eMedicine Specialties > Gastroenterology > Colon

Angiodysplasia of the Colon: Treatment & Medication

Author: Alan BR Thomson, MD, MSc, PhD, Professor, Department of Medicine, Division of Gastroenterology, University of Alberta Faculty of Medicine
Coauthor(s): Andrea Duchini, MD, Assistant Professor of Medicine, Associate Medical Director of Liver Transplantation, Division of Transplantation, Department of Surgery, The Methodist Hospital-Cornell University, Houston; John Godino, MD, Staff Physician, Department of Internal Medicine, Brooke Army Medical Center; Peter Wong, MD, Director of Gastroenterology Clinical Service/Manometry and Physiology, Brooke Army Medical Center; Assistant Professor, Department of Medicine, Division of Gastroenterology, University of Texas Health Science Center at San Antonio
Contributor Information and Disclosures

Updated: May 27, 2009

Treatment

Medical Care

Medically manage each patient with angiodysplasia in accordance with the severity of bleeding, hemodynamic stability, and recurrence of symptoms. A conservative approach to patients who are hemodynamically stable is recommended, because most bleeding angiodysplasias will cease spontaneously. Treatment is usually not advocated for asymptomatic patients when angiodysplasias are found incidentally.

Initially, hemodynamically stabilize all patients with active bleeding with intravenous fluid and packed red blood cells as needed. In addition, correct coagulopathies.

When intervention is warranted, institute steps to control hemorrhage. Endoscopic techniques have been employed most frequently.

Gastric and duodenal angiodysplastic lesions have been managed most commonly with endoscopic obliteration techniques. Rebleeding after these techniques has been attributed to other areas of bleeding angiodysplasia rather then failure of obliteration. These techniques include monopolar electrocautery, heater probe, sclerotherapy, band ligation, and argon and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers.

  • Monopolar electrocautery has been used to obliterate angiodysplasia; however, bleeding recurs in approximately 50% of subjects. A reduction in the posttherapy transfusion requirement was not reported to be statistically superior to no therapy. Heater probe or multipolar coagulation devices have more favorable results. Monopolar electrocautery has a higher risk of perforation.
  • Sclerotherapy using 0.5-1 mL of 1.5% sodium tetradecyl sulfate has been used to obliterate upper tract angiodysplastic lesions; however, bleeding recurs in half of the subjects. In each case, bleeding arose from another area of angiodysplasia. A significant rate of complications has been reported with sclerotherapy, including perforation, embolism, bacteremia, and stricture. The authors do not recommend the use of sclerotherapy for obliteration of colonic angiodysplasia.
  • Argon plasma coagulation (APC) and Nd:YAG lasers are the most successful endoscopic obliterative techniques for upper tract lesions. APC is a no-touch electrocoagulation technique in which high-frequency alternating current is delivered to the tissue through ionized argon gas. A reduction in both the bleeding rate and transfusion requirement has been demonstrated for at least 12 months after laser therapy. However, active bleeding decreases the ablative efficacy of APC by dissipation of the energy, and APC has been associated with colonic perforation. Submucosal injection of a saline epinephrine solution followed by the application of APC has been reported.31  Effectiveness appeared to be reduced in patients with more numerous lesions, those with coagulation disorders, and those who are older. Rebleeding commonly occurred over time.31
  • New endoscopic techniques such as the Olympus EVIS LUCERA variable indices of hemoglobin chart function have been developed to assess completeness of vascular mucosal ablation.32 However, their clinical use is still experimental. Argon coagulation appears the best endoscopic option at the moment to control bleeding in these patients with a low rate of adverse effects and complications and relatively lower costs.
  • Fifty percent of patients with distal small bowel lesions and no other defined GI bleeding sites have benefited from enteroscopy and lesion obliteration. 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.33  This group of patients had small bowel angiodysplastic lesions and unexplained bleeding. New endoscopic techniques to examine the small bowel, such as double-balloon enteroscopy, have been developed but are still time demanding and operator dependent. Angiodysplasia of colonic origin has been managed by endoscopic obliteration. Heater probe and multipolar electrocoagulation probe have been more successful than monopolar electrocoagulation. Rebleeding rates for monopolar electrocoagulation have been approximately 50%, with the transfusion requirement resembling that of patients receiving no therapy.
  • Super selective embolization of visceral arterial branches is central to the management of patients with lower GI bleeding, including from colonic angiodysplasia.34   Immediate cessation of bleeding was achieved in 97% of patients with injection of microcoils, polyvinyl alcohol particles, gel form, or by selective vasopressin infusion. Postembolization ischemia occurs in 3%, and overall mortality in high-risk patients is 9%.34 Selective infusion of vasopressin is less effective than embolization as a definitive therapy because of a high rebleeding rate. Despite the fact that intra-arterial vasopressin can achieve hemostasis for massive lower GI bleeding in 70-91% of patients, bleeding recurs after discontinuation of vasopressin in 22-71% of patients.
    • Endoscopic laser photocoagulation has been successful in controlling bleeding from colonic angiodysplasia, especially right-sided lesions.31,35 However, complications occur in as many as 15% of patients and are more common when the Nd:YAG laser is used in the right colon. Complications may be attributed to the deeper coagulation of the vascular abnormalities from laser sources, which incidentally has been responsible for more effective bleeding cessation. Patients with colonic angiodysplasia generally have a 60% chance of remaining free of bleeding at 24 months after laser obliteration.
    • Endoclips have been used in anecdotal case reports for bleeding angiodysplasia of the cecum and right colon.34
    • Angiodysplasia that presents with acute hemorrhage can be controlled effectively with angiography, although it is seldom needed. Angiography is appropriate in severely ill patients who are not candidates for surgical intervention. In these patients, transcatheter embolization of selected mesenteric arteries has been quite effective. However, the rate of complications is sufficiently high and must be balanced against the risk of surgical resection.
    • Angiography plays a more important role in preoperative localization of small bowel lesions immediately before surgical resection, because intraoperative palpation, endoscopy, and visual inspection through multiple enterotomies are of little value with angiodysplasia.
    • Injection of dyes, such as methylene blue, indigo carmine, and fluorescein, has been used to assist in localization of angiodysplasia before surgical resection.

