Angiodysplasia of the Colon Workup
- Author: Alan BR Thomson, MD; Chief Editor: Julian Katz, MD more...
Laboratory Studies
- Complete blood cell (CBC) count: Approximately 10% of patients who bleed from angiodysplasia present with anemia.
- Serum iron level: Iron deficiency is found in 10% of patients with bleeding angiodysplasia.
- Stool for occult blood: As many as 15% of patients with bleeding angiodysplasia will be intermittently positive for occult blood.
- See the algorithm for acute GI bleeding below.
Algorithm for acute gastrointestinal (GI) bleeding. CBC = complete blood cell count; CXR = chest x-ray; EKG = electrocardiography; IVF = intravenous fluid; NG = nasogastric.
Imaging Studies
Selective mesenteric angiography is a useful diagnostic technique for angiodysplasias, especially in patients with massive bleeding in whom a colonoscopic diagnosis is difficult.
The sensitivity of angiography ranges from 58% to 86%. Detection of bleeding depends on the rate of bleeding (as low as 0.5 mL/min), technique, and timing of angiography in relation to the period of bleeding.
The above 3 angiographic signs correspond to the development of ectatic changes in vascular lesions. Their prevalence has been recorded less systematically in other parts of the intestinal tract. However, the interpreter must consider all clinical information, because these angiographic findings may be observed in other disorders, such as malignancy.
The most frequent and earliest angiographic sign is a densely opacified, dilated, and slowly emptying draining vein within the intestinal wall. This vein is detected during the venous phase of the study and is present in more than 90% of angiodysplastic lesions.
As the lesion progresses, a vascular tuft may become apparent during the arterial phase of the study. This is observed in as many as 70-80% of patients with angiodysplasia. It represents an extension of the dilation process to the mucosal venules.
The latest sign, an early-filling vein, may be observed in the arterial phase, indicating a more developed arteriovenous communication through the angiodysplastic lesion. It is observed in only 60-70% of cases of angiodysplasia.
Demonstration of extravasation of contrast dye in the bowel lumen from angiodysplastic lesions is definite evidence of bleeding; however, this is observed in only 6-20% of patients. This low percentage is attributed to the episodic nature of bleeding lesions.
Angiography of resected specimens has been used to confirm appropriate resection when preoperative studies are equivocal or unsatisfactory. An intraluminal formalin fixation technique on the resected specimen, followed by mucosal dissection, has also been used for documenting correct resection. Vasopressin infusion during angiography can arrest bleeding, but potential complications of vasopressin include bowel infarction, arterial vasospasm, and lower extremity ischemia.
Small bowel angiodysplasia accounts for 30-40% of cases of obscure GI bleeding and is associated with significant morbidity and mortality. Small bowel capsule endoscopy (SBCE) is a significant advance on earlier diagnostic techniques. Lymphangiectasia are seen in about half of those with angiodysplasia, in 19% of those with obscure GI bleeding without angiodysplasia, and in 14% of those without GI bleeding. Lymphangiectasia are strongly associated with the presence of small intestinal angiodysplasia and may represent a useful clinical marker for this condition. Angiodysplasia is also associated with increasing age. Conditions associated with systemic atherosclerosis did not increase the risk of angiodysplasia.[41]
When endoscopy is not available, angiography is a useful diagnostic tool in cases with massive GI bleeding such as angiodysplasia and varicosis. Angiodysplasia and varicosis have distinguishable characteristic features on angiography, such as the presence of a nidus, visible late-draining veins, and the typical vascular tuft. Histological examination may reveal that the lesion is an angiodysplasia and not varicosis.[42]
Radionuclide scanning using technetium-99m (99m Tc)–labeled red blood cells or99m Tc sulfur colloid is helpful in detecting and localizing active bleeding from angiodysplasia. Scanning can detect bleeding with rates as low as 0.1 mL/min. The intermittent bleeding nature of angiodysplasia has limited the utility of radionuclide studies in this disorder.
