Angiodysplasia of the Colon Treatment & Management

  • Author: Alan BR Thomson, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jun 15, 2011
 

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.

GI angiodysplasia (GIAD) may be either asymptomatic, or may induce overt or obscure bleeding with a high risk of recurrence. Endoscopic destruction, preferably using noncontact endoscopic techniques, is most often proposed as a first-line treatment for GIAD. In addition, APC is preferred over Nd:Yag laser due to the lower risk of perforation. Octreotide and estroprogestative treatments are the best evaluated drugs; however, no appropriate comparison on cost-effectiveness and tolerance has been performed.[63]

Submucosal injection of a saline epinephrine solution followed by the application of APC has been reported.[64] 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.[64]

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.[65] 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.[66] 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.[67] 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%.[67] 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.[64, 68] 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.

Emergency embolization with a liquid polyvinyl alcohol copolymer in acute arterial bleeding of the GI tract may be clinically useful.

Endoclips have been used in anecdotal case reports for bleeding angiodysplasia of the cecum and right colon.[67]

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.

Patients with systemic sclerosis with severe, transfusion-GAVE refractory to laser ablation may show clinical and endoscopic improvement following intravenous (IV) pulse cyclophosphamide (CYC) treatment.[69] APC is an effective and safe endoscopic treatment for GAVE in patients with liver cirrhosis.[70]

Traditionally, gastroenterologists prefer to use endoscopic modalities like argon plasma coagulation and electrocoagulation to treat accessible vascular lesions. Prospective studies involving 10 or more patients were included in one analysis that showed a clinical response to treatment of 0.76 (95% CI, 0.64-0.85). The weighted mean difference in transfusion requirements before starting therapy (control group) and after treatment initiation (treatment group) was -2.2 (95% CI, -3.9 to -0.5).[71]

Recurrence of acute hemorrhage from GI angiodysplasia after hospital discharge occurred in 30% of patients after a mean follow-up (33±40 mo). In a multivariate analysis, earlier history of bleeding with a high bleeding rate, over anticoagulation, and the presence of multiple lesions were predictive factors of recurrence. Surprisingly endoscopic APC therapy was not associated with lower rates of recurrent bleeding.[72]

Different types of gastric vascular ectasia include focal vascular ectasia, portal hypertensive gastropathy, and GAVE. Endoscopic thermal ablation with APC is effective in managing upper GI bleeding.[73]

Endoscopic treatment by APC was successful in about 80% of patients with bleeding gastric vascular ectasia with or without cirrhosis. Noncirrhotic patients required significantly more APC sessions to achieve a complete treatment.[74]

Treatment of GAVE, characterized by mucosal and submucosal vascular ectasia causing recurrent GI hemorrhage, with endoscopic thermal therapy (ETT) requires multiple sessions for destruction of vascular ectasia and control of bleeding. Compared with ETT, EBL has a significantly higher rate of bleeding cessation (67% vs 23%, P = .04), fewer treatment sessions required for cessation of bleeding (1.9 vs 4.7, P = .05), a greater increase in hemoglobin values (2.8 g/dL vs 0.9 g/dL, P = .05), a greater decrease in transfusion requirements (-12.7 vs -5.2, P = .02), and a greater decrease in hospital admissions (-2.6 vs -0.5, P = .02) during the follow-up period.[75]

The role of somatostatin analogues for refractory bleeding GI angiodysplasias has been systematically reviewed by Brown et al.[76]

Treated with continuous octreotide LAR 20mg once a month, reduces transfusion requirements in persons with diffuse small bowel angiodysplasia.[77]

The use of short-acting SMS analogues is recognized in acute variceal hemorrhage secondary to portal hypertension in cirrhosis. Long-acting SMS analogue therapy has been successfully used in obscure GI bleeding though secondary to angiodysplasia.[78]

Rarely, thalidomide may be used in persons with GI angiodysplasia, which has shown no response to standard treatment.[79]

Thalidomide should be considered as a therapeutic option in patients who are resistant to conventional therapy for chronic angiodysplasia bleeding and who requiring ongoing transfusion. It has a high discontinuation rate because of its side-effects.[80] Thalidomide, with its antiangiogenic mechanism of action, is a promising drug in bleeding angiodysplasias as a treatment option for patients unable to benefit from other available modalities of treatment.[81]

Next

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.[82]

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.

Previous
Next

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.

Previous
Next

Diet

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

Previous
Next

Activity

Restrict activity until hemodynamic stability can be maintained.

