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Chataut D, Katwal S, Suwal S, Thapa A, Bhattarai B. Angiodysplasia simulating variceal bleeding: a challenging case report of diagnosis and intervention. Ann Med Surg (Lond) 2024; 86:3109-3112. [PMID: 38694381 PMCID: PMC11060247 DOI: 10.1097/ms9.0000000000001963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/05/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction and importance Angiodysplasia, a prevalent vascular anomaly in the gastrointestinal tract, often presents with upper gastrointestinal bleeding, sharing symptoms with gastric varices. The diagnostic challenge arises due to overlapping clinical features. This case report highlights the importance of considering angiodysplasia in the differential diagnosis, especially when variceal bleeding is less likely, and emphasizes the role of various diagnostic modalities in accurate identification. Case presentation A 52-year-old male presented with severe hematemesis and melena, mimicking variceal bleeding. Despite initial management, bleeding persisted. Contrast-enhanced computed tomography revealed dilated vascular channels, raising suspicion for both gastric varices and angiodysplasia. Endoscopy confirmed an angiomatous lesion, inadvertently disrupted during the procedure, necessitating angiography. The angiographic findings supported the diagnosis of angiodysplasia, and successful interventions included temporary glue embolization and argon laser coagulation during endoscopy. The patient was discharged with stable hemoglobin; a 2-year follow-up showed no recurrence. Clinical discussion The case discusses the challenges in differentiating angiodysplasia from varices, emphasizing the role of imaging and endoscopic modalities. It highlights the need for a tailored approach to treatment, including argon plasma coagulation, and underscores the significance of meticulous follow-up for recurrence. Conclusion This case report elucidates the diagnostic and therapeutic journey in managing a patient with angiodysplasia masquerading as variceal bleeding. It emphasizes the importance of considering vascular anomalies without typical signs and the significance of individualized interventions for optimal patient outcomes. The 2-year follow-up without recurrence signifies the successful management of the case.
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Affiliation(s)
- Dinesh Chataut
- Department of Radiology, Maharajgunj Medical Campus, Kathmandu
| | - Shailendra Katwal
- Department of Radiology, Dadeldhura Subregional Hospital, Dadeldhura
| | - Sundar Suwal
- Department of Radiology, Maharajgunj Medical Campus, Kathmandu
| | - Ajit Thapa
- Department of Radiology, Maharajgunj Medical Campus, Kathmandu
| | - Bharosha Bhattarai
- Department of Radiology, BP Koirala Institute of Health Science, Sunsari, Nepal
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2
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Rasheed W, Abu-Hassan F. 10-year trends and inpatient outcomes of gastrointestinal angiodysplasia with bleeding in the United States: National Inpatient Sample, 2011 to 2020. Proc AMIA Symp 2023; 36:277-285. [PMID: 37101908 PMCID: PMC10124974 DOI: 10.1080/08998280.2023.2172295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Gastrointestinal angiodysplasia (GIAD) is the presence of aberrant blood vessels in the gastrointestinal (GI) tract that can lead to GI bleeding. There has been an increase in the incidence of GI angiodysplasia, partly due to the availability of better diagnostic techniques. The cecum is known as the most common site for GIAD; therefore, GIAD is considered a frequent cause of lower GI bleeding. Studies have shown an increasing incidence of GIAD in the upper GI tract and jejunum. No population-based studies exist on inpatient outcomes of GIAD-bleeding (GIADB) in recent years, and no prior studies have compared the inpatient outcomes of upper vs lower GIADB. We identified 321,559 weighted hospitalizations and found a 32% increase in GIADB-related hospitalizations from 2011 to 2020. There were more hospitalizations for upper (57.38%) than lower GIADB (42.62%), indicating GIADB is an important cause of upper GI bleeding as well. No statistically significant difference in mortality was found between upper and lower GIADB cohorts; however, lower GIADB was associated with a 0.2-day longer length of stay (95% confidence interval 0.09-0.30, P < 0.001) and $3857 higher mean inpatient cost (95% confidence interval $2422-$5291, P < 0.001).
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Affiliation(s)
- Waqas Rasheed
- Department of Internal Medicine, Texas Tech University Health Science Center at Amarillo, Amarillo, Texas
| | - Falah Abu-Hassan
- Department of Internal Medicine, Texas Tech University Health Science Center at Amarillo, Amarillo, Texas
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3
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Strategic Management of Bleeding Small Bowel Gastrointestinal Angiodysplasias (GIADs): A 12 Year Retrospective Review in a Veteran Population and Cost Comparison. Diagnostics (Basel) 2023; 13:diagnostics13030525. [PMID: 36766630 PMCID: PMC9914120 DOI: 10.3390/diagnostics13030525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/18/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIADs), also known as gastrointestinal angioectasias, are dilated, abnormally thin-walled blood vessels that occur in the mucosa and submucosa throughout the gastrointestinal tract. As a common cause of small bowel bleeding, GIADs have a significant impact on patient's morbidity and healthcare costs. Presently, somatostatin has been used widely to treat GIADs, but it is unclear if other therapies are as beneficial and cost-effective as somatostatin in managing GIADs. (2) Methods: A retrospective chart review was performed, which included subjects treated with Lanreotide, a somatostatin analog, and other therapies at the VA Loma Linda Healthcare System (VALLHCC) from January 2006 to December 2018. Patients who had symptomatic GIADs were detected by video capsule endoscopy (VCE), a device-assisted enteroscopy (DAE) or, in our case, push enteroscopy (PE) with an Endocuff. (3) Results: Three hundred twelve patients were diagnosed with GIADs. In this group of patients, 72 underwent ablation (endoscopic BICAP) with the addition of Lanreotide (SST), 63 underwent ablation therapy, eight were treated with SST only, 128 received iron replacement only, 25 received iron plus SST therapy, and 61 were observed with no therapy. Each group was followed via their hemoglobin (Hgb) level immediately thereafter, and Hgb levels were then obtained every 3 months for a 12-month period. After ablation therapy, 63 patients maintained stable Hgb levels over the course of the study, suggesting a significant therapeutic effect by controlling active bleeding. The 27 patients receiving ablation +SST therapy did not show improvements when compared to ablation only and the 128 patients who received iron therapy alone. (4) Conclusions: Importantly, 12 years of managing these patients has given us a cost- and time-sensitive strategy to maintain the patients' Hgb levels and avoid hospital admissions for acute bleeding. Iron treatment alone is effective compared to SST treatment in recovering from GIADs. Eliminating SST treatment from therapeutic intervention would save $89,100-445,550 per patient, depending on the number of doses for private care patients and $14,286-28,772 for VA patients, respectively. A suggested therapy would be to perform DAE on actively bleeding patients, ablate the lesions using a coagulation method, and place the patient on iron. If that fails, gastroenterologists should repeat VCE and perform either PE with Endocuff or balloon enteroscopy (all DAEs).