Red blood cells that are labeled with technetium have a long half-life in the intravascular compartment and are especially useful in patients with intermittent hemorrhage. The usefulness of technetium-labeled red blood cells is attributed to the ability to detect bleeding during the 12 or so hours after a single injection of radiolabeled cells.
The reticuloendothelial system rapidly clears99m Tc sulfur colloid.99m Tc sulfur colloid has a half-life of only 3 minutes; hence, it is helpful only in patients with active bleeding. The extravasated labeled sulfur colloid easily demonstrates the site of bleeding in the absence of confusing background activity in the circulation, although uptake into the liver and spleen restricts the image area.
Nuclear scans lack the specificity of an angiogram in differentiating the nature of bleeding lesions, despite the fact that they are noninvasive and relatively easy to perform. Nuclear scans have proven more useful as an adjunct to angiography by localizing and confirming the presence of bleeding, minimizing the number of angiograms that do not yield meaningful diagnostic information, and allowing rapid selection of the artery to be injected by angiography. Confirm positive findings from a radionuclide study by colonoscopy or angiography if surgical resection is contemplated (see image below).
Angiodysplasia identified on cecum wall during colonoscopy. Helical computed tomography (CT) angiography can detect extravasation from angiodysplasia and is potentially an important noninvasive test in patients with obscure bleeding sites.
Capsule endoscopy has been reported to detect cecal angiodysplasias in selected cases. Capsule endoscopy is particularly useful to demonstrate small intestinal lesions, but its role as a diagnostic test for the colon is still experimental.[43]
Double-balloon endoscopy is useful to detect small bowel lesions, and retrograde double-balloon endoscopy may allow for careful inspection of the cecum and ileocecal valve.[44, 45]
Other Tests
Air contrast barium enema is not recommended during acute GI bleeding. Air contrast barium enemas can help exclude other causes of chronic colonic bleeding; however, they are not useful in detecting angiodysplasia, because the lesions are small and usually do not distort the colonic mucosa. In addition, barium enema can obscure other diagnostic studies.
Procedures
Endoscopy is the most common method of diagnosing angiodysplasia in both the upper and lower GI tract.
Upper endoscopy is used to establish a diagnosis of gastric and duodenal angiodysplasia. Celiac artery and superior mesenteric artery arteriograms frequently fail to demonstrate these lesions, although large lesions with well-formed and enlarged draining veins have been reported in the gastric antrum. Angiography can demonstrate lesions in the more distal small intestine, a region less accessible to endoscopic evaluation. Push enteroscopy has proven to be a successful method of identifying angiodysplasia of the proximal small intestine in patients with obscure bleeding. Other methods of visually evaluating the small bowel are double-balloon enteroscopy, which is still investigational, and capsule enteroscopy, which is currently used in clinical practice.
The endoscopic appearance of gastric lesions typically has been described as discrete, flat, or slightly raised (2-10 mm) and bright red. These lesions have fernlike margins or stellate configurations. Proximal small intestinal lesions are the size of a pinpoint, with a similar gross appearance. A surrounding pale rim or halo also characterizes upper tract lesions.
Either angiography or colonoscopy may be used to detect colonic lesions. Because colonoscopy is a principal method in the evaluation of GI bleeding, diagnosis of these lesions often results from colonoscopic examination.
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, thus, the entire colon must be examined. Angiography has the advantage of detecting additional angiodysplastic lesions not depicted by colonoscopy. In a series by Emanuel et al, 17% of subjects were found to have concomitant colonic and extracolonic angiodysplasia when studied by triple-vessel angiography.[22] Angiography and colonoscopy can play important complementary roles.