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Alan BR Thomson, MD  Professor of Medicine, Division of Gastroenterology, University of Alberta, Canada

Alan BR Thomson, MD is a member of the following medical societies: Alberta Medical Association, American College of Gastroenterology, American Gastroenterological Association, Canadian Association of Gastroenterology, Canadian Medical Association, College of Physicians and Surgeons of Alberta, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Andrea Duchini, MD  Associate Professor of Medicine and Surgery, Director of Hepatology, University of Texas Medical Branch School of Medicine; Medical Director of Liver Transplantation, Department of Surgery, The Methodist Hospital

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 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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Alex J Mechaber, MD, FACP  Senior 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

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 & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Anca Tapardel, MD, Narmin Kassam, MD, and Peter Wong, MD, to the development and writing of this article.

References

  1. Regula J, Wronska E, Pachlewski J. Vascular lesions of the gastrointestinal tract. Best Pract Res Clin Gastroenterol. 2008;22(2):313-28. [Medline].

  2. Heyde EC. Gastrointestinal bleeding in aortic stenosis. N Engl J Med. 1958;259:196.

  3. Margulis AR, Heinbecker P, Bernard HR. Operative mesenteric arteriography in the search for the site of bleeding in unexplained gastrointestinal hemorrhage: a preliminary report. Surgery. Sep 1960;48:534-9. [Medline].

  4. Akhtar AJ, Shaheen MA, Zha J. Organic colonic lesions in patients with irritable bowel syndrome (IBS). Med Sci Monit. Sep 2006;12(9):CR363-7. [Medline].

  5. Kim BK, Han HS, Lee SY, Kim CH, Jin CJ. Cecal polypoid arteriovenous malformations removed by endoscopic biopsy. J Korean Med Sci. Apr 2009;24(2):342-5. [Medline]. [Full Text].

  6. Clouse RE. Vascular lesions: ectasias, tumors, and malformations. In: Yamada T, Alpers DH, Laine L, Owyang C, Powell DW, eds. Textbook of Gastroenterology. Vol 2. 3rd ed. Philadelphia, Pa: JB Lippincott; 1999:2564-78.

  7. Ming SC, Goldman H. Vascular abnormalities of the gastrointestinal tract. In: Ming SC, Goldman H, eds. Pathology of the Gastrointestinal Tract. 2nd ed. Baltimore, Md: Williams & Wilkins Company; 1998:272-4.

  8. Mudhar HS, Balsitis M. Colonic angiodysplasia and true diverticula: is there an association?. Histopathology. Jan 2005;46(1):81-8. [Medline].

  9. Biss T, Hamilton P. Myelofibrosis and angiodysplasia of the colon: another manifestation of portal hypertension and massive splenomegaly?. J Clin Pathol. Sep 2004;57(9):999-1000. [Medline]. [Full Text].

  10. Schmidmaier R, Bittmann I, Gotzberger M, et al. Vascular ectasia of the whole intestine as a cause of recurrent gastrointestinal bleeding after high-dose chemotherapy. Endoscopy. Sep 2006;38(9):940-2. [Medline].

  11. Lanas A, Garcia-Rodriguez LA, Polo-Tomas M, Ponce M, Quintero E, Perez-Aisa MA. The changing face of hospitalisation due to gastrointestinal bleeding and perforation. Aliment Pharmacol Ther. Mar 2011;33(5):585-91. [Medline].

  12. Foutch PG, Rex DK, Lieberman DA. Prevalence and natural history of colonic angiodysplasia among healthy asymptomatic people. Am J Gastroenterol. Apr 1995;90(4):564-7. [Medline].

  13. Liao Z, Gao R, Xu C, Li ZS. Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review. Gastrointest Endosc. Feb 2010;71(2):280-6. [Medline].

  14. Rosborough TK, Swaim WR. Acquired von Willebrand's disease, platelet-release defect and angiodysplasia. Am J Med. Jul 1978;65(1):96-100. [Medline].

  15. Cass AJ, Bliss BP, Bolton RP, Cooper BT. Gastrointestinal bleeding, angiodysplasia of the colon and acquired von Willebrand's disease. Br J Surg. Sep 1980;67(9):639-41. [Medline].

  16. Duray PH, Marcal JM Jr, LiVolsi VA, et al. Gastrointestinal angiodysplasia: a possible component of von Willebrand's disease. Hum Pathol. Jun 1984;15(6):539-44. [Medline].