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Del Cueto-Aguilera Á, García-Compeán D, Jiménez-Rodríguez A, Borjas-Almaguer O, Wah-Suárez M, González-González J, Maldonado-Garza H. Efficacy of octreotide in bleeding recurrence from small bowel angioectasia: A comparative study. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2022; 87:411-419. [DOI: 10.1016/j.rgmxen.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 02/05/2021] [Indexed: 02/07/2023] Open
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Del Cueto-Aguilera Á, García-Compeán D, Jiménez-Rodríguez A, Borjas-Almaguer O, Wah-Suárez M, González-González J, Maldonado-Garza H. Eficacia del octreótido sobre la recurrencia hemorrágica de las angiectasias del intestino delgado. Estudio comparativo. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2022. [DOI: 10.1016/j.rgmx.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Khan A, Gupta K, Chowdry M, Sharma S, Maheshwari S, Patel C, Naseem K, Pervez H, Bilal M, Ali Khan M, Singh S. Thirty-day readmission rates, reasons, and costs for gastrointestinal angiodysplasia-related bleeding in the USA. Eur J Gastroenterol Hepatol 2022; 34:11-17. [PMID: 33405425 DOI: 10.1097/meg.0000000000002027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Patients with gastrointestinal angiodysplasia (GIA)-related bleeding are at high risk for readmissions, resulting in significant morbidity and an economic burden on the healthcare system. AIM The aim of the study was to determine the 30-day readmission rate with reasons, predictors, and costs associated with GIA-related bleeding in the USA. METHODS We queried the National Readmission Database to identify patients hospitalized with GIA-related bleeding in the year 2016 using the International Classification of Diseases, Tenth Revision (ICD-10) codes. Primary outcomes included the 30-day readmission rate, and secondary outcomes were in-hospital mortality and resource utilization for index and re-hospitalizations. We also performed univariate and multivariate cox regression analysis to identify predictors of readmissions. RESULTS A total of 25 079 index hospitalizations for GIA-related bleeding were identified in 2016. Out of these, 5047 (20.34%) patients got readmitted within the next 30 days. The most common diagnosis associated with readmissions were related to recurrent gastrointestinal bleeding. Readmissions compared to index hospitalization has significantly higher length of stay (5.38 vs. 5.11 days, P = 0.03), but mean hospitalization charges ($52 114 vs. $49 691, P = 0.11) and mean total hospitalization costs ($12 870 vs. $12 405, P = 0.16) were similar. Patients with multiple co-morbidities, length of stay >5 days, and end-stage renal disease were found to be independent predictors for 30-day readmissions. CONCLUSION Our study shows that one in five patients hospitalized with GIA-related bleeding was readmitted within 30 days of index hospitalization, placing a heavy economic burden on the healthcare system. Further research identifying strategies to reduce readmissions in these patients is needed.
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Affiliation(s)
- Ahmad Khan
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Kamesh Gupta
- Department of Medicine, UMass Medical Center, Springfield, Massachusetts
| | - Monica Chowdry
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Sachit Sharma
- Department of Medicine, The Toledo Hospital, Toledo, Ohio
| | | | - Chirag Patel
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Khadija Naseem
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Hira Pervez
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mohammad Bilal
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Muhammad Ali Khan
- Division of Gastroenterology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama
| | - Shailendra Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
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Al-Radaideh O, Farouji I, Abed H, Shaaban H. Recurrent gastrointestinal bleeding in a patient with Heyde syndrome with elevated factor VIII levels: A case report. Int J Crit Illn Inj Sci 2021; 11:253-256. [PMID: 35070916 PMCID: PMC8725811 DOI: 10.4103/ijciis.ijciis_151_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 03/11/2021] [Accepted: 03/26/2021] [Indexed: 11/23/2022] Open
Abstract
Heyde syndrome is the association between gastrointestinal (GI) bleeding from intestinal angiodysplasia (IA) and aortic stenosis (AS). Although the course of disease progression that links AS and GI bleeding has not been determined, overlaps among AS, intestinal dysplasia, and acquired von Willebrand's syndrome is thought to result in GI bleeding. Proper repair of the aortic valve can result in significant improvement of GI bleeding and its recurrence. Herein, we are reporting this rare case, in which a patient with moderate AS on echocardiogram presents with recurrent GI bleeding from multiple IA in the setting of elevated factor VIII levels, to propose a theory that angiodysplasia could potentially develop due to intermittent, recurrent low-grade obstruction of submucosal veins at the level of the muscularis propria secondary to venous thrombosis related to elevated factor VIII levels.
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Affiliation(s)
- Omar Al-Radaideh
- Department of Medical Education, Saint Michael's Medical Center, New York Medical College, Newark, NJ, USA
| | - Iyad Farouji
- Department of Medical Education, Saint Michael's Medical Center, New York Medical College, Newark, NJ, USA
| | - Hossam Abed
- Department of Medical Education, Saint Michael's Medical Center, New York Medical College, Newark, NJ, USA
| | - Hamid Shaaban
- Department of Medical Education, Saint Michael's Medical Center, New York Medical College, Newark, NJ, USA.,Department of Hematology/Oncology, Saint Michael's Medical Center, New York Medical College, Newark, NJ, USA
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Notsu T, Adachi K, Mishiro T, Kishi K, Ishimura N, Ishihara S. Prevalence of Angiodysplasia Detected in Upper Gastrointestinal Endoscopic Examinations. Cureus 2021; 13:e14353. [PMID: 33972910 PMCID: PMC8105191 DOI: 10.7759/cureus.14353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background This study was performed to examine the prevalence of asymptomatic angiodysplasia detected in upper gastrointestinal endoscopic examinations and of hereditary hemorrhagic telangiectasia (HHT) suspected cases. Methodology The study participants were 5,034 individuals (3,206 males, 1,828 females; mean age 53.5 ± 9.8 years) who underwent an upper gastrointestinal endoscopic examination as part of a medical check-up. The presence of angiodysplasia was examined endoscopically from the pharynx to duodenal second portion. HHT suspected cases were diagnosed based on the presence of both upper gastrointestinal angiodysplasia and recurrent nasal bleeding episodes occurring in the subject as well as a first-degree relative. Results Angiodysplasia was endoscopically detected in 494 (9.8%) of the 5,061 subjects. Those with angiodysplasia lesions in the pharynx, larynx, esophagus, stomach, and duodenum numbered 44, 4, 155, 322, and 12, respectively. None had symptoms of upper gastrointestinal bleeding or severe anemia. Subjects with angiodysplasia showed significant male predominance and were significantly older than those without. A total of 11 (0.2%) were diagnosed as HHT suspected cases by the presence of upper gastrointestinal angiodysplasia and recurrent epistaxis episodes from childhood in the subject as well as a first-degree relative. Conclusions Asymptomatic angiodysplasia was detected in 9.8% of the subjects who underwent screening upper gastrointestinal endoscopic examinations.
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Affiliation(s)
- Takumi Notsu
- Health Center, Shimane Environment and Health Public Corporation, Matsue, JPN
| | - Kyoichi Adachi
- Health Center, Shimane Environment and Health Public Corporation, Matsue, JPN
| | - Tomoko Mishiro
- Health Center, Shimane Environment and Health Public Corporation, Matsue, JPN
| | - Kanako Kishi
- Health Center, Shimane Environment and Health Public Corporation, Matsue, JPN
| | - Norihisa Ishimura
- Second Department of Internal Medicine, Shimane University Faculty of Medicine, Izumo, JPN
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9
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Lara LF, Silva R, Thakkar S, Stanich PP, Mai D, Samarasena JB. Multicenter case series of patients with small-bowel angiodysplasias treated with a small-bowel radiofrequency ablation catheter. VideoGIE 2020; 5:162-167. [PMID: 32258850 PMCID: PMC7125393 DOI: 10.1016/j.vgie.2019.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background and Aims GI angiodysplasia is the most common cause of small-bowel bleeding. Argon plasma coagulation (APC) is preferred for ablation because of its availability, ease of use, and perceived safety, but it has limitations. An instrument capable of repeated use through the enteroscope, which covers more area of intestinal mucosa per treatment with low risk of damage to healthy mucosa, and which improves ablation, is desirable. A series of patients treated with a through-the-scope radiofrequency ablation (RFA) catheter is reported. Methods Patients with a previous diagnosis of small-bowel angiodysplasia (SBA) and ongoing bleeding with melena, hematochezia, or iron-deficiency anemia were eligible for treatment. A small-bowel radiofrequency ablation (SBRFA) catheter was passed through the enteroscope instrument channel. The treatment paddle was pushed against the SBA, achieving coaptive coagulation, and the SBA was treated up to 2 times at standard settings of 10 J/cm2. The patients' demographics, pretreatment and posttreatment hemoglobin levels, time to recurrence of bleeding, and need for more therapy were recorded. This study was approved by the institutional review boards of the respective institutions. Results Twenty consecutive patients were treated from March until October 2018 and followed up until March 2019. There were 6 women (average age 68 years, standard deviation ± 11.1), and 14 men (average age 73 years, standard deviation ± 10.4). All had undergone at least 1 previous EGD and colonoscopy; 14 patients (70%) had SBA on video capsule endoscopy, and 14 patients had undergone previous endoscopic treatment of SBA with APC. A median of 23 treatments were applied (range, 2-99). The median follow-up time was 195 days (range, 30-240 days). Four patients, including 3 with a left ventricular assist device (LVAD), had recurrent bleeding between 45 and 210 days after treatment, and 2 patients received repeated blood transfusions. Three of those patients underwent repeated endoscopies, including a push enteroscopy and an upper endoscopy with no treatment, and a repeated enteroscopy with SBA treated with APC, respectively. One patient with LVAD underwent arterial embolization. Conclusions In this case series, bleeding recurred in 20% of patients in a follow-up time of ≤240 days. Notably, 3 of the 4 patients who had recurrent bleeding had an LVAD. These rates compare favorably with reported bleeding recurrence after APC of SBA. More studies on the benefits of SBRFA, which may include reduced risk of recurrent bleeding or prolonging the time to recurrent bleeding, resource utilization, and factors associated with bleeding recurrence are needed.