Skibba et al first described the colonoscopic appearance of angiodysplasia in 1976.[46] Angiodysplastic lesions are often described as discrete and small, with scalloped or frondlike edges and a visible draining vein. They can be flat or slightly raised and can be hidden within mucosal folds. Although angiodysplasia may be detected anywhere in the colon, a strong propensity exists for the cecum and ascending colon.
Angiodysplastic lesions encountered as incidental findings are generally small lesions with pale coloration compared with lesions with recent hemorrhage, which are described as extremely bright with elevated centers.
The endoscopic appearance of angiodysplasia can be confused with the ectasias associated with systemic diseases, such as hereditary hemorrhagic telangiectasia (HHT), Turner syndrome, Ehlers-Danlos syndrome, blue rubber web nevus syndrome, the CREST variant syndrome (calcinosis, Raynaud phenomenon, esophageal hypomotility, sclerodactyly, and telangiectasia) of scleroderma, gastric antral vascular ectasia (GAVE), portal hypertensive colopathy, and radiation-induced injury. The lack of systemic manifestations distinguishes angiodysplasia from these syndromes.
In addition, the endoscopic appearance of angiodysplasia may be difficult to discern from spider angiomata, radiation injury, ulcerative colitis (see image below), Crohn disease (see image below), ischemic colitis, and suction artifacts.
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. Evaluation of a patient who may have angiodysplasia requires that the colonoscope be inserted carefully, with minimal use of suction, and that the mucosa be examined more carefully as the instrument is advanced than during withdrawal. Obtaining a biopsy of suspicious lesions may be necessary if classic features are not present.
Because blood pressure and volume influence the colonoscopic appearance of vascular lesions, angiodysplasia may not be evident in patients who have bled recently. Accurate evaluation of the colon may not be possible until effective fluid resuscitation and blood transfusions.
Some studies have noted that administering meperidine may diminish the prominence of some vascular abnormalities, and some researchers have advocated reversal by naloxone to aid in the accurate detection of these lesions.
In persons with obscure GI bleeding, the overall diagnostic yield of video capsule endoscopy was 61%. Angiodysplasia was diagnosed in (54%) patients older than 65 years, whereas mucosal breaks, (such as erosions or ulcers), accounted for over a quarter of finding in persons aged 65 years or younger.[47] .
The underlying etiologies for lower GI bleeding included diverticular disease (59%), angiodysplasia (19%), ulcers (19%), and malignancy (3%). The use of superselective mesenteric embolization for the treatment of lower GI bleeding is technically successful in 97%, and 3% develop postembolization ischemia.[48]
Lesions outside the small bowel as possible sources of obscure GI bleeding are found in about half of patients; a definite source of bleeding outside the small bowel (SB) was detected in about a quarter. Therefore, repeat esophagogastroduodenoscopy (EGD) and ileocolonoscopy should be taken into consideration before double balloon endoscopy.[49]
Despite standard endoscopic diagnostic evaluations with EGD and colonoscopy, as many as 30% of patients with iron deficiency anemia (IDA) are without a definitive diagnosis.[50]
In one study, capsule endoscopy (CE) in persons with unexplained IDA revealed angiodysplasias in 51 patients; jejunal and/or ileal micro-ulcerations in 12 patients; tumors/polyps in 9 patients; erosive gastritis in 4 patients; Crohn disease in 5 patients; jejunal villous atrophy in 5 patients; a solitary ileal ulcer in 1 patient, and active bleeding in the last 4 patients. Follow-up data were available for 80 of 91 patients (87.9%). In a third of patients with angiodysplasias, IDA spontaneously resolved without any treatment; about one fifth of the patients required iron supplementation, and one fifth healed after lanreotide administration. APC was performed in one fifth of patients, and the reminder underwent regular blood transfusion.[51]
Angiodysplasia is the most common reason (50%) for obscure GI bleeding, as shown on CE. The pooled completion rate of CE was 84%. The pooled retention rates were approximately 2%.[52]
Angiodysplasia can be detected infrequently by visual inspection of the serosal side of the bowel during laparotomy. Richardson et al made a correct diagnosis of angiodysplasia during surgical exploration in only 1 of 39 cases (2.6%).[53] The remaining patients were diagnosed by angiography or colonoscopy. Fourteen of these individuals had undergone 21 nondiagnostic surgeries before their evaluation.
