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Nationwide cohort study identifies clinical outcomes of angioectasia in patients with acute hematochezia. J Gastroenterol 2022; 58:367-378. [PMID: 36564578 DOI: 10.1007/s00535-022-01945-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND While angioectasia is an important cause of acute hematochezia, relevant clinical features remain unclear. This study aims to reveal risk factors, clinical outcomes, and the effectiveness of therapeutic endoscopy for patients with acute hematochezia due to angioectasia. METHODS This retrospective cohort study was conducted at 49 Japanese hospitals between January 2010 and December 2019, enrolling patients hospitalized for acute hematochezia (CODE BLUE-J study). Baseline factors and clinical outcomes for angioectasia were analyzed. RESULTS Among 10,342 patients with acute hematochezia, 129 patients (1.2%) were diagnosed with angioectasia by colonoscopy. The following factors were significantly associated with angioectasia: chronic kidney disease, liver disease, female, body mass index < 25, and anticoagulant use. Patients with angioectasia were at a significant increased risk of blood transfusions compared to those without angioectasia (odds ratio [OR] 2.61; 95% confidence interval [CI] 1.69-4.02). Among patients with angioectasia, 36 patients (28%) experienced rebleeding during 1-year follow-up. The 1-year cumulative rebleeding rates were 37.0% in the endoscopic clipping group, 14.3% in the coagulation group, and 32.8% in the conservative management group. Compared to conservative management, coagulation therapy significantly reduced rebleeding risk (P = 0.038), while clipping did not (P = 0.81). Multivariate analysis showed coagulation therapy was an independent factor for reducing rebleeding risk (hazard ratio [HR] 0.40; 95% CI 0.16-0.96). CONCLUSIONS Our data showed patients with angioectasia had a greater comorbidity burden and needed more blood transfusions in comparison with those without angioectasia. To reduce rebleeding risk, coagulation therapy can be superior for controlling hematochezia secondary to angioectasia.
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Gastrointestinal Bleeding in Left Ventricular Assist Device: Octreotide and Other Treatment Modalities. ASAIO J 2019; 64:433-439. [PMID: 29406356 DOI: 10.1097/mat.0000000000000758] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Left ventricular assist devices (LVADs) offer a therapeutic strategy for patients with end-stage heart failure. Increased device utilization has also increased the incidence of device-related complications including gastrointestinal bleeding (GIB). Multiple mechanisms have been proposed in the pathophysiology of continuous-flow LVAD-associated GIB including physiologic changes associated with high shear and nonpulsatile flow such as gastrointestinal arteriovenous malformations and acquired von Willebrand syndrome. Strategies to minimize the morbidity and mortality of LVAD-associated GIB are needed. Octreotide, a somatostatin analogue, has been described as an adjunct to current therapies and interventions. Factors that contribute to LVAD-associated GIB may be targeted by the pharmacologic effects of octreotide, including improved platelet aggregation, increased vascular resistance, and decreased splanchnic circulation. Octreotide has demonstrated clinical benefit in several case series and clinical trials for the treatment of LVAD-associated GIB. The focus of this article will be to review the pathophysiology of LVAD-associated GIB, discuss pharmacologic and nonpharmacologic treatment modalities, and review available literature on the role of octreotide in the management of LVAD-associated GIB.
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Abstract
PURPOSE OF REVIEW The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial. RECENT FINDINGS Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias. SUMMARY SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.
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Chetcuti Zammit S, Koulaouzidis A, Sanders DS, McAlindon ME, Rondonotti E, Yung DE, Sidhu R. Overview of small bowel angioectasias: clinical presentation and treatment options. Expert Rev Gastroenterol Hepatol 2018; 12:125-139. [PMID: 28994309 DOI: 10.1080/17474124.2018.1390429] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging.
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Affiliation(s)
| | | | - David S Sanders
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
| | - Mark E McAlindon
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
| | | | - Diana E Yung
- b Endoscopy Unit , the Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Reena Sidhu
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
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5
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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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Gutsche JT, Atluri P, Augoustides JG. Treatment of ventricular assist-device-associated gastrointestinal bleeding with hormonal therapy. J Cardiothorac Vasc Anesth 2014; 27:939-43. [PMID: 24054188 DOI: 10.1053/j.jvca.2013.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Indexed: 12/16/2022]
Affiliation(s)
- Jacob T Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA.