  17. Gostout CJ, Bowie EJW, Balm R, Fischer PK. Is angiodysplasia associated with von Willebrand's disease?. Gastroenterology. 1990;98:A172.

  18. Fressinaud E, Meyer D. International survey of patients with von Willebrand disease and angiodysplasia. Thromb Haemost. Sep 1 1993;70(3):546. [Medline].

  19. Makris M. Gastrointestinal bleeding in von Willebrand disease. Thromb Res. 2006;118 suppl 1:S13-7. [Medline].

  20. Hirri HM, Green PJ, Lindsay J. Von Willebrand's disease and angiodysplasia treated with thalidomide. Haemophilia. May 2006;12(3):285-6. [Medline].

  21. Ueno S, Nakase H, Kasahara K, et al. Clinical features of Japanese patients with colonic angiodysplasia. J Gastroenterol Hepatol. Aug 2008;23(8 Pt 2):e363-6. [Medline].

  22. Emanuel RB, Weiser MM, Shenoy SS, Satchidanand SK, Asirwatham J. Arteriovenous malformations as a cause of gastrointestinal bleeding: the importance of triple-vessel angiographic studies in diagnosis and prevention of rebleeding. J Clin Gastroenterol. Jun 1985;7(3):237-46. [Medline].

  23. Kaaroud H, Fatma LB, Beji S, et al. Gastrointestinal angiodysplasia in chronic renal failure. Saudi J Kidney Dis Transpl. Sep 2008;19(5):809-12. [Medline].

  24. Schwartz J, Rozenfeld V, Habot B. Cessation of recurrent bleeding from gastrointestinal angiodysplasia, after beta blocker treatment in a patient with hypertrophic subaortic stenosis--a case history. Angiology. Mar 1992;43(3 pt 1):244-8. [Medline].

  25. Pate GE, Chandavimol M, Naiman SC, Webb JG. Heyde's syndrome: a review. J Heart Valve Dis. Sep 2004;13(5):701-12. [Medline].

  26. Ueno S, Nakase H, Kasahara K, et al. Clinical features of Japanese patients with colonic angiodysplasia. J Gastroenterol Hepatol. Aug 2008;23(8 pt 2):e363-6. [Medline].

  27. Imperiale TF, Ransohoff DF. Aortic stenosis, idiopathic gastrointestinal bleeding, and angiodysplasia: is there an association? A methodologic critique of the literature. Gastroenterology. Dec 1988;95(6):1670-6. [Medline].

  28. Kaaroud H, Fatma LB, Beji S, et al. Gastrointestinal angiodysplasia in chronic renal failure. Saudi J Kidney Dis Transpl. Sep 2008;19(5):809-12. [Medline]. [Full Text].

  29. Gola W, Lelonek M. Clinical implication of gastrointestinal bleeding in degenerative aortic stenosis: an update. Cardiol J. 2010;17(4):330-4. [Medline].

  30. Roskell DE, Biddolph SC, Warren BF. Apparent deficiency of mucosal vascular collagen type IV associated with angiodysplasia of the colon. J Clin Pathol. Jan 1998;51(1):18-20. [Medline]. [Full Text].

  31. Junquera F, Saperas E, de Torres I, Vidal MT, Malagelada JR. Increased expression of angiogenic factors in human colonic angiodysplasia. Am J Gastroenterol. Apr 1999;94(4):1070-6. [Medline].

  32. Slaughter MS. Hematologic effects of continuous flow left ventricular assist devices. J Cardiovasc Transl Res. Dec 2010;3(6):618-24. [Medline].

  33. Mishra PK, Kovac J, de Caestecker J, et al. Intestinal angiodysplasia and aortic valve stenosis: let's not close the book on this association. Eur J Cardiothorac Surg. Apr 2009;35(4):628-34. [Medline].

  34. Vaz A, Correia A, Martins B, et al. Heyde syndrome--the link between aortic stenosis and gastrointestinal bleeding. Rev Port Cardiol. Feb 2010;29(2):309-14. [Medline].

  35. Massyn MW, Khan SA. Heyde syndrome: a common diagnosis in older patients with severe aortic stenosis. Age Ageing. May 2009;38(3):267-70; discussion 251. [Medline].

  36. Lee HE, Sagong C, Yeo KY, et al. A case of hereditary hemorrhagic telangiectasia. Ann Dermatol. May 2009;21(2):206-8. [Medline].

  37. Boubaker K, Boubaker S, Ounissi M, et al. [Colic angiodysplasia and chronic haemodialysis. Argon plasma treatment. A case report]. Nephrol Ther. Jul 2010;6(4):248-50. [Medline].