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Affiliation(s)
- Luis F Lara
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Rogelio Silva
- Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Shyam Thakkar
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Peter P Stanich
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Mai
- University of California, Irvine, California USA
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:jcm9020402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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Costa-Moreira P, Vilas-Boas F, Teixeira Fraga A, Macedo G. Particular aspects of gastroenterological disorders in chronic kidney disease and end-stage renal disease patients: a clinically focused review. Scand J Gastroenterol 2020; 55:129-138. [PMID: 32027522 DOI: 10.1080/00365521.2020.1722217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Besides renal disease, gastrointestinal (GI) disorders are frequently reported in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Related gastrointestinal symptoms tend to increase as the renal disease progresses. Also, in patients with ESRD, the modality of dialysis is related to particular forms of GI disorders.The kidney can interact with the digestive organs through functional endogenous systems such as the 'kidney-colon axis' and the 'kidney-liver axis'. Digestive diseases are one of the visible manifestations of the disturbance between hemostatic, hemodynamic and immunological balance in such patients.No clear management guidelines currently exist for many of the gastrointestinal problems that accompany renal failure. This review aims to describe the particular aspects of GI diseases present in CKD/ESRD. We focus our discussion in the specificities of epidemiology, diagnosis, and prognosis of such disorders between the different segments of the digestive system.
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Affiliation(s)
- Pedro Costa-Moreira
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, Medicine Department, University of Porto, Portugal
| | - Filipe Vilas-Boas
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, Medicine Department, University of Porto, Portugal
| | | | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, Medicine Department, University of Porto, Portugal
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Patel H, Mehershahi S, Shaikh DH, Makker J, Nayudu S, Remy P, Chilimuri S. Thalidomide for the treatment of angiodysplasia-related recurrent gastrointestinal hemorrhage: Is low dose a safe and viable option? Clin Case Rep 2019; 7:2363-2367. [PMID: 31893059 PMCID: PMC6935600 DOI: 10.1002/ccr3.2501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/01/2019] [Accepted: 08/25/2019] [Indexed: 12/16/2022] Open
Abstract
Thalidomide is often used for the management of refractory gastrointestinal angiodysplasia (GIAD). The tolerance, toxic profile, and compliance of thalidomide are dose-dependent. The low-dose thalidomide (50 mg) is safe and a viable option for bleeding related to GIAD.
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Affiliation(s)
- Harish Patel
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Shehriyar Mehershahi
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Danial Haris Shaikh
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Jasbir Makker
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Sureshkumar Nayudu
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Prospere Remy
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
| | - Sridhar Chilimuri
- Division of GastroenterologyBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
- Department of MedicineBronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of MedicineBronxNew York
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Comparison of Argon Plasma Coagulation and Injection Therapy with Adrenalin and Polidocanol in the Management of Bleeding Angiodysplasia in Upper Gastrointestinal Tract. ACTA ACUST UNITED AC 2019; 39:63-68. [PMID: 30864370 DOI: 10.2478/prilozi-2018-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The term angiodysplasia (AD) refers to acquired malformation of the blood vessels (communications between veins and capillaries), frequently found within the gastrointestinal mucosa and submucosa. AD of stomach and duodenum are cause of upper gastrointestinal bleeding in 4%-7% of patients. The means of treatment are usually endoscopic, including argon plasma coagulation (APC), electrocoagulation, mechanical hemostasis by clippsing, laser photo-coagulation and injection therapy. AIM To compare the success rate, and adverse events (ulcer lesions, perforations) of APC and injection therapy in the treatment of bleeding angiodysplasia in the upper gastrointestinal tract (GIT). MATERIAL AND METHODS In a prospective study including 50 patients with bleeding angiodysplasia of the upper GIT, 35 patients were treated with APC, and remaining 15 with injection therapy using adrenaline and 1.5% solution of polidocanol. Follow-up period was 6 months. RESULTS A total of 50 patients aged 18 to 64 years, 64% male and 36% female, have been treated during 2 years period. The rate of recurrent bleeding and side effects was significantly higher in the adrenaline group (p <0.01). Blood transfusion was required in 68% during the first hospital admission. Angiodysplasia of the stomach was present in 66%, versus 34% in duodenum. CONCLUSION Endoscopy is "gold standard" for diagnosis and treatment of AD in the gastrointestinal tract. The study unveiled APC as more effective treatment option with lower degree of complications and adverse events in comparison to injection therapy in patients with bleeding AD.
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García-Compeán D, Del Cueto-Aguilera ÁN, Jiménez-Rodríguez AR, González-González JA, Maldonado-Garza HJ. Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points. World J Gastroenterol 2019; 25:2549-2564. [PMID: 31210709 PMCID: PMC6558444 DOI: 10.3748/wjg.v25.i21.2549] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/19/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient’s quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.
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Affiliation(s)
- Diego García-Compeán
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Ángel N Del Cueto-Aguilera
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Alan R Jiménez-Rodríguez
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - José A González-González
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Héctor J Maldonado-Garza
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
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A Risk Assessment of Factors for the Presence of Angiodysplasias During Endoscopy and Factors Contributing to Symptomatic Bleeding and Rebleeds. Dig Dis Sci 2019; 64:2923-2932. [PMID: 31190204 PMCID: PMC6744377 DOI: 10.1007/s10620-019-05683-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 05/23/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Few studies have assessed factors associated with angiodysplasias during endoscopy or factors associated with symptomatic disease. AIMS To evaluate risk factors for the presence of and contribution to symptomatic disease in patients with angiodysplasias. METHODS We performed a systematic MEDLINE, EMBASE and Cochrane Library search according to the PRISMA guidelines for studies assessing risk factors involved in angiodysplasias detected during endoscopy and factors that lead to anemia or overt bleeding. Study quality was assessed with the Newcastle-Ottawa scale. A risk assessment was performed by selecting risk factors identified by two independent studies and/or by a large effect size. RESULTS Twenty-three studies involving 92,634 participants were included. The overall quality of the evidence was moderate. Risk factors for the diagnosis of angiodysplasias during endoscopy confirmed by at least two studies were increasing age (OR 1.09 per year, 95% CI 1.04-1.1), chronic kidney disease (OR 4.5, 95% CI 1.9-10.5) and cardiovascular disease (2.9, 95% CI 1.4-6.2). The risk of rebleeds was higher in the presence of multiple lesions (OR 4.2, 95% CI 1.1-16.2 and 3.8, 95% CI 1.3-11.3 and 8.6, 95% CI 1.4-52.6), liver cirrhosis (OR 4.0, 95% 1.1-15.0) and prothrombin time < 30% (OR 4.2, 95% 1.1-15.4) with a moderate effect size. Multiple comorbidities were associated with an increased in-hospital mortality (OR 2.29, 95% CI 1.2-4.3). CONCLUSIONS This systematic review identified age, chronic kidney disease and cardiovascular disease as the most important risk factors for the diagnosis of angiodysplasias during endoscopy. Multiple lesions increase the risk of recurrent bleeding.