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Eddi R, DePasquale JR. Radiofrequency ablation for the treatment of radiation proctitis: a case report and review of literature. Therap Adv Gastroenterol 2013; 6:69-76. [PMID: 23320051 PMCID: PMC3539292 DOI: 10.1177/1756283x12456895] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Radiation proctitis is a frequent complication of pelvic radiation for cancer. This condition can present acutely within several weeks of radiation, or chronically many months or years after radiation, leading to rectal bleeding and transfusion-dependent anemia. Various medical and endoscopic therapies have been described to treat this condition; however, some patients fail to respond to the current standard therapies. Here we present a case of refractory radiation proctitis, with suboptimal response to other therapies, treated successfully with a novel method, radiofrequency ablation.
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Affiliation(s)
- Rodney Eddi
- Seton Hall University, School of Health and Medical Sciences – St. Michael’s Medical Center, Department of Medicine, Division of Gastroenterology, 111 Central Avenue, Newark, NJ 07102, USA
| | - Joseph R. DePasquale
- Seton Hall University, School of Health and Medical Sciences – St. Michael’s Medical Center, Department of Medicine, Division of Gastroenterology, Newark, USA
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Vase P. Estrogen treatment of hereditary hemorrhagic telangiectasia. A double-blind controlled clinical trial. ACTA MEDICA SCANDINAVICA 2009; 209:393-6. [PMID: 7018182 DOI: 10.1111/j.0954-6820.1981.tb11614.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The effect of estrogen treatment in 31 patients with hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease was evaluated in a randomized double-blind trial. After a 3-month control period there was a 3-month treatment period during which 17 patients were treated with peroral estrogen (estradiol valerate), 4 mg dialy, and 14 with placebo. The results showed no significant reduction in the frequency of bleeding or its intensity. The hemoglobin values remained unchanged in the estrogen group compared with the previous control period as well as with the placebo group. The only demonstrable effect of estrogen treatment was a significant fall in transferrin.
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Effects of conjugated oestrogens and aminocaproic acid upon exercise-induced pulmonary haemorrhage (EIPH). COMPARATIVE EXERCISE PHYSIOLOGY 2008. [DOI: 10.1017/s1478061508120242] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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10
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Juares AJC, Dell'Aringa AR, Nardi JC, Kobari K, Gradim Moron Rodrigues VLM, Perches Filho RM. Rendu-Osler-Weber Syndrome: case report and literature review. Braz J Otorhinolaryngol 2008; 74:452-7. [PMID: 18661022 PMCID: PMC9442136 DOI: 10.1016/s1808-8694(15)30582-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2005] [Accepted: 09/13/2005] [Indexed: 11/01/2022] Open
Abstract
Hereditary Hemorrhagic Telangiectasia or Rendu-Osler-Weber Disease is a rare fibrovascular dysplasia that makes vascular walls vulnerable to trauma and rupture, causing skin and mucosa bleeding. It is of dominant autosomal inheritance, characterized by recurrent epistaxis and telangiectasia on the face, hands and oral cavity; visceral arteriovenous malformations and positive family history. Epistaxis is often the first and foremost manifestation. It's associated to arteriovenous malformations in several organs. There are possible hematologic, neurologic, pulmonary, dermatologic and gastrointestinal complications. Treatment is supportive and helps prevent complications. This study is a case report of a patient with this syndrome who came to the ENT Outpatient Ward of the Faculdade de Medicina de Marília; and we have done a bibliographic review of the disease's etiopathogenesis, clinical manifestations and clinical-surgical treatment options.
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Abstract
Obscure gastrointestinal bleeding (OGIB) is defined as an intermittent or continuous loss of blood in which the source has not been identified after upper endoscopy and colonoscopy. It constitutes a diagnostic and therapeutic challenge for the general internist and the gastroenterologist. This article provides an overview of the etiology, clinical presentation, and diagnostic modalities of OGIB including push enteroscopy, double balloon enteroscopy, wireless capsule endoscopy, enteroclysis, angiography, bleeding scanning with labeled red blood cells, and surgery with intraoperative enteroscopy. Therapeutic modalities including iron replacement, combined hormones, octreotide acetate, therapeutic endoscopy, and surgery are also discussed. In addition, a rational approach to patients with OGIB according to the clinical presentation is presented herein.