Intraoperative enteroscopy can help in localization of distal small bowel lesions. In addition, an angiographic catheter can be placed before surgery into the appropriate feeding vessel supplying the angiodysplastic lesion. The surgeon then can identify the catheter during surgery and explore and resect the appropriate small bowel segment.
Angiodysplasia (9 mm), GI stromal tumor (15 mm), and AVM may be clearly detected by virtual enteroscopy.
CT enteroclysis is a noninvasive method and useful approach in the diagnosis of small intestinal diseases.
A likely cause for obscure GI bleeding was found in the small bowel during balloon-assisted enteroscopy (BAE); angiodysplasia or AVM were found in 70% of patients, ulcerative lesions was found in 12% of patients, tumors were found in 5% of patients, and other findings were found in 13% of patients. In 76% of patients with findings at BAE, endoscopic treatment was administered in 71% but anemia also improved spontaneously in 63% with normal findings during BAE.[54]
To evaluate the diagnostic value of DBE for obscure GI bleeding, one study showed that bleeding was most commonly associated with small bowel tumor (28%), angiodysplasia (19%), and Crohn disease (11%).[55]
The overall complication rate DBE is about 0.9, with no significant difference between age groups. Elderly patients were more likely to have angiectasias (39% vs 23%; P = .01), and were more likely to require endoscopic therapy during DBE (46.8% vs 29.2%; P = .01).[56]
One of the main indications for DBE is suspected small-bowel bleeding (SSBB). The most common finding may be angiodysplasia. The rate of rebleeding in patients who had undergone therapeutic interventions (20%) was similar to that in patients who had not (18%).[57]
The combination of double-balloon enteroscopy (DBE) and laparoscopically assisted bowel surgery (LABS) represents useful therapeutic method for obscure GI bleeding caused by small bleeding neoplasms or vascular lesions.[58]
No consensus has been reached on the relative accuracy of CE versus DBE to investigate obscure GI bleeding. The positive findings for each type of lesion were similar for angiodysplasia (CE, 65% and DBE, 61%), ulcers (CE, 20% and DBE, 19%), and mass (CE, 10% and DBE, 9%). CE was superior to DBE in detecting bleeding lesions (CE, 43% and DBE, 15%, P=0.0004). DBE provides the advantage of therapeutic intervention by argon plasma coagulation, clipping, polypectomy, tattooing, and biopsies. CE and DBE are complementary, and both evaluate obscure GI bleeding more fully than either modality alone.[59]
CE and magnetic resonance enterography (MRE) are complementary methods which, when used in conjunction, may better characterize suspected small bowel disease.[60]
Histologic Findings
Endoscopic forceps biopsy has revealed characteristic histopathologic features of angiodysplasia in only 31-60% of specimens. Endoscopic mucosal biopsies for purposes of diagnosis are generally not recommended because of the low diagnostic yield and the risk of provoking hemorrhage.
However, the histologic diagnosis of angiodysplasia is difficult. Acquired lesions such as angiodysplasias must be differentiated from vascular tumors, lesions associated with congenital or systemic disease, or radiation damage.
Angiodysplasias typically are irregularly shaped clusters of ectatic small arteries, small veins, and their capillary connections. They are more often multiple than single. Microscopically, angiodysplastic lesions are dilated, distorted, thin-walled vessels. The amount of smooth muscle in the vessel wall is variable. The vessel wall can become so thinned that it appears to be composed only of endothelium.