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Tsai YY, Chen BC, Chou YC, Lin JC, Lin HH, Huang HH, Huang TY. Clinical characteristics and risk factors of active bleeding in colonic angiodysplasia among the Taiwanese. J Formos Med Assoc 2018; 118:876-882. [PMID: 30348493 DOI: 10.1016/j.jfma.2018.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 09/23/2018] [Accepted: 10/02/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Colonic angiodysplasia (AGD) is a common cause of gastrointestinal bleeding. However, information on the characteristics and prevalence of colonic AGD is limited. We determined the clinical features of and risk factors for active bleeding in colonic AGD in a Taiwanese population. METHODS From February 2007 to December 2016, 13,047 patients undergoing 16,760 colonoscopies at the Tri-Service General Hospital were included in this study. Eighty-four patients were diagnosed with AGD. We conducted a retrospective study by analyzing the medical records of these patients. The clinical features and endoscopic findings were evaluated. Furthermore, we distinguished colonic AGD into bleeding and non-bleeding types and identified the risk factors for bleeding in colonic AGD. RESULTS In our study, the prevalence of colonic AGD was 0.6% among all patients who received colonoscopy. Among patients with colonic AGD, we found that many were aged; in all, 58.3% of patients with colonic AGD were older than 65 years. More than half of the patients had hypertensive cardiovascular disease (53.6%) and the AGD lesions were predominantly located in the left-sided colon (41.7%). We analyzed several factors to identify those associated with bleeding colonic AGD. Our results indicated that age (p < 0.001), hypertension (p = 0.020), atrial fibrillation (p = 0.027), and in-patient status (p = 0.006) were significant factors associated with active bleeding lesions. On multivariate analysis, old age was the only significant risk factor. CONCLUSION Angiodysplastic lesions in Taiwanese patients were predominantly identified in the left-sided colon. Old age was an independent risk factor associated with active bleeding in colonic angiodysplasia.
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Affiliation(s)
- Yi-Yen Tsai
- National Defense Medical Center, Taipei, Taiwan
| | - Bao-Chung Chen
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | | | - Jung-Chun Lin
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsuan-Hwai Lin
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsin-Hung Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan.
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Hicks SB, Kamboj AK, Loftus CG. 39-Year-Old Woman With Constipation and Abdominal Pain. Mayo Clin Proc 2018; 93:1315-1319. [PMID: 29804725 DOI: 10.1016/j.mayocp.2017.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/02/2017] [Accepted: 10/10/2017] [Indexed: 11/30/2022]
Affiliation(s)
- S Bradley Hicks
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Amrit K Kamboj
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Conor G Loftus
- Advisor to residents and Consultant in Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Nonisolated Small Bowel Gastrointestinal Angiodysplasias are Associated With Higher Rebleeding Rates When Compared With Isolated Small Bowel Gastrointestinal Angiodysplasia on Video Capsule Endoscopy. J Clin Gastroenterol 2018; 52:726-733. [PMID: 28617760 DOI: 10.1097/mcg.0000000000000836] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIAD) are commonly diagnosed in the small bowel but can be located in other areas of the gastrointestinal tract. About half of patients diagnosed with GIAD have more than 1 lesion and 20% of patients have GIAD in both the small bowel and a source outside of the small bowel (nonisolated to small bowel GIAD or NISGIAD). The remaining patients with GIAD have lesions isolated to the small bowel (ISGIAD). Complications including rebleeding, hospitalization and mortality rates have not been previously analyzed between these 2 groups. AIM To compare rebleeding, hospitalization and mortality rates between ISGIAD and NISGIAD. The secondary goals were to evaluate comorbidities that may be associated with ISGIAD and/or NISGIAD, and to determine if any of these comorbidities are associated with a higher risk of rebleeding from GIAD. MATERIALS AND METHODS This was a retrospective study that included 425 patients who underwent video capsule endoscopy between 2006 and 2013. Patients underwent esophagogastroduodenoscopy and colonoscopy before video capsule endoscopy. The primary indications for workup included obscure gastrointestinal bleeding. After exclusion criteria, 87 patients diagnosed with GIAD remained, 57 patients with ISGIAD and 30 with NISGIAD. Categorical variables were compared by the Fisher exact test or χ test and continuous data were compared using the Student T test. RESULTS Risk factors associated with rebleeding rates included coronary artery disease, chronic kidney disease, and congestive heart failure on multivariate analysis. Odds ratios for rebleeding was found in patients with NISGIAD (odds ratio, 4.222; P=0.036). There was no difference in hospitalization rates between patients with ISGIAD and NISGIAD. There was no statistically significant difference in mortality from any cause at 30, 60, and 90 days in patients with ISGIAD and NISGIAD. CONCLUSIONS In this retrospective analysis of GIAD at a single institution, patients with NISGIAD compared with ISGIAD had a 4 times odds of rebleeding within 1 year after capsule endoscopy. This is a novel study, as the distribution of GIAD has not been previously described as being a risk factor for rebleeding.
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Nardone G, Compare D, Martino A, Rocco A. Pharmacological treatment of gastrointestinal bleeding due to angiodysplasias: A position paper of the Italian Society of Gastroenterology (SIGE). Dig Liver Dis 2018; 50:542-548. [PMID: 29610020 DOI: 10.1016/j.dld.2018.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/11/2018] [Accepted: 02/08/2018] [Indexed: 02/08/2023]
Abstract
Angioectasias (AD) belong to benign vascular malformations of the gastrointestinal tract and are responsible for about 4-7% of upper non variceal bleeding, 30-40% of small bowel occult bleeding and 3-40% of colonic bleeding episodes. Gastrointestinal haemorrhage secondary to AD represents an important diagnostic and therapeutic problem that negatively impacts on the quality of life of patients and heath care costs. Endoscopic interventions are the mainstay in both diagnosis and treatment of vascular malformations. However, in a substantial percentage of the cases, age of the patients, comorbidities, clinical severity of anaemia and blood loss as well as size, site and number of lesions prevent this therapeutic approach. Hormonal therapy, thalidomide and somatostatin analogues have been investigated for their potential role as rescue therapies in controlling AD bleeding although, thus far, no recommendations have been provided on their use in this clinical setting. In order to implement appropriate prescription of pharmacological agents to manage gastrointestinal bleeding due to ADs, the Italian Society of Gastroenterology (SIGE) nominated a panel of experts who reviewed the available clinical literature and produced practical clinical recommendations.
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Affiliation(s)
- Gerardo Nardone
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy.
| | - Debora Compare
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Alberto Martino
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
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Becq A, Rahmi G, Perrod G, Cellier C. Hemorrhagic angiodysplasia of the digestive tract: pathogenesis, diagnosis, and management. Gastrointest Endosc 2017; 86:792-806. [PMID: 28554655 DOI: 10.1016/j.gie.2017.05.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/18/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Aymeric Becq
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Gabriel Rahmi
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Guillaume Perrod
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Christophe Cellier
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
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Abstract
BACKGROUND Gastrointestinal angioectasias (AEs) represent the most common vascular malformation within the gastrointestinal tract. This study sought to characterize epidemiologic/comorbid risk factors for AEs, rebleeding, and patterns of anatomic distribution within the small intestine. STUDY This retrospective observational cohort study included 158 patients with AEs on capsule endoscopy (CE) from 2007 to 2015. Epidemiologic/comorbid data were collected and incorporated into final analysis. Each AE was categorized by location using a small bowel transit time-based quartile system. Rebleeding was evaluated following CE. Multivariate logistic regression was applied to statistically significant factors on univariate analysis to determine independent risk factors for rebleeding. RESULTS Most lesions were found in the first quartile (67.1%). Rebleeding occurred in 46 (29.7%) of the 156 patients for whom data were available. Rates of rebleeding were significantly higher among older patients (74.4 vs. 67.7 y, P=0.001), those with active bleeding on CE (41.3% vs. 16.5%, P=0.001), those with a history of aortic stenosis (21.7% vs. 9.2%, P=0.033), and those with AEs presents in quartile 3 (26.1% vs. 8.3%, P=0.003). Age, active bleeding on CE, and AE presence in quartile 3 were independently associated with rebleeding in multivariate analysis (P=0.009, 0.023, and 0.008, respectively). CONCLUSIONS These data help improve our knowledge of AEs regarding risk factors for rebleeding, and utilizes a novel small bowel transit time-based quartile localization method that may simplify future research and comparisons of anatomic distribution and behavior of small bowel AEs.
