Angiodysplasia of the Colon Treatment & Management
- Author: Hussein Al-Hamid, MD; Chief Editor: BS Anand, MD more...
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 fluids and packed red blood cells as needed. In addition, correct coagulopathies.
Admit the patient with colonic angiodysplasia to the intensive care unit (ICU) if the patient is hemodynamically unstable. Monitor for recurrent bleeding and stabilization of the hematocrit. Transfuse as needed.
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 than 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.
Submucosal injection of a saline epinephrine solution followed by the application of APC has been reported. 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.
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. However, their clinical use is still experimental. Argon plasma 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. 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 time intensive 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 are 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 bleeding from colonic angiodysplasia. 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%.[80, 81] Selective infusion of vasopressin is less effective than embolization as a definitive therapy because of high rebleeding rates associated with its use. 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.[77, 82] 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.
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 the 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 GAVE refractory to laser ablation may show clinical and endoscopic improvement following intravenous (IV) pulse cyclophosphamide (CYC) treatment. APC is an effective and safe endoscopic treatment for GAVE in patients with liver cirrhosis.
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).
Recurrence of acute hemorrhage from GI angiodysplasia after hospital discharge occurred in 30% of patients after a mean follow-up of 33 (±40) months. 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.
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.
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 complete treatment.
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.
The role of somatostatin analogues for refractory bleeding GI angiodysplasias has been systematically reviewed by Brown et al.
Treatment with continuous octreotide LAR 20mg once a month, reduces transfusion requirements in persons with diffuse small bowel angiodysplasia.
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 thought to be secondary to angiodysplasia.
Rarely, thalidomide may be used in persons with GI angiodysplasia, which has shown no response to standard treatment.
Thalidomide should be considered as a therapeutic option in patients who are resistant to conventional therapy for chronic angiodysplasia bleeding requiring ongoing transfusions. It has a high discontinuation rate because of its side-effects. 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.
No preventive methods for angiodysplasia have been definitely identified at this time. Avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended in patients with chronic bleeding.
Diet and activity
Withhold oral intake until the diagnosis has been made and treatment has been initiated.
Restrict activity until hemodynamic stability can be maintained.
No preventive methods for angiodysplasia have been definitely identified at this time. Avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended in patients with chronic bleeding.
Surgical resection is the definitive treatment for angiodysplasia.
Partial or complete gastrectomy for the 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 a 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.
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 the acute management of severe hemorrhage or for the management of recurrent hemorrhage over a relatively short period accompanied by a large transfusion requirement.
The exact time frame for follow-up colonoscopy in patients with angiodysplasia is controversial. If the patient is asymptomatic, a repeat colonoscopy is not recommended. Outpatient monitoring of hemoglobin and repeated tests for occult blood can be performed. Patients with chronic GI bleeding may need repeated colonoscopies.
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