  38. Ingraham KM, O'Brien MS, Shenin M, Derk CT, Steen VD. Gastric antral vascular ectasia in systemic sclerosis: demographics and disease predictors. J Rheumatol. Mar 2010;37(3):603-7. [Medline].

  39. Rosenfeld G, Enns R. Argon photocoagulation in the treatment of gastric antral vascular ectasia and radiation proctitis. Can J Gastroenterol. Dec 2009;23(12):801-4. [Medline]. [Full Text].

  40. Selinger CP, Ang YS. Gastric antral vascular ectasia (GAVE): an update on clinical presentation, pathophysiology and treatment. Digestion. 2008;77(2):131-7. [Medline].

  41. Macdonald J, Porter V, Scott NW, McNamara D. Small bowel lymphangiectasia and angiodysplasia: a positive association; novel clinical marker or shared pathophysiology?. J Clin Gastroenterol. Oct 2010;44(9):610-4. [Medline].

  42. Uhm MS, Kim N, Nah JC, et al. Congenital angiodysplasia in a woman presenting with idiopathic jejunal varicosis on angiography. Gut Liver. Jun 2009;3(2):122-6. [Medline]. [Full Text].

  43. Kovacs M, Pak P, Pak G, Feheer J, Huttl K. [Multiple angiodysplasias diagnosed by capsule endoscopy] [Hungarian]. Orv Hetil. Dec 23 2007;148(51):2435-40. [Medline].

  44. Jarbandhan S, van der Veer WM, Mulder CJ. Double-balloon endoscopy in the diagnosis and treatment of hemorrhage from retrovalvular angiodysplasias. J Gastrointestin Liver Dis. Sep 2008;17(3):333-4. [Medline]. [Full Text].

  45. Monkemuller K, Fry LC, Neumann H, Rickes S, Malfertheiner P. [Diagnostic and therapeutic utility of double balloon endoscopy: experience with 225 procedures] [Spanish]. Acta Gastroenterol Latinoam. Dec 2007;37(4):216-23. [Medline].

  46. Skibba RM, Hartong WA, Mantz FA, Hinthorn DR, Rhodes JB. Angiodysplasia of the cecum: colonoscopic diagnosis. Gastrointest Endosc. Feb 1976;22(3):177-9. [Medline].

  47. Scaglione G, Russo F, Franco MR, et al. Age and video capsule endoscopy in obscure gastrointestinal bleeding: a prospective study on hospitalized patients. Dig Dis Sci. Apr 2011;56(4):1188-93. [Medline].

  48. Tan KK, Wong D, Sim R. Superselective embolization for lower gastrointestinal hemorrhage: an institutional review over 7 years. World J Surg. Dec 2008;32(12):2707-15. [Medline].

  49. Fry LC, Bellutti M, Neumann H, Malfertheiner P, Monkemuller K. Incidence of bleeding lesions within reach of conventional upper and lower endoscopes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding. Aliment Pharmacol Ther. Feb 1 2009;29(3):342-9. [Medline].

  50. Muhammad A, Pitchumoni CS. Evaluation of iron deficiency anemia in older adults: the role of wireless capsule endoscopy. J Clin Gastroenterol. Aug 2009;43(7):627-31. [Medline].

  51. Riccioni ME, Urgesi R, Spada C, et al. Unexplained iron deficiency anaemia: Is it worthwhile to perform capsule endoscopy?. Dig Liver Dis. Aug 2010;42(8):560-6. [Medline].

  52. Liao Z, Gao R, Xu C, Li ZS. Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review. Gastrointest Endosc. Feb 2010;71(2):280-6. [Medline].

  53. Richardson JD, Max MH, Flint LM Jr, et al. Bleeding vascular malformations of the intestine. Surgery. Sep 1978;84(3):430-6. [Medline].

  54. Godeschalk MF, Mensink PB, van Buuren HR, Kuipers EJ. Primary balloon-assisted enteroscopy in patients with obscure gastrointestinal bleeding: findings and outcome of therapy. J Clin Gastroenterol. Oct 2010;44(9):e195-200. [Medline].

  55. Chen LH, Chen WG, Cao HJ, et al. Double-balloon enteroscopy for obscure gastrointestinal bleeding: a single center experience in China. World J Gastroenterol. Apr 7 2010;16(13):1655-9. [Medline].