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Bosch X, Montori E, Guerra-García M, Costa-Rodríguez J, Quintanilla MH, Tolosa-Chapasian PE, Moreno P, Guasch N, López-Soto A. A comprehensive evaluation of the gastrointestinal tract in iron-deficiency anemia with predefined hemoglobin below 9mg/dL: A prospective cohort study. Dig Liver Dis 2017; 49:417-426. [PMID: 28065528 DOI: 10.1016/j.dld.2016.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 12/06/2016] [Accepted: 12/09/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anemia is defined as hemoglobin below the cutoff of normal in studies examining the gastrointestinal (GI) tract in iron-deficiency anemia (IDA). Although the risk of GI cancer (GIC) increases as hemoglobin decreases, guidelines do not usually recommend hemoglobin thresholds for IDA investigation. METHODS To elucidate whether underlying GI disorders explain the different hemoglobin values and clinical outcomes observed initially in IDA patients referred for GI workup, we prospectively investigated the diagnostic yield of a thorough GI examination in consecutive IDA adults with predefined hemoglobin <9g/dL and no extraintestinal bleeding. RESULTS 4552 patients were enrolled over 10 years. 96% of 4038 GI lesions were consistent with occult bleeding disorders and 4% with non-bleeding disorders. Predominant bleeding disorders included upper GI ulcerative/erosive lesions (51%), GIC (15%), and angiodysplasias (12%). Diffuse angiodysplasias (45% of angiodysplasias) and GIC showed the lowest hemoglobin values (6.3 [1.5] and 6.4 [1.3]g/dL, respectively). While the spread (diffuse vs. localized) and number (<3 vs. ≥3) of angiodysplasias correlated with the degree of anemia, hemoglobin values were lower in GIC with vs. without ulcerated/friable lesions (6.0 [1.1] vs. 7.0 [1.2]g/dL, P<0.001). CONCLUSION Not only GIC but also diffuse angiodysplasias caused the most severe anemia in IDA with predefined hemoglobin values <9g/dL.
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Affiliation(s)
- Xavier Bosch
- Quick Diagnosis Unit, Adult Day Care Center, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Department of Internal Medicine, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Elisabet Montori
- Quick Diagnosis Unit, Department of Internal Medicine, Hospital Plató, Barcelona, Spain
| | - Mar Guerra-García
- Quick Diagnosis Unit, Adult Day Care Center, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | | | | | | | - Pedro Moreno
- Department of Internal Medicine, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Neus Guasch
- Quick Diagnosis Unit, Adult Day Care Center, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Alfons López-Soto
- Department of Internal Medicine, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Beg S, Ragunath K. Review on gastrointestinal angiodysplasia throughout the gastrointestinal tract. Best Pract Res Clin Gastroenterol 2017; 31:119-125. [PMID: 28395783 DOI: 10.1016/j.bpg.2016.11.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 11/27/2016] [Accepted: 11/29/2016] [Indexed: 01/31/2023]
Abstract
Gastrointestinal angiodysplasia are rare but clinically important vascular aberrations found within the gastrointestinal mucosa and submucosa. Their clinical impact varies from being an asymptomatic incidental finding, to causing life threatening bleeding. In this review we critically appraise the key findings from the current literature on the pathology, clinical presentation and management of these lesions.
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Affiliation(s)
- Sabina Beg
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Queen Medical Centre, Nottingham, United Kingdom.
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Queen Medical Centre, Nottingham, United Kingdom.
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Dhar Chowdhury S, Simon EG, Kirubakaran R, Goel A. Efficacy of thalidomide in management of bleeding from gastrointestinal angiodysplasia. Hippokratia 2016. [DOI: 10.1002/14651858.cd012461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Sudipta Dhar Chowdhury
- Christian Medical College; Department of Gastrointestinal Sciences; Ida Scudder Road Vellore Tamil Nadu India 632004
| | - Ebby G Simon
- Christian Medical College; Department of Gastrointestinal Sciences; Ida Scudder Road Vellore Tamil Nadu India 632004
| | - Richard Kirubakaran
- Christian Medical College; Cochrane South Asia, Prof. BV Moses Center for Evidence-Informed Health Care and Health Policy; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
| | - Ashish Goel
- Christian Medical College; Department of Gastrointestinal Sciences; Ida Scudder Road Vellore Tamil Nadu India 632004
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In-hospital weekend outcomes in patients diagnosed with bleeding gastroduodenal angiodysplasia: a population-based study, 2000 to 2011. Gastrointest Endosc 2016; 84:416-23. [PMID: 26972023 DOI: 10.1016/j.gie.2016.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 02/26/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS GI angiodysplastic (GIAD) lesions are an important cause of blood loss throughout the GI tract, particularly in elderly persons. The aim of this study was to determine whether mortality rates in patients with GIAD were higher for weekend compared with weekday hospital admissions. METHODS We performed a retrospective study using the National Inpatient Sample database from 2000 to 2011 including inpatients with an International Classification of Diseases, Ninth Revision, Clinical Modification code for gastrointestinal GIAD (code 537.82 or 537.83). We assessed rates of delayed endoscopy (examinations performed >24 hours after admission), intensive care unit (ICU) admissions, and in-hospital mortality rates. Bivariate and multivariate logistic regression analyses were performed to identify risk factors for mortality. RESULTS There were 85,971 discharges for GIAD between 2000 and 2011, of which 69,984 (81%) were weekday hospital admissions and 15,987 (19%) were weekend admissions. Patients with weekend versus weekday admissions were more likely to undergo delayed endoscopic examination (35% vs 26%, P ≤ .0001). Mortality rates were higher for patients with weekend admissions (2% vs 1%, P = .0002). The adjusted odds ratio (aOR) for inpatient mortality associated with weekend admissions was elevated (2.4; 95% confidence interval [CI], 1.5-3.9; P = .0005). Rates of delayed endoscopic examinations were lower in patients with higher socioeconomic status (aOR = 0.77; 95% CI, 0.68-0.88). ICU admission rates were higher for weekend compared with weekday admissions (8% vs 6%, P = .004). The presence of a delayed endoscopic examination was associated with an increased length of stay of 1.3 days (95% CI, 1.2-1.4 days). CONCLUSIONS Weekend admissions for angiodysplasia were associated with higher odds of mortality, ICU admissions, higher rates of delayed endoscopic procedures, longer lengths of stay, and higher hospital charges.
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Kim DB, Chung WC, Lee SJ, Sung HJ, Woo S, Kim HS, Jeong YO, Lee H, Kim YJ. Analysis of risk factor and clinical characteristics of angiodysplasia presenting as upper gastrointestinal bleeding. Korean J Intern Med 2016; 31:669-77. [PMID: 26828247 PMCID: PMC4939498 DOI: 10.3904/kjim.2015.087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/07/2015] [Accepted: 06/25/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND/AIMS Angiodysplasia is important in the differential diagnosis of upper gastrointestinal bleeding (UGIB), but the clinical features and outcomes associated with UGIB from angiodysplasia have not been characterized. We aimed to analyze the clinical characteristics and outcomes of angiodysplasia presented as UGIB. METHODS Between January 2004 and December 2013, a consecutive series of patients admitted with UGIB were retrospectively analyzed. Thirty-five patients with bleeding from angiodysplasia were enrolled. We compared them with an asymptomatic control group (incidental finding of angiodysplasia in health screening, n = 58) and bleeding control group (simultaneous finding of angiodysplasia and peptic ulcer bleeding, n = 28). RESULTS When patients with UGIB from angiodysplasia were compared with the asymptomatic control group, more frequent rates of nonantral location and large sized lesion (≥ 1 cm) were evident in multivariate analysis. When these patients were compared with the bleeding control group, they were older (mean age: 67.94 ± 9.16 years vs.55.07 ± 13.29 years, p = 0.03) and received less transfusions (p = 0.03). They also had more frequent rate of recurrence (40.0% vs. 20.7%, p = 0.02). CONCLUSIONS Non-antral location and large lesions (≥ 1 cm) could be risk factors of UGIB of angiodysplasia. UGIB due to angiodysplasia was more common in older patients. Transfusion requirement would be less and a tendency of clinical recurrence might be apparent.