Surgical Care

Surgical resection is the definitive treatment for angiodysplasia.

  • Partial or complete gastrectomy for management of gastric angiodysplasia has been reported to be followed by bleeding in as many as 50% of patients. Rebleeding was attributed to other angiodysplastic lesions.
  • 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.
  • The mortality rate associated with surgical resection ranges from 10% to 50%. This is based on the view that surgery carries a much higher risk in elderly patients, who often have multiple coexisting medical problems, including coronary artery disease, coagulopathy, and renal and pulmonary dysfunction.
    • In a study by Meyer et al, right hemicolectomy resulted in 63% of the subjects remaining free of intestinal bleeding (mean follow-up, 3.6 y), and 37% had some degree of recurrent bleeding.36
    • Trends toward reduced transfusion requirements have been observed after surgical resection, as well as after electrocoagulation as the only mode of therapy, and in patients who received no specific intervention.
    • Surgical resection is preferred for acute management of severe hemorrhage or for management of recurrent hemorrhage over a relatively short period accompanied by a large transfusion requirement.

Consultations

Consultation with both a gastroenterologist and a surgeon is recommended for cases of angiodysplasia. Interventional radiology often plays a critical role in the management of these patients.

Diet

Withhold oral intake until the diagnosis has been made and treatment has been initiated.

Activity

Restrict activity until hemodynamic stability can be maintained.

Medication

Medical treatment has been used in active and recurrent bleeding from colonic angiodysplasia with controversial results. Hormonal treatment with estrogen and progesterone has been evaluated by randomized trials but remains controversial and is probably not effective. Octreotide, both short and long acting, has been described as effective in a few case reports and case series only. Other agents, such as thalidomide, remain experimental. Desmopressin (DDAVP) has also been used in specific subsets of patients. At the moment, no medical therapy has been proven to effectively treat bleeding from angiodysplasia.

Oral Contraceptives

Only use hormonal therapy for the small subset of patients who are transfusion-dependent from bleeding angiodysplasia refractory to conservative and endoscopic therapy and who are poor surgical candidates. This therapy is not for routine management of bleeding angiodysplasia. No large-scale, randomized, double-blinded studies have demonstrated its effectiveness.

Estrogen-progesterone therapy, previously used to treat bleeding associated with HHT, also has been tried in patients with GI bleeding from angiodysplasia.

Proposed mechanisms by which hormonal therapy might affect bleeding include improvement in coagulation, alterations in microvascular circulation, and improvements in endothelial integrity.

Data from a double-blinded, crossover trial using 0.05 mg ethinyl estradiol and 1 mg norethisterone administered daily to 10 elderly patients with GI ectasia (6 of the patients had HHT) have indicated that the combination significantly reduced bleeding and transfusion requirements. Several other small series with anecdotal success have been described, but one must be skeptical.

A retrospective cohort study of 64 patients by Lewis et al refutes the benefits of hormonal therapy in angiodysplasia.37 Thirty patients were administered 5-10 mg of norethynodrel with mestranol (0.075-0.15 mg) or with conjugated estrogens (0.625 mg), and the bleeding rates did not differ before and after therapy, and they did not differ from bleeding rates of historical controls or from patients who refused therapy.37 Treatment adverse effects in this study included vaginal bleeding, fluid retention, and stroke (23% of the treated patients).