  56. Hegde SR, Iffrig K, Li T, Downey S, Heller SJ, Tokar JL. Double-balloon enteroscopy in the elderly: safety, findings, and diagnostic and therapeutic success. Gastrointest Endosc. May 2010;71(6):983-9. [Medline].

  57. Madisch A, Schmolders J, Bruckner S, Aust D, Miehlke S. Less favorable clinical outcome after diagnostic and interventional double balloon enteroscopy in patients with suspected small-bowel bleeding?. Endoscopy. Sep 2008;40(9):731-4. [Medline].

  58. Yeh TS, Liu KH, Su MY, et la. Laparoscopically assisted bowel surgery in an era of double-balloon enteroscopy: from inside to outside. Surg Endosc. Apr 2009;23(4):739-44. [Medline].

  59. Kamalaporn P, Cho S, Basset N, et al. Double-balloon enteroscopy following capsule endoscopy in the management of obscure gastrointestinal bleeding: outcome of a combined approach. Can J Gastroenterol. May 2008;22(5):491-5. [Medline].

  60. Crook DW, Knuesel PR, Froehlich JM, et al. Comparison of magnetic resonance enterography and video capsule endoscopy in evaluating small bowel disease. Eur J Gastroenterol Hepatol. Jan 2009;21(1):54-65. [Medline].

  61. Westerhoff M, Tretiakova M, Hovan L, Miller J, Noffsinger A, Hart J. CD61, CD31, and CD34 improve diagnostic accuracy in gastric antral vascular ectasia and portal hypertensive gastropathy: An immunohistochemical and digital morphometric study. Am J Surg Pathol. Apr 2010;34(4):494-501. [Medline].

  62. Pavlov KA, Chekmaryova IA, Shchyogolev AI, Mishnyov OD. Ultrastructural characteristics of peripheral arteriovenous and venous angiodysplasias. Bull Exp Biol Med. Apr 2009;147(4):480-4. [Medline].

  63. Dray X, Camus M, Coelho J, et al. Treatment of gastrointestinal angiodysplasia and unmet needs. Dig Liver Dis. Jul 2011;43(7):515-22. [Medline].

  64. Suzuki N, Arebi N, Saunders BP. A novel method of treating colonic angiodysplasia. Gastrointest Endosc. Sep 2006;64(3):424-7. [Medline].

  65. Hurlstone DP, Karageh M, Sanders DS. The Olympus EVIS LUCERA variable indices of haemoglobin chart function: a novel technique for establishing the completeness of vascular mucosal ablation in colonic angiodysplasia. Endoscopy. Jan 2006;38(1):102. [Medline]. [Full Text].

  66. Vakil N, Huilgol V, Khan I. Effect of push enteroscopy on transfusion requirements and quality of life in patients with unexplained gastrointestinal bleeding. Am J Gastroenterol. Mar 1997;92(3):425-8. [Medline].

  67. Pishvaian AC, Lewis JH. Use of endoclips to obliterate a colonic arteriovenous malformation before cauterization. Gastrointest Endosc. May 2006;63(6):865-6. [Medline].

  68. Polese L, Angriman I, Pagano D, et al. Laser therapy and surgical treatment in transfusion-dependent patients with upper-gastrointestinal vascular ectasia. Lasers Med Sci. Sep 2006;21(3):140-6. [Medline].

  69. Schulz SW, O'Brien M, Maqsood M, et al. Improvement of severe systemic sclerosis-associated gastric antral vascular ectasia following immunosuppressive treatment with intravenous cyclophosphamide. J Rheumatol. Aug 2009;36(8):1653-6. [Medline].

  70. Fuccio L, Zagari RM, Serrani M, et al. Endoscopic argon plasma coagulation for the treatment of gastric antral vascular ectasia-related bleeding in patients with liver cirrhosis. Digestion. 2009;79(3):143-50. [Medline].

  71. Brown C, Subramanian V, Wilcox CM, Peter S. Somatostatin analogues in the treatment of recurrent bleeding from gastrointestinal vascular malformations: an overview and systematic review of prospective observational studies. Dig Dis Sci. Aug 2010;55(8):2129-34. [Medline].

  72. Saperas E, Videla S, Dot J, et al. Risk factors for recurrence of acute gastrointestinal bleeding from angiodysplasia. Eur J Gastroenterol Hepatol. Dec 2009;21(12):1333-9. [Medline].

  73. Herrera S, Bordas JM, Llach J, et al. The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in patients admitted for GI hemorrhage. Gastrointest Endosc. Sep 2008;68(3):440-6. [Medline].