Markedly dilated submucosal vasculature is the most consistent abnormality and the earliest change identified. More advanced lesions involve the mucosa. Because the major portion of the lesion is often submucosal, endoscopic mucosal biopsies are often not diagnostic. Characteristic histopathologic findings of angiodysplasia are identified only in 31-60% of endoscopically obtained biopsies.
In addition, routine pathologic examination usually discovers less than one third of lesions. Injecting the colonic vasculature with silicone rubber and clearing the specimen can be used to identify almost all lesions. In this process, the rubber compound is injected through a catheter placed in one or more of the arteries supplying the colon, after which the specimen is refrigerated for 24 hours to allow the silicone to polymerize. Specimens are then dehydrated in increasing concentrations of ethyl alcohol and cleared with methyl salicylate. The result is a transparent specimen with a filled vascular bed, which is studied through a dissecting microscope using direct light as well as transillumination.
Overlapping features and poor endoscopic-histologic correlation make the distinction challenging between portal hypertensive gastropathy (PHG) and GAVE. Thrombi were revealed in 100% of histologically confirmed cases of GAVE and in 60% of cases suspected of GAVE on endoscopy alone; control biopsies were negative. Mucosal microvessel density (MVD) was significantly higher in GAVE than PHG.[61]
Comparative histological and electron microscopic study of arteriovenous and venous angiodysplasias revealed specific features of their structure, presumably reflecting differences in their morphogenesis. Specific ultrastructural characteristics of angiodysplasias are modified shape of endotheliocytes, impaired structure of the basal membrane, and reduced count of pericytes.[62]
Regula J, Wronska E, Pachlewski J. Vascular lesions of the gastrointestinal tract. Best Pract Res Clin Gastroenterol. 2008;22(2):313-28. [Medline].
Heyde EC. Gastrointestinal bleeding in aortic stenosis. N Engl J Med. 1958;259:196.
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].
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].
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].
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.
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.
Mudhar HS, Balsitis M. Colonic angiodysplasia and true diverticula: is there an association?. Histopathology. Jan 2005;46(1):81-8. [Medline].
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].
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].
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].
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].
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].
Rosborough TK, Swaim WR. Acquired von Willebrand's disease, platelet-release defect and angiodysplasia. Am J Med. Jul 1978;65(1):96-100. [Medline].
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].
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].
Gostout CJ, Bowie EJW, Balm R, Fischer PK. Is angiodysplasia associated with von Willebrand's disease?. Gastroenterology. 1990;98:A172.
Fressinaud E, Meyer D. International survey of patients with von Willebrand disease and angiodysplasia. Thromb Haemost. Sep 1 1993;70(3):546. [Medline].
Makris M. Gastrointestinal bleeding in von Willebrand disease. Thromb Res. 2006;118 suppl 1:S13-7. [Medline].
Hirri HM, Green PJ, Lindsay J. Von Willebrand's disease and angiodysplasia treated with thalidomide. Haemophilia. May 2006;12(3):285-6. [Medline].
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].
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].
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].
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].
Pate GE, Chandavimol M, Naiman SC, Webb JG. Heyde's syndrome: a review. J Heart Valve Dis. Sep 2004;13(5):701-12. [Medline].
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].
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].
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].
Gola W, Lelonek M. Clinical implication of gastrointestinal bleeding in degenerative aortic stenosis: an update. Cardiol J. 2010;17(4):330-4. [Medline].
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].
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].
Slaughter MS. Hematologic effects of continuous flow left ventricular assist devices. J Cardiovasc Transl Res. Dec 2010;3(6):618-24. [Medline].
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].
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].
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].
Lee HE, Sagong C, Yeo KY, et al. A case of hereditary hemorrhagic telangiectasia. Ann Dermatol. May 2009;21(2):206-8. [Medline].
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].
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].
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].
