented with exertional dyspnea. Physical examination revealed angiectasias on the palate, tongue, and lips (Figure 1A) with conjunctival pallor. Laboratory workup showed anemia (Hgb of 6) and a normal metabolic panel. He received blood transfusions for his anemia. Endoscopy revealed multiple angiectasias in the stomach and duodenum (Figure 1B), which were treated with argon plasma therapy and had normal findings on colonoscopy. Despite treatment, the patient experienced persistent drops in hemoglobin without evidence of overt bleeding. A wireless video capsule endoscopy identified multiple gastroduodenal AVMs with recent bleeding (Figure 1C). Due to the extensive nature of the angiectasias and the patient's poor surgical candidacy, he was initiated on subcutaneous octreotide 200 mg subcutaneously twice daily during hospitalization and transitioned to long-acting octreotide, 20 mg once a month for 6 months after discharge. The patient's hemoglobin stabilized at 9.8 during a 6-month follow-up period, with no further episodes of gastrointestinal bleeding. Discussion: GI bleeding in HHT can present with varying severity, and treatment options include local therapies such as APC or resection. Systemic therapies like bevacizumab and thalidomide have shown only moderate evidence of effectiveness. However, octreotide, a somatostatin analog that reduces mesenteric blood flow, can be used in managing refractory GI bleeding caused by AVMs. With its favorable safety profile, octreotide can be a promising alternative for non-surgical candidates. Therefore, it should be considered as a valuable option in the management of refractory GI bleeding in patients with HHT.Figure 1.: Clinical and endoscopic findings. A - angiectasias on the palate, tongue, and lips, B - multiple non bleeding angiectasias in the second portion of the duodenum & C - Capsule endoscopy showing multiple duodenal AVMs with recent bleeding.