Angiodysplasia

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Angiodysplasia

• By
• Ahmed C. Khalifa

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Historical background

• 1839 Phillips first described a vascular
  abnormality that caused bleeding from the large
  bowel in a letter to the London Medical Gazette.
• 1920s, neoplasms were considered the major source
  of GI hemorrhage.
• 1940s and 1950s diverticular disease was
  recognized as an important source of bleeding.
• 1951 Smith described active bleeding from a
  diverticulum visualized through a sigmoidoscope.
• 1960 Margulis and colleagues identified a
  vascular malformation in the cecum of a
  69-year-old woman who presented with massive
  bleeding. This diagnosis was accomplished with
  operative mesenteric arteriography.
• 1974 Galdabini first used the name angiodysplasia

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• Important vascular GI lesion representing a
  source of significant morbidity from bleeding.
• Recognized more frequently now because endoscopy
  and angiography are used more extensively.
• Degenerative lesion of previously healthy blood
  vessels and is typically nonpalpable and small
  (lt5 mm).
• Solitary or multiple vascular lesions.
• Not associated with angiomatous lesions of the
  skin or other viscera.

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• Most common vascular abnormality of the GI tract.
  
• Second leading cause of lower GI bleeding after
  diverticulosis in patients older than 60.
• 6 of cases of lower GI bleeding.
• Incidental finding in 0.8 of patients older than
  50.
• Small bowel angiodysplasia may account for 30-40
  of cases of GI bleeding of obscure origin.
• Site 77 cecum and ascending colon
• 15 jejunum and ileum
• 8 throughout alimentary tract

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Presentation

• Patients may present with maroon-colored stool,
  melena, hematochezia, or even hematemesis.
• Bleeding usually is low-grade, but about 15 of
  patients present with massive hemorrhage.
• In 20-25 of episodes, only tarry stools are
  passed.
• In 10-15 of patients, only iron deficiency
  anemia and stools that are intermittently
  positive for occult blood are evidence of
  bleeding.
• Bleeding stops spontaneously in over 90

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PathophysiologyMost prominent theory

• Repeated episodes of colonic distention
  associated with transient increases in lumen
  pressure and size.
• This results in multiple episodes of increasing
  wall tension with obstruction of submucosal
  venous outflow,
• Over many years, this process causes gradual
  dilation of the submucosal veins and, eventually,
  dilation of the venules and arteriolar capillary
  units feeding them.

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III.Epidemiology

• Frequency
• US Incidental finding in 0.8 of screening
  colonoscopies above 50y
• Internationally No wide-scale studies
• Mortality/Morbidity
• Bleeding usually self-limited (chronic,
  recurrent, acute and life threatening).
• 90 of bleeding ceases spontaneously
• Mortality related to the severity of bleeding,
  hemodynamic instability, age, and the presence of
  comorbid medical conditions.
• Race
• No racial predilection exists.
• Sex
• Equal frequency in men and women.
• Age
• Most are older than 60 years

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IV. Clinical picture

• History
• Angiodysplasia manifests only through GI bleeding
  (low-grade, painless..venous source)
• Lesions often in more than one location within
  the GIT
• Colonic lesions in 15-20 of persons with upper
  GI tract lesions.
• Small bowel lesions in 22 of suspected colonic
  index source of bleeding
• 40 to 60 have multiple lesions observed at
  endoscopy.
• Hematemesis in patients with angiodysplasia of
  the upper GIT
• Colonic angiodysplasia hematochezia (0-60),
  melena (0-26), hemoccult positive stool (4-47),
  or iron deficiency anemia (0-51).

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Physical examination

• Assessment of hemodynamic stability and the
  likely origin of blood loss.
• Vital signs tachycardia, hypotension, and
  postural changes ( ? amount of blood loss.)
• Stool typically is guaiac positive.
• In most cases bright red blood but also can be
  maroon in color or melena.

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Lab Studies

• CBC microcytic hypochromic anemia in 10 .
• Serum iron level Iron deficiency in 10
• Stool for occult blood 15 of patients with
  bleeding angiodysplasia will be intermittently
  positive for occult blood.

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Imaging Studies

• a) Selective mesenteric angiography
• especially in massive bleeding when colonoscopy
  is difficult.
• sensitivity 58-86 (due to intermittent nature of
  bleeding).
• Detection depends on the rate of bleeding (as low
  as 0.5 mL/min), technique, and timing of
  angiography in relation to period of bleeding.
• Vasopressin infusion during angiography can
  arrest bleeding, but potential complications
  include bowel infarction, arterial vasospasm, and
  lower extremity ischemia.
• b) Radionuclide scanning using technetium Tc
  99mlabeled red blood cells or 99mTc sulfur
  colloid
• Scanning can detect bleeding with rates as low as
  0.1 mL/min. (only in active bleeding)

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Imaging Studies

• c) Angiography of resected specimens
• used to confirm appropriate resection when
  preoperative studies are equivocal or
  unsatisfactory.
• d) Helical CT angiography
• can detect extravasation from angiodysplasia and
  potentially is an important noninvasive test in
  patients with obscure bleeding sites.
• e)Other Tests
• Air contrast barium enema is not recommended
  during acute GI bleeding.

