<P> Digestive tract telangiectasias may be identified on esophagogastroduodenoscopy (endoscopy of the esophagus, stomach and first part of the small intestine). This procedure will typically only be undertaken if there is anemia that is more marked than expected by the severity of nosebleeds, or if there is evidence of severe bleeding (vomiting blood, black stools). If the number of lesions seen on endoscopy is unexpectedly low, the remainder of the small intestine may be examined with capsule endoscopy, in which the patient swallows a capsule - shaped device containing a miniature camera which transmits images of the digestive tract to a portable digital recorder . </P> <P> Identification of AVMs requires detailed medical imaging of the organs most commonly affected by these lesions . Not all AVMs cause symptoms or are at risk of doing so, and hence there is a degree of variation between specialists as to whether such investigations would be performed, and by which modality; often, decisions on this issue are reached together with the patient . </P> <P> Lung AVMs may be suspected because of the abnormal appearance of the lungs on a chest X-ray, or hypoxia (low oxygen levels) on pulse oximetry or arterial blood gas determination . Bubble contrast echocardiography (bubble echo) may be used as a screening tool to identify abnormal connections between the lung arteries and veins . This involves the injection of agitated saline into a vein, followed by ultrasound - based imaging of the heart . Normally, the lungs remove small air bubbles from the circulation, and they are therefore only seen in the right atrium and the right ventricle . If an AVM is present, bubbles appear in the left atrium and left ventricle, usually 3--10 cardiac cycles after the right side; this is slower than in heart defects, in which there are direct connections between the right and left side of the heart . A larger number of bubbles is more likely to indicate the presence of an AVM . Bubble echo is not a perfect screening tool as it can miss smaller AVMs and does not identify the site of AVMs . Often contrast - enhanced computed tomography (CT angiography) is used to identify lung lesions; this modality has a sensitivity of over 90% . It may be possible to omit contrast administration on modern CT scanners . Echocardiography is also used if there is a suspicion of pulmonary hypertension or high - output cardiac failure due to large liver lesions, sometimes followed by cardiac catheterization to measure the pressures inside the various chambers of the heart . </P> <P> Liver AVMs may be suspected because of abnormal liver function tests in the blood, because the symptoms of heart failure develop, or because of jaundice or other symptoms of liver dysfunction . The most reliable initial screening test is Doppler ultrasonography of the liver; this has a very high sensitivity for identifying vascular lesions in the liver . If necessary, contrast - enhanced CT may be used to further characterize AVMs . It is extremely common to find incidental nodules on liver scans, most commonly due to focal nodular hyperplasia (FNH), as these are a hundredfold times more common in HHT compared to the general population . FNH is regarded as harmless . Generally, tumor markers and additional imaging modalities are used to differentiate between FNH and malignant tumors of the liver . Liver biopsy is discouraged in people with HHT as the risk of hemorrhage from liver AVMs may be significant . Liver scans may be useful if someone is suspected of HHT, but does not meet the criteria (see below) unless liver lesions can be demonstrated . </P>

Family history of hereditary hemorrhagic telangiectasia icd 10