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Affiliation(s)
| | - Woo Chul Chung
- Correspondence to Woo Chul Chung, M.D. Department of Internal Medicine, College of Medicine, St. Vincent’s Hospital, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea Tel: +82-31-249-7138 Fax: +82-31-253-8898 E-mail:
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Kalman RS, Pedrosa MC. Evidence-based review of gastrointestinal bleeding in the chronic kidney disease patient. Semin Dial 2014; 28:68-74. [PMID: 25215610 DOI: 10.1111/sdi.12301] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patients with end-stage renal disease are more likely to suffer from gastrointestinal (GI) problems, including bleeding from upper and lower sources. Peptic ulcer disease is the most common cause of upper GI bleeding, and although there is some debate in the literature regarding whether the frequency of ulcer disease is higher in patients with kidney disease, it is well established that outcomes are worse in patients with compromised renal function. Angioectasias can be found throughout the GI tract and are another common cause of bleeding; management can be divided into localized endoscopic therapy and systemic hormonal treatment, or surgery for refractory cases. The most frequent causes of lower GI bleeding in this population, in addition to angioectasias, are diverticulosis, hemorrhoids, and ischemic colitis.
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Affiliation(s)
- Richard S Kalman
- Section of Gastroenterology, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
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Salgueiro P, Marcos-Pinto R, Liberal R, Lago P, Magalhães R, Magalhães M, Ferreira J, Pedroto I. Octreotide Long-Acting Release is effective in preventing gastrointestinal bleeding due to angiodysplasias. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2014. [DOI: 10.1016/j.jpg.2014.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Management of gastrointestinal angiodysplastic lesions (GIADs): a systematic review and meta-analysis. Am J Gastroenterol 2014; 109:474-83; quiz 484. [PMID: 24642577 DOI: 10.1038/ajg.2014.19] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 01/03/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Gastrointestinal angiodysplastic lesions (GIADs) are defined as pathologically dilated communications between veins and capillaries. The objective of this systematic review and meta-analysis was to determine the efficacy of available treatment modalities for GIADs. METHODS We identified eligible studies by searching through PubMed, SCOPUS, and Cochrane central register of controlled trials. We searched for clinical trials examining the efficacy of endoscopic, pharmacologic, or surgical therapy for GIADs. Data were pooled using a random-effects model, and the effect of response to medical or surgical therapy was reported as odds ratios with 95% confidence intervals (CIs). Data and quality indicators were extracted by two authors from 22 studies, including 831 individuals with GIADs. The analysis included 623 patients treated with endoscopic therapy, 63 with hormonal therapy, 72 patients with octreotide, and 73 status post aortic valve replacement surgery. RESULTS Hormonal therapy, based on two case-control studies, was not effective for bleeding cessation (odds ratio: 1.0, 95% CI: 0.5-1.96). On the basis of 14 studies including patients with gastric, colonic, and small-bowel GIADs, endoscopic therapy was effective as initial therapy, but the pooled recurrence bleeding rate was 36% (95% CI: 28-44%) over a mean (±s.d.) of 22±13 months. The event rate for re-bleeding increased to 45% (95% CI: 37-52%) when studies including only small-bowel GIADs were included (N=341). In four studies assessing the efficacy of somatostatin analogs, the pooled odds ratio was 14.5 (95% CI: 5.9-36) for bleeding cessation. In two studies assessing the role of aortic valve replacement (AVR) in 73 patients with Heyde's syndrome, the event rate for re-bleeding was 0.19 (95% CI: 0.11-0.30) over a mean follow-up period of 4 years postoperatively. CONCLUSIONS Over one-third of patients with GIADs experienced re-bleeding after endoscopic therapy. Somatostatin analogs and AVR for Heyde's syndrome appeared to be effective therapy for GIADs.
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Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2014; 39:15-34. [PMID: 24138285 DOI: 10.1111/apt.12527] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/14/2013] [Accepted: 09/18/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality. AIM To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors. METHODS A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract. RESULTS Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively. CONCLUSIONS Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.
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Affiliation(s)
- S S Sami
- Nottingham Digestive Diseases Centre & NIHR Biomedical research Unit, Queens Medical Centre, Nottingham, UK
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Imai Y, Mizuno Y, Yoshino K, Watanabe K, Sugawara K, Motoya D, Oka M, Mochida S. Long-term efficacy of endoscopic coagulation for different types of gastric vascular ectasia. World J Gastroenterol 2013; 19:2799-2805. [PMID: 23687417 PMCID: PMC3653154 DOI: 10.3748/wjg.v19.i18.2799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Revised: 02/01/2013] [Accepted: 03/07/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To examine the long-term therapeutic efficacies of endoscopic cauterization for gastric vascular ectasia, according to the type of lesion.
METHODS: Thirty-eight patients with hemorrhagic gastric vascular ectasia (VE) were treated by endoscopic cauterization: 13 by heater probe coagulationand 25 by argon plasma coagulation. Depending on the number of lesions, 14 and 24 patients were classified into localized VE (≤ 10; LVE) and extensive VE (> 10; EVE), respectively. The patients were followed-up by repeated endoscopic examinations after the therapy, and the incidences of VE recurrence and re-bleeding from the lesions were evaluated.
RESULTS: Although the VE lesions disappeared initially in all the patients after the therapy, the recurrence of VE developed in 25 patients (66%) over a mid-term observation period of 32 mo, and re-bleeding occurred in 15 patients (39%). The recurrence of VE was found in all patients with EVE, with re-bleeding occurring in 14 patients (58%). In contrast, only 1 patient (7%) with LVE showed recurrence of the lesions and complicating hemorrhage. Both the cumulative recurrence-free rates and cumulative re-bleeding-free rates were significantly lower in the EVE group than in the LVE group (P < 0.001 and P < 0.001, respectively). Moreover, the cumulative re-bleeding-free rate in the EVE group was 47.6% at 1 year and 25.4% at 2 years in patients with chronic renal failure, which were significantly lower than the rates in the patients without chronic renal failure (83.3% and 74.1%, respectively) (P < 0.05).
CONCLUSION: The recurrence of VE and re-bleeding from the lesions was more frequent in the patients with EVE, especially in those with complicating renal failure.
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Frigstad SO, Jønsson V, Moum B. [A woman in her 60s with multifactorial anaemia]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:965-8. [PMID: 22562330 DOI: 10.4045/tidsskr.10.1449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Anaemia may be multifactorial in origin. We present a woman with autoimmune hepatitis and secondary warm autoimmune haemolytic anaemia and most likely also concomitant anaemia of chronic disease. A relapse of autoimmune haemolysis was successfully treated with steroids and high-dose intravenous immunoglobulin. At the same time, bleeding from angiodysplasia in the coecum was masked by unauthorised perorally administrated iron. No other cause of bleeding was found. During that period, she required extensive blood transfusions, up to several times per month. Surgical or endoscopic treatment of the bleeding angiodysplasia was not possible. Alloimmunisation developed as a complication to the large number of transfusions, despite the use of steroids. Treatment with somatostatin analogue markedly reduced the need of our patient for blood transfusions for a follow-up period of more than one year, and she has not experienced any side effects. We do not know how long the haemostasis achieved will last, however, we believe that this treatment may be an alternative for other patients as bleeding from angiodysplasia is not uncommon and is often difficult to eradicate.