  74. Lecleire S, Ben-Soussan E, Antonietti M, et al. Bleeding gastric vascular ectasia treated by argon plasma coagulation: a comparison between patients with and without cirrhosis. Gastrointest Endosc. Feb 2008;67(2):219-25. [Medline].

  75. Wells CD, Harrison ME, Gurudu SR, et al. Treatment of gastric antral vascular ectasia (watermelon stomach) with endoscopic band ligation. Gastrointest Endosc. Aug 2008;68(2):231-6. [Medline].

  76. Molina Infante J, Perez Gallardo B, Hernandez Alonso M, et al. [Octreotide long acting release for severe obscure gastrointestinal haemorrhage in elderly patients with serious comorbidities]. Med Clin (Barc). Nov 7 2009;133(17):667-70. [Medline].

  77. Molina-Infante J, Perez-Gallardo B. Somatostatin analogues for bleeding gastrointestinal angiodysplasias: when should thalidomide be prescribed?. Dig Dis Sci. Jan 2011;56(1):266-7. [Medline].

  78. Hutchinson JM, Jennings JS, Jones RL. Long-acting somatostatin analogue therapy in obscure-overt gastrointestinal bleeding in noncirrhotic portal hypertension: a case report and literature review. Eur J Gastroenterol Hepatol. Jun 2010;22(6):754-8. [Medline].

  79. Belard E, Foss CH, Christensen LA, Schmidt P, Nojgaard C. [Thalidomide therapy for gastrointestinal angiodysplasia]. Ugeskr Laeger. Nov 16 2009;171(47):3454-5. [Medline].

  80. Kamalaporn P, Saravanan R, Cirocco M, et al. Thalidomide for the treatment of chronic gastrointestinal bleeding from angiodysplasias: a case series. Eur J Gastroenterol Hepatol. Dec 2009;21(12):1347-50. [Medline].

  81. Dabak V, Kuriakose P, Kamboj G, Shurafa M. A pilot study of thalidomide in recurrent GI bleeding due to angiodysplasias. Dig Dis Sci. Jun 2008;53(6):1632-5. [Medline].

  82. Meyer CT, Troncale FJ, Galloway S, Sheahan DG. Arteriovenous malformations of the bowel: an analysis of 22 cases and a review of the literature. Medicine (Baltimore). Jan 1981;60(1):36-48. [Medline].

  83. Lewis BS, Salomon P, Rivera-MacMurray S, et al. Does hormonal therapy have any benefit for bleeding angiodysplasia?. J Clin Gastroenterol. Sep 1992;15(2):99-103. [Medline].

  84. Richter JM, Hedberg SE, Athanasoulis CA, Schapiro RH. Angiodysplasia. Clinical presentation and colonoscopic diagnosis. Dig Dis Sci. Jun 1984;29(6):481-5. [Medline].

  85. Redondo-Cerezo E, Gomez-Ruiz CJ, Sanchez-Manjavacas N, et al. Long-term follow-up of patients with small-bowel angiodysplasia on capsule endoscopy. Determinants of a higher clinical impact and rebleeding rate. Rev Esp Enferm Dig. Apr 2008;100(4):202-7. [Medline].

  86. Alavi A, Ring EJ. Localization of gastrointestinal bleeding: superiority of 99mTc sulfur colloid compared with angiography. AJR Am J Roentgenol. Oct 1981;137(4):741-8. [Medline]. [Full Text].

  87. Alvarez L, Puleo J, Balint JA. Investigation of gastrointestinal bleeding in patients with end stage renal disease. Am J Gastroenterol. Jan 1993;88(1):30-3. [Medline].

  88. Apostolakis E, Doering C, Kantartzis M, Winter J, Schulte HD. Calcific aortic-valve stenosis and angiodysplasia of the colon: Heyde's syndrome--report of two cases. Thorac Cardiovasc Surg. Dec 1990;38(6):374-6. [Medline].

  89. Bhutani MS, Gupta SC, Markert RJ, et al. A prospective controlled evaluation of endoscopic detection of angiodysplasia and its association with aortic valve disease. Gastrointest Endosc. Nov 1995;42(5):398-402. [Medline].

  90. Boley SJ, Sammartano R, Adams A, et al. On the nature and etiology of vascular ectasias of the colon. Degenerative lesions of aging. Gastroenterology. Apr 1977;72(4 pt 1):650-60. [Medline].

