An unusual cause of upper gastrointestinal haemorrhage

Clinical presentation

A 59 year old man presented with melena. There was no history of non-steroidal anti-inflammatory drug use, peptic ulcer, or chronic liver disease. He had a history of iron deficiency anaemia for the past five years that required oral iron supplements intermittently. Previous oesophagogastroduodenoscopy and colonoscopy were negative.

Physical examination disclosed bluish vascular lesions on the upper trunk and undersurface of the tongue (fig 1A, 1B). Laboratory investigations revealed a haemoglobin level of 4.2 mg/dl and haematocrit of 15%, but normal international normalised ratio and platelet count. Oesophagogastroduodenoscopy and colonoscopy on an emergent basis were negative.

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Figure 1

 Physical examination of the patient revealed bluish vascular lesions on the upper trunk (A) and on the undersurface of the tongue (B).

Question

What further investigation should be obtained to make a definitive diagnosis? What is the most likely diagnosis?

See page 373 for answer

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