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Islam S, Islam E, Cevik C, Attaya H, Otahbachi M, Nugent K. Aortic stenosis and angiodysplastic gastrointestinal bleeding: Heyde’s disease. Heart Lung 2012; 41:90-4. [DOI: 10.1016/j.hrtlng.2010.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 06/23/2010] [Accepted: 07/17/2010] [Indexed: 11/25/2022]
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Johnson-Wimbley TD, Graham DY. Diagnosis and management of iron deficiency anemia in the 21st century. Therap Adv Gastroenterol 2011; 4:177-84. [PMID: 21694802 PMCID: PMC3105608 DOI: 10.1177/1756283x11398736] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Iron deficiency is the single most prevalent nutritional deficiency worldwide. It accounts for anemia in 5% of American women and 2% of American men. The goal of this review article is to assist practitioners in understanding the physiology of iron metabolism and to aid in accurately diagnosing iron deficiency anemia. The current first line of therapy for patients with iron deficiency anemia is oral iron supplementation. Oral supplementation is cheap, safe, and effective at correcting iron deficiency anemia; however, it is not tolerated by some patients and in a subset of patients it is insufficient. Patients in whom the gastrointestinal blood loss exceeds the intestinal ability to absorb iron (e.g. intestinal angiodysplasia) may develop iron deficiency anemia refractory to oral iron supplementation. This population of patients proves to be the most challenging to manage. Historically, these patients have required numerous and frequent blood transfusions and suffer end-organ damage resultant from their refractory anemia. Intravenous iron supplementation fell out of favor secondary to the presence of infrequent but serious side effects. Newer and safer intravenous iron preparations are now available and are likely currently underutilized. This article discusses the possible use of intravenous iron supplementation in the management of patients with severe iron deficiency anemia and those who have failed oral iron supplementation.
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Affiliation(s)
| | - David Y. Graham
- Michael E. DeBakey VA Medical Center, Room 3A-320 (111D), 2002 Holcombe Boulevard, Houston, TX 77030, USA
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Abstract
BACKGROUND AND AIMS Recurrent bleeding from gastrointestinal (GI) angiodysplasia remains a therapeutic challenge. Identification of factors predicting poor outcome of haemorrhage from angiodysplasia would help us to select the patients who may likely benefit from further therapy. Thus, we analysed risk factors for recurrence of acute GI haemorrhage from angiodysplasia. PATIENTS AND METHODS 62 patients admitted consecutively with acute GI bleeding from angiodysplasia, between June 2002 and June 2006, were included. Bivariate, multivariate and survival analysis were performed to identify risk factors for recurrence of bleeding after hospital discharge. RESULTS Recurrence of acute haemorrhage after hospital discharge occurred in 17 of 57 (30%) patients (38 men; mean age: 74+/-6 years), after a mean follow-up (33+/-40 months). On Cox analysis, earlier history of bleeding with a high bleeding rate, over anticoagulation and the presence of multiple lesions were predictive factors of recurrence in a multivariate analysis. In contrast, endoscopic argon plasma coagulation (APC) therapy was not associated with lower rates of recurrent bleeding. CONCLUSION In patients with acute GI haemorrhage from angiodysplasia, earlier bleeding with a high bleeding rate, over anticoagulation and multiple angiodisplasic lesions predict an increased risk of recurrent bleeding. Although there is a trend towards better management with endoscopic APC therapy for the prevention of recurrence of bleeding, endoscopic APC therapy is not predictive of a lower rate of recurrence.
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36
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YAMADA M, ICHIKAWA M, TAKAHARA O, TSUCHIDA T, ISHIHARA A, YAMADA M, NISHIMURA D, HOSHINO H, KATADA N, KATO K. Gastroduodenal Vascular Ectasia in Patients with Liver Cirrhosis. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1999.tb00010.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
| | | | - Osamu TAKAHARA
- *Department of Internal Medicine, Anjo Kosei Hospital, Aichi, Japan
| | - Takeshi TSUCHIDA
- *Department of Internal Medicine, Anjo Kosei Hospital, Aichi, Japan
| | - Akira ISHIHARA
- *Department of Internal Medicine, Anjo Kosei Hospital, Aichi, Japan
| | - Masahiro YAMADA
- *Department of Internal Medicine, Anjo Kosei Hospital, Aichi, Japan
| | | | - Hiroshi HOSHINO
- *Department of Internal Medicine, Anjo Kosei Hospital, Aichi, Japan
| | - Naoyuki KATADA
- *Department of Internal Medicine, Anjo Kosei Hospital, Aichi, Japan
| | - Katsumoto KATO
- **Department of Internal Medicine, Kamo Hospital, Aichi, Japan
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Lee BJ, Park JJ, Seo YS, Kim JH, Kim A, Yeon JE, Kim JS, Byun KS, Bak YT. Upper gastrointestinal bleeding from duodenal vascular ectasia in a patient with cirrhosis. World J Gastroenterol 2007; 13:5154-7. [PMID: 17876885 PMCID: PMC4434649 DOI: 10.3748/wjg.v13.i38.5154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We report a cirrhotic patient with duodenal vascular ectasia and spontaneous bleeding. The bleeding was successfully controlled with argon plasma coagulation. Duodenal vascular ectasia may be a cause of upper gastrointestinal bleeding in patients with cirrhosis, and argon plasma coagulation may be effective and safe to achieve hemostasis of this lesion.
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Affiliation(s)
- Beom Jae Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Gurodong-gil 97, Guro-gu, Seoul 152-703, Korea
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40
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Abstract
Lower gastrointestinal (GI) hemorrhage is a significant cause of morbidity and mortality, particularly in elderly patients. Lower endoscopic evaluation is established as the diagnostic procedure of choice in the setting of acute lower GI hemorrhage.
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Affiliation(s)
- Brenna Casey Bounds
- Harvard Medical School, Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Blake 453D, Boston, MA 02114, USA.
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41
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Kaya Z, Gürsel T, Dalgic B, Aslan D. Gastric angiodysplasia in a child with Bernard-Soulier syndrome: efficacy of octreotide in long-term management. Pediatr Hematol Oncol 2005; 22:223-7. [PMID: 16020106 DOI: 10.1080/08880010590921568] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Gastrointestinal angiodysplasia in association with Bernard-Soulier syndrome has been previously described in adults. The authors report on a 14year-old boy presenting with massive upper gastrointestinal bleeding due to a large gastric angiodysplasia, in whom medical history and laboratory investigations were consistent with Bernard-Soulier syndrome. The vascular lesion was so widespread that surgical or endoscopic therapy was not considered. Therefore, treatment with octreotide, a somatostatin analog, was commenced, following a short course of tranexamic acid and proton pump inhibitor. During the 16-month follow-up with octreotide therapy, no occult or gross bleeding occurred. This case illustrates the utility of using octreotide for the long-term treatment of children with bleeding disorders and angiodysplasia.
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Affiliation(s)
- Zühre Kaya
- Department of Pediatrics, Faculty of Medicine, Gazi University, Besevler, Ankara, Turkey
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42
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Erden A, Bozkaya H, Türkmen Soygür I, Bektaş M, Erden I. Duodenal angiodysplasia: MR angiographic evaluation. ACTA ACUST UNITED AC 2004; 29:12-4. [PMID: 15160746 DOI: 10.1007/s00261-003-0077-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We describe a patient in whom endoscopy failed to determine the origin of gastrointestinal bleeding, and magnetic resonance angiography showed dilated inferior pancreaticoduodenal veins that were considered indirect signs of the duodenal angiodysplasia. Incidentally, a connection between the inferior vena cava and the inferior pancreaticoduodenal veins were also noted. Repeat endoscopy and catheter angiography confirmed the presence of the angiodysplasias.
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Affiliation(s)
- A Erden
- Department of Radiology, Faculty of Medicine, Ankara University, Síhhiye, 06100 Ankara, Turkey.