  91. Boley SJ, Sprayregen S, Sammartano RJ, Adams A, Kleinhaus S. The pathophysiologic basis for the angiographic signs of vascular ectasias of the colon. Radiology. Dec 1977;125(3):615-21. [Medline].

  92. Brandt LJ, Mukhopadhyay D. Masking of colon vascular ectasias by cold water lavage. Gastrointest Endosc. Jan 1999;49(1):141-2. [Medline].

  93. Britt LG, Warren L, Moore OF 3rd. Selective management of lower gastrointestinal bleeding. Am Surg. Mar 1983;49(3):121-5. [Medline].

  94. Browder W, Cerise EJ, Litwin MS. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg. Nov 1986;204(5):530-6. [Medline]. [Full Text].

  95. Chalasani N, Cotsonis G, Wilcox CM. Upper gastrointestinal bleeding in patients with chronic renal failure: role of vascular ectasia. Am J Gastroenterol. Nov 1996;91(11):2329-32. [Medline].

  96. Chou CC, Dabney JM. Interrelation of ileal wall compliance and vascular resistance. Am J Dig Dis. Dec 1967;12(12):1198-208. [Medline].

  97. Cottone C, Disclafani G, Genova G, et al. Use of BICAP in a case of colon angiodysplasia. Surg Endosc. 1991;5(2):99-100. [Medline].

  98. Duchini A, Sessoms SL. Gastrointestinal hemorrhage in patients with systemic sclerosis and CREST syndrome. Am J Gastroenterol. Sep 1998;93(9):1453-6. [Medline].

  99. Ettorre GC, Francioso G, Garribba AP, et al. Helical CT angiography in gastrointestinal bleeding of obscure origin. AJR Am J Roentgenol. Mar 1997;168(3):727-31. [Medline]. [Full Text].

  100. Flynn CT, Chandran PK. Renal failure and angiodysplasia of the colon. Ann Intern Med. Jul 1985;103(1):154. [Medline].

  101. Foutch PG. Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol. Jun 1993;88(6):807-18. [Medline].

  102. Foutch PG. Colonic angiodysplasia. Gastroenterologist. Jun 1997;5(2):148-56. [Medline].

  103. Ghosh J, Speake D, Benbow EW, Watson AJ. Co-existence of true colonic diverticula with angiodysplasia. Colorectal Dis. Sep 2005;7(5):530-2. [Medline].

  104. Greason KL, Acosta JA, Magrino TJ, Choe M. Angiodysplasia as the cause of massive lower gastrointestinal hemorrhage in a young adult. Report of a case. Dis Colon Rectum. Jun 1996;39(6):702-4. [Medline].

  105. Gupta N, Longo WE, Vernava AM 3rd. Angiodysplasia of the lower gastrointestinal tract: an entity readily diagnosed by colonoscopy and primarily managed nonoperatively. Dis Colon Rectum. Sep 1995;38(9):979-82. [Medline].

  106. Hemingway AP. Angiodysplasia as a cause of iron deficiency anaemia. Blood Rev. Sep 1989;3(3):147-51. [Medline].

  107. Ho S, Jackson J. The angiographic diagnosis of colonic carcinoma. Clin Radiol. May 1998;53(5):345-9. [Medline].

  108. Hochter W, Weingart J, Kuhner W, Frimberger E, Ottenjann R. Angiodysplasia in the colon and rectum. Endoscopic morphology, localisation and frequency. Endoscopy. Sep 1985;17(5):182-5. [Medline].

  109. Howard OM, Buchanan JD, Hunt RH. Angiodysplasia of the colon. Experience of 26 cases. Lancet. Jul 3 1982;2(8288):16-9. [Medline].

  110. Katsinelos P, Paroutoglou G, Beltsis A, et al. Recurrent colonic Dieulafoy's lesion associated with bizarre vascular malformations and abnormal von Willebrand factor. Acta Gastroenterol Belg. Oct-Dec 2005;68(4):443-5. [Medline].

  111. Kheterpal S. Angiodysplasia: a review. J R Soc Med. Oct 1991;84(10):615-8. [Medline]. [Full Text].

  112. Kitiyakara T, Selby W. Non-small-bowel lesions detected by capsule endoscopy in patients with obscure GI bleeding. Gastrointest Endosc. Aug 2005;62(2):234-8. [Medline].

  113. Krevsky B. Detection and treatment of angiodysplasia. Gastrointest Endosc Clin N Am. Jul 1997;7(3):509-24. [Medline].