Overall, the current data do not support the use of hormonal therapy in patients with colonic angiodysplasia.


Ethinyl estradiol and norethindrone (Ovcon 50)

Suggested mechanisms by which hormonal therapy might affect bleeding include improvement in coagulation, alterations in the microvascular circulation, and improvements in endothelial integrity. One active tab contains ethinyl estradiol 0.05 mg and norethindrone 1 mg.

Adult

1 tab PO qd

Pediatric

Not established

May reduce the hypoprothrombinemic effects of anticoagulants; estrogen levels may be reduced with coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes; an increase in corticosteroid levels may occur when administered concurrently with ethinyl estradiol; use of ethinyl estradiol with hydantoins may cause spotting, breakthrough bleeding, and pregnancy; increase in fluid retention caused by estrogen intake may reduce seizure control

Documented hypersensitivity; thrombophlebitis; undiagnosed vaginal bleeding; pregnancy; estrogen-dependent neoplasia; severe hepatic disease; breast cancer

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Cigarette smoking increases the risk of serious cardiovascular adverse effects; caution in patients with hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease; associated adverse effects include GI distress, breakthrough bleeding, breast tenderness, weight change, and contact lens intolerance; in males, adverse effects include gynecomastia and decreased libido

Somatostatin Analogues

Somatostatin analogues have been reported to decrease the rate of bleeding from intestinal angiodysplasia. In our experience, these agents are usually well tolerated and may decrease the rate of chronic bleeding. Octreotide should be the first choice in patients with portal hypertension.


Octreotide (Sandostatin)

Mechanism of action in this setting is not fully understood. Used in acute variceal bleeding and for recurrent bleeding after endoscopic therapy.
May reduce the transfusion requirement.

Adult

100 mcg SC bid

Pediatric

Not established

May reduce the effects of cyclosporine; patients on insulin, oral hypoglycemics, beta-blockers and calcium channel blockers may need dosage adjustments

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adverse effects primarily related to altered GI motility, and include nausea, abdominal pain, diarrhea, and increased incidence of gallstones and biliary sludge; because of alteration in counter-regulatory hormones, (insulin, glucagon and GH) hypo- or hyperglycemia may be seen; bradycardia, cardiac conduction abnormalities and arrhythmias have been reported; due to inhibition of TSH secretion, hypothyroidism may also occur; exercise caution in patients with renal impairment; cholelithiasis may occur

More on Angiodysplasia of the Colon

Overview: Angiodysplasia of the Colon
Differential Diagnoses & Workup: Angiodysplasia of the Colon
Treatment & Medication: Angiodysplasia of the Colon
Follow-up: Angiodysplasia of the Colon
Multimedia: Angiodysplasia of the Colon
References
Further Reading
[ CLOSE WINDOW ]

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Further Reading

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Keywords

angiodysplasia of the colon, colonic angiodysplasia, angiodysplasia, arteriovenous malformation, AVM, angiomatosis, vascular ectasia, hemangioma, telangiectasia, vascular lesion of the gastrointestinal tract, gastrointestinal bleeding, GI bleeding, GI hemorrhage, gastrointestinal hemorrhage, rectal bleeding, blood in stool, colonoscopy

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Contributor Information and Disclosures

Author

Alan BR Thomson, MD, MSc, PhD, Professor, Department of Medicine, Division of Gastroenterology, University of Alberta Faculty of Medicine
Alan BR Thomson, MD, MSc, PhD is a member of the following medical societies: American Federation for Aging Research, American Federation for Clinical Research, American Gastroenterological Association, American Geriatrics Society, American Physiological Society, Canadian Association of Gastroenterology, Gastroenterology Research Group, New York Academy of Sciences, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Andrea Duchini, MD, Assistant Professor of Medicine, Associate Medical Director of Liver Transplantation, Division of Transplantation, Department of Surgery, The Methodist Hospital-Cornell University, Houston
Andrea Duchini, MD is a member of the following medical societies: American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and International Liver Transplantation Society
Disclosure: Nothing to disclose.

John Godino, MD, Staff Physician, Department of Internal Medicine, Brooke Army Medical Center
John Godino, MD is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Peter Wong, MD, Director of Gastroenterology Clinical Service/Manometry and Physiology, Brooke Army Medical Center; Assistant Professor, Department of Medicine, Division of Gastroenterology, University of Texas Health Science Center at San Antonio
Peter Wong, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

Marco G Patti, MD, Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine
Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine
James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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