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ProceduresEndoscopy is the most common method
of diagnosing angiodysplasia

• Gastric duodenal angiodysplasia
• Celiac superior mesenteric arteriograms
  frequently fail
• Angiography can demonstrate lesions in the more
  distal small intestine, a region less accessible
  to endoscopic evaluation. Push enteroscopy and
  capsule endoscopy are evolving useful techniques
• Endoscopic appearance
• discrete, flat, or slightly raised (2-10 mm) and
  bright red
• with stellate configurations and a surrounding
  pale rim or halo

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Procedures

• Colonic lesions
• Either angiography or colonoscopy may be used.
• Usually diagnosed by colonoscopy as it is the
  principal method in evaluating lower GI bleeding.
• Comparative studies using selective angiography
  and colonoscopy indicate that the sensitivity of
  colonoscopy exceeds 80 when the lesions are
  located in the area examined by colonoscopy.
• Most angiodysplastic lesions are located in the
  right colon, so the entire colon must be
  examined.

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• Endoscopic mucosal biopsies are not recommended
  because of low diagnostic yield (31-60) and risk
  of hemorrhage.
• Incidental lesions are generally small with pale
  coloration compared to lesions with recent
  hemorrhage (extremely bright with elevated
  centers.)
• BP and volume influence the colonoscopic
  appearance (lesions may not be evident in
  patients who have bled recently.

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Endoscopic differential diagnosis

• Systemic diseases
• HHT, Turner syndrome, and the CREST
  syndrome
• (dd..lack of systemic manifestations)
• Local causes
• spider angiomata, radiation injury,
  ulcerative colitis, Crohn disease, ischemic
  colitis, and suction artifacts.
• Thus evaluation requires careful insertion,
  minimal use of suction, and examination of the
  mucosa during insertion rather than withdrawal.

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Management

• According to severity of bleeding, hemodynamic
  stability, and recurrence of symptoms.
• Incidental finding at colonoscopy no ttt
• Haemodynamically stable conservative approach
  (90 cease spontaneously)
• IV fluid and packed RBCs as needed.
• Endoscopic techniques have been employed most
  frequently.

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Gastric and duodenal lesions

• Endoscopic obliteration techniques.
• Rebleeding after these techniques has been
  attributed to other areas of bleeding
  angiodysplasia rather then failure of
  obliteration.
• Include monopolar electrocautery, heater probe,
  sclerotherapy, band ligation, and argon and
  NdYAG lasers.

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Gastric and duodenal lesions

• Monopolar Electrocautery
• 50 recurrence (from other areas).
• Reduction in post-therapy transfusion
  requirement was not reported to be statistically
  superior to no therapy.
• Heater probe and multipolar devices have
  better results.
• Sclerotherapy using 0.5-1 mL of 1.5 sodium
  tetradecyl sulfate
• 50 recurrence (from other areas)
• Endoscopic band ligation for angiodysplasia is of
  theoretical value.

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Gastric and duodenal lesions

• Argon and NdYAG lasers
• The most successful endoscopic obliterative
  techniques for upper tract lesions.
• Reduction in bleeding rate and transfusion
  requirement for at least 12 months after laser
  therapy.
• Effectiveness reduced with more numerous lesions,
  coagulation disorders, and older age. Rebleeding
  commonly occurred over time.

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Gastric and duodenal lesions

• Enteroscopy and lesion ablation
• Benefits 50 of distal small bowel lesions and no
  other defined GI bleeding sites
• In one report, blood replacement requirements for
  a group of 13 patients decreased by more than
  50, comparing the years before and after
  endoscopic treatment, and 31 required no further
  transfusion (Vakil, 1997).

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Colonic lesions

• Endoscopic obliteration techniques.
• Transfusion requirement resembling that of
  patients receiving no therapy.
• Endoscopic laser photocoagulation
• Successful (60 free of bleeding at 24m)
  however complications occur in as many as 15 of
  patients and are more common when the NdYAG
  laser is used in the right colon.
• Transcatheter embolization of selected mesenteric
  arteries (angiography) for acute hemorrhage is
  appropiate in severely ill patients who are not
  candidates for surgical intervention. (high
  complication rate)
• Selective infusion of vasopressin.. high
  rebleeding rate.
• Injection of dyes, such as methylene blue, indigo
  carmine, and fluorescein, has been used to assist
  in localization of angiodysplasia before surgical
  resection.

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Surgical Care

• Partial or complete gastrectomy
• Rebleeding in 50 from other sites
• Right hemicolectomy for angiodysplasia is
  second-line therapy after endoscopic ablation, if
  repeated endoscopic coagulation has failed, if
  endoscopic therapies are not available, and for
  life-threatening hemorrhage.
• Mortality rate with surgical resection ranges
  from 10-50.
• (patients are often old with comorbid
  conditions)

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Medical treatmenthormonal therapy

• Only for the small subset who are
  transfusion-dependent from bleeding
  angiodysplasia refractory to conservative and
  endoscopic therapy and who are poor surgical
  candidates. This is not for routine management of
  bleeding angiodysplasia. No large-scale,
  randomized, double-blinded studies have
  demonstrated its effectiveness.
• Hormonal therapy might improve coagulation,
  alters the microvascular circulation, and
  improves in endothelial integrity.
• Reports are controversial until now and side
  effects include vaginal bleeding, fluid
  retention, and stroke (23 of the treated
  patients).

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Thank you