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Affiliation(s)
- Ronald Concha
- Division of Gastroenterology, University of Miami, Miller School of Medicine/Mt. Sinai Medical Center, Miami Beach, FL 33140, USA
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12
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Sadick H, Sadick M, Götte K, Naim R, Riedel F, Bran G, Hörmann K. Hereditary hemorrhagic telangiectasia: an update on clinical manifestations and diagnostic measures. Wien Klin Wochenschr 2006; 118:72-80. [PMID: 16703249 DOI: 10.1007/s00508-006-0561-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2005] [Accepted: 01/10/2006] [Indexed: 12/19/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber disease, is an autosomal dominant disorder of the fibrovascular tissue. It is characterized by the classic triad of (muco-)cutaneous telangiectases, arteriovenous malformations with recurrent epistaxis and hemorrhages, and inheritance. A wide variety of clinical manifestations in HHT have been described. In more than 90% of the patients, nosebleeds are the first predominant symptom, therefore ENT physicians often play a key role as far as diagnosis and management of the disease are concerned. In spite of recent diagnostic and therapeutic progress, a cure for this often burdening and handicapping disease is still not available. Apart from affecting the nose, arteriovenous malformations (AVMs) may also affect the skin, lungs, brain, liver and gastrointestinal tract. The two known genes that are implicated in HHT are endoglin (ENG) located on chromosome 9q33-q34 and activin-receptor-like kinase (ALK1) located on chromosome 12q13. Mutations of ENG are observed in HHT type 1 with an incidence up to 40% for pulmonary AVMs, whereas mutations of ALK1 are observed in HHT type 2 with an incidence of only 14% for pulmonary AVMs, which clinically distinguishes these two types of mutation. The emphasis of this paper is mainly on the clinical manifestation, molecular genetics and diagnosis of HHT, taking account of current literature on HHT in order to better understand the complexity of the disease. Recent therapeutic options in the treatment of HHT have been omitted from this paper as they are subject of a following paper. HHT is more common than previously thought and shows a broad range of different clinical organ manifestations that can be sources of substantial morbidity and mortality, making HHT a continuing challenge for many sub-specialties where interdisciplinary diagnostic screening is mandatory in the management of the disease.
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MESH Headings
- Activin Receptors, Type I/genetics
- Activin Receptors, Type II
- Adult
- Antigens, CD
- Arteriovenous Malformations/diagnosis
- Chromosomes, Human, Pair 12/genetics
- Chromosomes, Human, Pair 9/genetics
- Endoglin
- Epistaxis/etiology
- Forecasting
- Humans
- Incidence
- Mutation
- Prevalence
- Receptors, Cell Surface
- Telangiectasia, Hereditary Hemorrhagic/complications
- Telangiectasia, Hereditary Hemorrhagic/diagnosis
- Telangiectasia, Hereditary Hemorrhagic/epidemiology
- Telangiectasia, Hereditary Hemorrhagic/genetics
- Telangiectasia, Hereditary Hemorrhagic/physiopathology
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Affiliation(s)
- Haneen Sadick
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany,
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13
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Ichimura K, Tanaka H, Yamamoto Y, Nakamura KI. Nasal dermoplasty for Japanese hereditary hemorrhagic telangiectasia. Auris Nasus Larynx 2006; 33:423-8. [PMID: 16707240 DOI: 10.1016/j.anl.2006.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2005] [Revised: 02/15/2006] [Accepted: 03/17/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVE While generally considered an effective treatment for moderate to severe epistaxis in hereditary hemorrhagic telangiectasia (HHT), nasal dermoplasty (ND) has not been well established in Japan. This prompted the present Japanese assessment of clinical efficacy and patient satisfaction following this procedure. METHODS Retrospective analysis of clinical records of 15 patients with HHT undergoing ND between August 1991 and May 2004 and survey of these patients as to postsurgical conditions. Main outcome measures were skin graft "take" frequency after surgery (all patients), reported patient satisfaction (eight recent patients), and reported volume and frequency of epistaxis after versus before surgery (eight recent patients). RESULTS Graft take rate was 100%. Most patients experienced reduced frequency and volume of bleeding. One patient required an additional operation, total closure of the external nares, 2 years later. Overall patients felt satisfied with ND, experiencing less nasal obstruction than expected. CONCLUSIONS ND is effective in Japanese patients with moderate and severe nasal bleeding from HHT, reducing their risk of bleeding.