  114. Moparty B, Raju GS. Role of hemoclips in a patient with cecal angiodysplasia at high risk of recurrent bleeding from antithrombotic therapy to maintain coronary stent patency: a case report. Gastrointest Endosc. Sep 2005;62(3):468-9. [Medline].

  115. Noer RJ, Derr JW. Effect of distention on intestinal revascularization. Arch Surg. Sep 1949;59(3):542-9. [Medline].

  116. Orsi P, Guatti-Zuliani C, Okolicsanyi L. Long-acting octreotide is effective in controlling rebleeding angiodysplasia of the gastrointestinal tract. Dig Liver Dis. May 2001;33(4):330-4. [Medline].

  117. Potter GD, Sellin JH. Lower gastrointestinal bleeding. Gastroenterol Clin North Am. Jun 1988;17(2):341-56. [Medline].

  118. Reinus JF, Brandt LJ. Vascular ectasias and diverticulosis. Common causes of lower intestinal bleeding. Gastroenterol Clin North Am. Mar 1994;23(1):1-20. [Medline].

  119. Roberts PL, Schoetz DJ Jr, Coller JA. Vascular ectasia. Diagnosis and treatment by colonoscopy. Am Surg. Jan 1988;54(1):56-9. [Medline].

  120. Sabanathan S, Nag SB. Angiodysplasia of the colon: a post-mortem study. J R Coll Surg Edinb. Sep 1982;27(5):285-91. [Medline].

  121. Scheffer SM, Leatherman LL. Resolution of Heyde's syndrome of aortic stenosis and gastrointestinal bleeding after aortic valve replacement. Ann Thorac Surg. Oct 1986;42(4):477-80. [Medline].

  122. Semba T, Fujii Y. Relationship between venous flow and colonic peristalsis. Jpn J Physiol. Aug 1970;20(4):408-16. [Medline].

  123. Serin E, Paydas S, Yildizer K, Seyrek N, Sagliker Y. von Recklinghausen's disease associated with angiodysplasia of colon and end-stage renal disease. Nephron. 1995;71(2):243. [Medline].

  124. Sharma R, Gorbien MJ. Angiodysplasia and lower gastrointestinal tract bleeding in elderly patients. Arch Intern Med. Apr 24 1995;155(8):807-12. [Medline].

  125. Szilagyi A, Ghali MP. Pharmacological therapy of vascular malformations of the gastrointestinal tract. Can J Gastroenterol. Mar 2006;20(3):171-8. [Medline]. [Full Text].

  126. Tedesco FJ, Waye JD, Raskin JB, Morris SJ, Greenwald RA. Colonoscopic evaluation of rectal bleeding: a study of 304 patients. Ann Intern Med. Dec 1978;89(6):907-9. [Medline].

  127. Thelmo WL, Vetrano JA, Wibowo A, et al. Angiodysplasia of colon revisited: pathologic demonstration without the use of intravascular injection technique. Hum Pathol. Jan 1992;23(1):37-40. [Medline].

  128. Welch CE, Athanasoulis CA, Galdabini JJ. Hemorrhage from the large bowel with special reference to angiodysplasia and diverticular disease. World J Surg. Jan 1978;2(1):73-83. [Medline].

  129. Wright HK, Pelliccia O, Higgins EF Jr, Sreenivas V, Gupta A. Controlled, semielective, segmental resection for massive colonic hemorrhage. Am J Surg. Apr 1980;139(4):535-8. [Medline].

  130. Zuckerman G, Benitez J. A prospective study of bidirectional endoscopy (colonoscopy and upper endoscopy) in the evaluation of patients with occult gastrointestinal bleeding. Am J Gastroenterol. Jan 1992;87(1):62-6. [Medline].

  131. Zuckerman GR, Cornette GL, Clouse RE, Harter HR. Upper gastrointestinal bleeding in patients with chronic renal failure. Ann Intern Med. May 1985;102(5):588-92. [Medline].

 
Previous
Next
 
Algorithm for acute gastrointestinal (GI) bleeding. CBC = complete blood cell count; CXR = chest x-ray; EKG = electrocardiography; IVF = intravenous fluid; NG = nasogastric.
Angiodysplasia identified on cecum wall during colonoscopy.
Double-contrast barium enema studies in a 44-year-old man known to have a long history of ulcerative colitis. These images show total colitis and extensive pseudopolyposis.
Double-contrast barium enema examination in a patient with Crohn colitis demonstrates numerous aphthous ulcers.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.