Selinger CP, Ang YS. Gastric antral vascular ectasia (GAVE): an update on clinical presentation, pathophysiology and treatment. Digestion. 2008;77(2):131-7. [Medline].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
Richardson JD, Max MH, Flint LM Jr, et al. Bleeding vascular malformations of the intestine. Surgery. Sep 1978;84(3):430-6. [Medline].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
Suzuki N, Arebi N, Saunders BP. A novel method of treating colonic angiodysplasia. Gastrointest Endosc. Sep 2006;64(3):424-7. [Medline].
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].
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].
Pishvaian AC, Lewis JH. Use of endoclips to obliterate a colonic arteriovenous malformation before cauterization. Gastrointest Endosc. May 2006;63(6):865-6. [Medline].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
Richter JM, Hedberg SE, Athanasoulis CA, Schapiro RH. Angiodysplasia. Clinical presentation and colonoscopic diagnosis. Dig Dis Sci. Jun 1984;29(6):481-5. [Medline].
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].
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].
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].
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].
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].
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].
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].
Brandt LJ, Mukhopadhyay D. Masking of colon vascular ectasias by cold water lavage. Gastrointest Endosc. Jan 1999;49(1):141-2. [Medline].
Britt LG, Warren L, Moore OF 3rd. Selective management of lower gastrointestinal bleeding. Am Surg. Mar 1983;49(3):121-5. [Medline].
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].
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].
Chou CC, Dabney JM. Interrelation of ileal wall compliance and vascular resistance. Am J Dig Dis. Dec 1967;12(12):1198-208. [Medline].
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].
Duchini A, Sessoms SL. Gastrointestinal hemorrhage in patients with systemic sclerosis and CREST syndrome. Am J Gastroenterol. Sep 1998;93(9):1453-6. [Medline].
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].
Flynn CT, Chandran PK. Renal failure and angiodysplasia of the colon. Ann Intern Med. Jul 1985;103(1):154. [Medline].
Foutch PG. Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol. Jun 1993;88(6):807-18. [Medline].
Foutch PG. Colonic angiodysplasia. Gastroenterologist. Jun 1997;5(2):148-56. [Medline].
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].
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].
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].
Hemingway AP. Angiodysplasia as a cause of iron deficiency anaemia. Blood Rev. Sep 1989;3(3):147-51. [Medline].
Ho S, Jackson J. The angiographic diagnosis of colonic carcinoma. Clin Radiol. May 1998;53(5):345-9. [Medline].
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].
Howard OM, Buchanan JD, Hunt RH. Angiodysplasia of the colon. Experience of 26 cases. Lancet. Jul 3 1982;2(8288):16-9. [Medline].
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].
Kheterpal S. Angiodysplasia: a review. J R Soc Med. Oct 1991;84(10):615-8. [Medline]. [Full Text].
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].
Krevsky B. Detection and treatment of angiodysplasia. Gastrointest Endosc Clin N Am. Jul 1997;7(3):509-24. [Medline].
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].
Noer RJ, Derr JW. Effect of distention on intestinal revascularization. Arch Surg. Sep 1949;59(3):542-9. [Medline].
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].
Potter GD, Sellin JH. Lower gastrointestinal bleeding. Gastroenterol Clin North Am. Jun 1988;17(2):341-56. [Medline].
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].
Roberts PL, Schoetz DJ Jr, Coller JA. Vascular ectasia. Diagnosis and treatment by colonoscopy. Am Surg. Jan 1988;54(1):56-9. [Medline].
Sabanathan S, Nag SB. Angiodysplasia of the colon: a post-mortem study. J R Coll Surg Edinb. Sep 1982;27(5):285-91. [Medline].
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].
Semba T, Fujii Y. Relationship between venous flow and colonic peristalsis. Jpn J Physiol. Aug 1970;20(4):408-16. [Medline].
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].
Sharma R, Gorbien MJ. Angiodysplasia and lower gastrointestinal tract bleeding in elderly patients. Arch Intern Med. Apr 24 1995;155(8):807-12. [Medline].
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].
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].
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].
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].
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].
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].
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].
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