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Affiliation(s)
- Keiichi Ichimura
- Department of Otolaryngology-Head and Neck Surgery, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, Japan.
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Yoshino S, Matsumoto T, Esaki M, Yada S, Iida M. DIFFUSE ANTRAL VASCULAR ECTASIA OF THE STOMACH EFFECTIVELY TREATED BY ESTROGEN-PROGESTERONE THERAPY. Dig Endosc 2005. [DOI: 10.1111/j.1443-1661.2005.00555.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]
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15
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Jameson JJ, Cave DR. Hormonal and Antihormonal Therapy for Epistaxis in Hereditary Hemorrhagic Telangiectasia. Laryngoscope 2004; 114:705-9. [PMID: 15064628 DOI: 10.1097/00005537-200404000-00021] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES/HYPOTHESIS Objectives were to assess available information on hormonal therapy for bleeding in hereditary hemorrhagic telangiectasia (HHT), to determine whether there is a role for hormonal therapy as an initial therapeutic option, and to report the second known case of response in HHT to antihormonal therapy. STUDY DESIGN Literature review and case report. METHODS The literature on hormonal and antihormonal therapy for HHT was reviewed. Medical records for the case reported in the present study were evaluated to confirm the diagnosis and assess responses to surgical and nonsurgical treatments. RESULTS All reports of success using hormonal therapy for HHT-related bleeding were either retrospective or uncontrolled with the exception of two. Anecdotal evidence with high-dose estrogen appeared to show success, but serious side effects have discouraged use. One controlled trial found no benefit for intermediate dose, single-agent estrogen. The other controlled trial appeared to show benefit with low-dose estrogen-progesterone in HHT with gastrointestinal tract bleeding and was supported by an uncontrolled study showing efficacy in epistaxis. The case reported in the present study demonstrated long-term cessation of epistaxis with tamoxifen in a postmenopausal woman. CONCLUSIONS Systemic estrogen-progesterone at doses used for oral contraception may eliminate bleeding in symptomatic HHT and is a reasonable initial option in fertile women. There is no information on possible effects of lower-dose estrogen-progesterone used in postmenopausal women for hormone replacement therapy. Tamoxifen has dramatically eliminated HHT-related bleeding in two cases. It is well tolerated in postmenopausal women and should be considered for randomized clinical trials.
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Affiliation(s)
- John J Jameson
- Department of Surgery, Caritas St. Elizabeth's Medical Center of Boston and Tufts University School of Medicine, Boston, Massachusetts, USA.
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16
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Cheng MW, Madanick RD, Barkin JS. Pharmacologic management of obscure gastrointestinal bleeding. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2003. [DOI: 10.1053/j.tgie.2003.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, is an hereditary disorder that results in fibrovascular dysplasia with the development of telangiectasias and arteriovenous malformations. It predominantly involves the skin, mucous membranes, viscera, lungs, and brain. Hereditary hemorrhagic telangiectasia shows great genetic heterogeneity, and its phenotypes have been classified based on the recently identified mutated genes: endoglin (HHT-1) and activin-like kinase receptor-1 (HHT-2). Other families with phenotypic HHT do not bear these mutations; therefore, other genes are probably involved as well. Liver involvement is reported in up to 30% of persons affected by HHT. Large arteriovenous malformations in the liver can lead to significant complications, including high-output congestive heart failure, portal hypertension, hepatic encephalopathy, biliary ischemia, and liver failure. Embolization of large arteriovenous malformations in the liver remains controversial; however, liver transplantation can successfully eradicate these complications.
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Affiliation(s)
- Anne M Larson
- Department of Medicine, University of Washington, Seattle, 98195-6174, USA.