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43
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Abstract
BACKGROUND Upper-GI vascular ectasias, including angiodysplasia and gastric antral vascular ectasia may present with either acute or chronic bleeding. Endoscopic thermal modalities have been used to control acute bleeding and reduce transfusion requirements. METHODS Endoscopic experience was reviewed for a 6-year period during which 32 patients requiring blood transfusions for upper-GI angiodysplasia or gastric antral vascular ectasia were evaluated. Patients seen during the first 5 years were treated with either Nd:YAG laser photocoagulation or multipolar electrocoagulation. During the most recent 12 months, all patients were treated by argon plasma coagulation. Response to therapy was assessed by change in mean Hb and transfusion requirements. RESULTS Overall, 16 patients were treated by laser photoablation alone; 9, argon plasma coagulation with or without laser; and 7, multipolar electrocoagulation with or without laser. Mean follow-up for all patients was 19 months. After therapy, mean Hb concentration rose from 76 to 114 g/L for patients with gastric antral vascular ectasia and from 85 to 118 g/L for those with angiodysplasia. Endoscopic therapy abolished or reduced transfusion requirements in 93% of patients with gastric antral vascular ectasia and 76% with angiodysplasia. Patients with gastric antral vascular ectasia required a mean of 6 treatment sessions, while those with angiodysplasia required one to two sessions. CONCLUSIONS Endoscopic thermal ablation effectively controls acute bleeding and reduces transfusion requirements in most patients with upper-GI vascular ectasias. Patients with gastric antral vascular ectasia require significantly more treatment sessions to achieve this effect.
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Affiliation(s)
- Darren A Pavey
- Department of Gastroenterology, St George Hospital, Sydney, Australia
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44
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OKAMOTO TETSU, OKAYAMA YASUTAKA, HIRAI MASAAKI, KITAJIMA YASUHIRO, HAYASHI KAZUKI, IMAI HIDETO, AKITA SHINJI, GOTOH KAZUO, OHARA HIROTAKA, NOMURA TOMOYUKI, JOH TAKASHI, YOKOYAMA YOSHIFUMI, ITOH MAKOTO. Gastric vascular ectasia treated by endoscopic mucosal resection. Dig Endosc 2002. [DOI: 10.1046/j.1443-1661.2002.00155.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- TETSU OKAMOTO
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Gifu,
| | - YASUTAKA OKAYAMA
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Gifu,
| | - MASAAKI HIRAI
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Gifu,
| | - YASUHIRO KITAJIMA
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Gifu,
| | - KAZUKI HAYASHI
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Gifu,
| | - HIDETO IMAI
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Gifu,
| | - SHINJI AKITA
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Gifu,
| | - KAZUO GOTOH
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Gifu,
| | - HIROTAKA OHARA
- The First Department of Internal Medicine, Nagoya City University Medical School, Nagoya, Japan
| | - TOMOYUKI NOMURA
- The First Department of Internal Medicine, Nagoya City University Medical School, Nagoya, Japan
| | - TAKASHI JOH
- The First Department of Internal Medicine, Nagoya City University Medical School, Nagoya, Japan
| | - YOSHIFUMI YOKOYAMA
- The First Department of Internal Medicine, Nagoya City University Medical School, Nagoya, Japan
| | - MAKOTO ITOH
- The First Department of Internal Medicine, Nagoya City University Medical School, Nagoya, Japan
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45
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Yamada M, Ichikawa M, Takahara O, Tsuchida T, Matsubara A, Yamada M. Gastric Antral Vascular Ectasia as a Cause of Anemia in Systemic Sclerosis. Dig Endosc 2000. [DOI: 10.1046/j.1443-1661.2000.00052.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Masahiko Yamada
- Department of Internal Medicine, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Masafumi Ichikawa
- Department of Internal Medicine, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Osamu Takahara
- Department of Internal Medicine, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Takeshi Tsuchida
- Department of Internal Medicine, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Akira Matsubara
- Department of Internal Medicine, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Masahiro Yamada
- Department of Internal Medicine, Anjo Kosei Hospital, Anjo, Aichi, Japan
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46
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Krevsky B, Sher DJ, Horwitz BJ. Enhanced imaging of angiodysplasias using remote endoscopic digital spectroscopy. Gastrointest Endosc 1996; 44:598-602. [PMID: 8934169 DOI: 10.1016/s0016-5107(96)70016-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- B Krevsky
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA
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Weinstock LB, Larson RS, Stahl DJ, Fleshman JW. Diffuse microscopic angiodysplasia--a previously unreported variant of angiodysplasia. Report of a case. Dis Colon Rectum 1995; 38:428-32. [PMID: 7720454 DOI: 10.1007/bf02054235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The entity of diffuse microscopic angiodysplasia is described, and a patient with severe gastrointestinal hemorrhage because of this submucosal source of bleeding is reported. METHOD Case records of a patient with severe gastrointestinal hemorrhage were reviewed, and histologic findings were compared with colonoscopic and operative findings. The patient received 51 units of packed red blood cells over 3.5 months and remained undiagnosed, despite an exhaustive evaluation, until autopsy. RESULTS Ectatic veins, venules, and capillaries were present within the submucosa in virtually every section of the small and large intestine examined (79 of 86 sections). Histologic evidence of bleeding from these submucosal vessels was identified in three sites (colon, jejunum, and ileum). The absence of endoscopically visible lesions was explained by findings that vessels did not traverse the muscularis mucosa and that mucosal depth was normal. This case of diffuse microscopic angiodysplasia, therefore, represents a unique variant, because the vascular findings were so diffuse and the mucosa remained histologically and endoscopically uninvolved, despite severe bleeding. CONCLUSION Gastrointestinal bleeding from angiodysplasia is generally assumed to arise from endoscopically recognizable vascular ectasia within the mucosa. Thus, this case helps provide an explanation for some cases in which occult or massive bleeding is assumed to be secondary to angiodysplasia, even when endoscopic verification is not possible. Recognition of this disease process may require segmental resection or deep biopsy of endoscopically normal intestine.
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Affiliation(s)
- L B Weinstock
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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48
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Scott-Conner CE, Subramony C. Localization of small intestinal bleeding. The role of intraoperative endoscopy. Surg Endosc 1994; 8:915-7. [PMID: 7992166 DOI: 10.1007/bf00843472] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The preoperative identification of a bleeding site is not always possible, particularly when bleeding originates in the small intestine. Small vascular abnormalities, such as the telangiectatic lesion described in this report, comprise about 40-60% of such cases. Preoperative location using arteriography, radionuclide bleeding scan, and enteroclysis were nondiagnostic. The lesion was demonstrated by intraoperative endoscopy. A segment of small intestine was resected, and the patient made an uneventful recovery.
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Affiliation(s)
- C E Scott-Conner
- Department of Surgery, University of Mississippi School of Medicine, Jackson 39216-4505
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49
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Schwartz J, Rozenfeld V, Stelian J, Leibovitz A, Rabinovitz H, Habot B. Bleeding angiodysplasia of stomach associated with severe ischemic congestive cardiomyopathy--a case history. Angiology 1993; 44:584-6. [PMID: 8328689 DOI: 10.1177/000331979304400713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The authors present a case of gastric angiodysplasia with upper gastrointestinal bleeding, associated with severe ischemic congestive cardiomyopathy.
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Affiliation(s)
- J Schwartz
- Geriatric Medical Center, Shmuel Harofe Hospital, Beer-Yaakov, Israel
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50
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Chey WD, Hasler WL, Bockenstedt PL. Angiodysplasia and von Willebrand's disease type IIB treated with estrogen/progesterone therapy. Am J Hematol 1992; 41:276-9. [PMID: 1288289 DOI: 10.1002/ajh.2830410410] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The association between angiodysplasia and von Willebrand's disease was first reported in 1967. The cases reported to date have involved patients with type I and IIA von Willebrand's disease. We report a patient with type IIB von Willebrand's disease who suffered gastrointestinal bleeding attributable to gastric angiodysplasia. The patient underwent endoscopic electrocautery acutely and has been treated long-term with estrogen/progesterone therapy. She has suffered no recurrent gastrointestinal bleeding at over 11 months of follow-up. We suggest hormonal therapy as an alternative to repeated blood product transfusion or extensive surgical resection in patients with von Willebrand's disease and gastrointestinal bleeding from angiodysplasia.
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Affiliation(s)
- W D Chey
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor 48109-0362
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