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18
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Longacre AV, Gross CP, Gallitelli M, Henderson KJ, White RI, Proctor DD. Diagnosis and management of gastrointestinal bleeding in patients with hereditary hemorrhagic telangiectasia. Am J Gastroenterol 2003; 98:59-65. [PMID: 12526937 DOI: 10.1111/j.1572-0241.2003.07185.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Our aim was to report our experience with treating GI bleeding in patients with hereditary hemorrhagic telangiectasia (HHT). METHODS Consecutive patients with GI bleeding referred to the Yale University Vascular Malformation Center underwent clinical evaluation and endoscopy. Hb and blood transfusion requirements for 1 yr before and after evaluation were documented. Patients with a mean Hb <or= 8 mg/dl or blood transfusion requirements >or= 12 units packed red blood cells (PRBC)/yr were defined as patients with significant bleeding. Drug therapies, including ethinyl estradiol/norethindrone, danazol, and aminocaproic acid, were prescribed on an individual patient basis. RESULTS The study included 43 HHT patients with a mean age of 57 yr. Endoscopy revealed telangiectases in the esophagus (1/41), stomach (33/41), duodenum (33/41), jejunum (5/9), and colon (10/32). Patients with > 20 telangiectases visualized on esophagogastroduodenoscopy had a significantly lower mean Hb of 7.9, compared with 9.4 (p = 0.007), and a trend toward higher blood transfusion requirements. Non-HHT-related causes of GI bleeding were diagnosed in four patients. During a mean follow up of 18.9 months, the group of 40 patients with HHT-related bleeding had improvements in their mean Hb and blood transfusion requirements. CONCLUSIONS Some HHT patients with GI bleeding improve on drug therapies, but others fail. Transfusion-dependent GI bleeding is difficult to manage, and optimal management may include both medical and endoscopic treatments.
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Affiliation(s)
- Anna V Longacre
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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Eroglu Y, Emerick KM, Chou PM, Reynolds M. Gastrointestinal bleeding in Turner's syndrome: a case report and literature review. J Pediatr Gastroenterol Nutr 2002; 35:84-7. [PMID: 12142816 DOI: 10.1097/00005176-200207000-00018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Yasemen Eroglu
- Departments of Gastroenterology, Hepatology and Nutrition, Pathology and Surgery, Children's Memorial Hospital, Northwestern University Medical School, Chicago, Illinois 60614, USA
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Abstract
This review has summarized the more important diseases that may be accompanied by or lead to a disorder of hemostasis or thrombosis via alterations of the vasculature. It is to be stressed that the vascular component of hemostasis is often overlooked by clinicians caring for patients with disorders of hemostasis and thrombosis. It should be appreciated that the vasculature is intricately related to the coagulation protein system and to platelets when involved in thrombohemorrhagic diatheses. Although many vascular disorders may lead to hemorrhage or thrombosis, it must be appreciated that often it is impossible to discern between a primary vascular defect/damage and a defect that has been induced by platelet activation/dysfunction or procoagulant abnormalities.
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Affiliation(s)
- R Bick
- Dallas Thrombosis Hemostasis Clinical Center, Texas 75231, USA
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Pau H, Carney AS, Murty GE. Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome): otorhinolaryngological manifestations. CLINICAL OTOLARYNGOLOGY AND ALLIED SCIENCES 2001; 26:93-8. [PMID: 11309047 DOI: 10.1046/j.1365-2273.2001.00442.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant disorder affecting blood vessels of the skin, mucous membrane and viscera. The otorhinolaryngologist is the commonest clinician involved in management as epistaxis occurs in 93% of the patients. As marked advances have recently been made regarding the pathogenesis and management of the condition, the otorhinolaryngological perspective is reviewed.
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MESH Headings
- Administration, Intranasal
- Administration, Topical
- Chromosome Aberrations/genetics
- Chromosome Disorders
- Chromosomes, Human, Pair 12/genetics
- Chromosomes, Human, Pair 9/genetics
- Embolization, Therapeutic
- Estrogens/administration & dosage
- Estrogens/therapeutic use
- Female
- Gene Expression
- Humans
- Laser Therapy
- Male
- Molecular Biology/methods
- Nasal Mucosa/pathology
- Otorhinolaryngologic Surgical Procedures/methods
- Progesterone/administration & dosage
- Progesterone/therapeutic use
- Telangiectasia, Hereditary Hemorrhagic/genetics
- Telangiectasia, Hereditary Hemorrhagic/pathology
- Telangiectasia, Hereditary Hemorrhagic/therapy
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Affiliation(s)
- H Pau
- Department of Otorhinolarynogology, Leicester Royal Infirmary, Leicester, UK.
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Pau H, Carney AS, Walker R, Murty GE. Is oestrogen therapy justified in the treatment of hereditary haemorrhagic telangiectasia: a biochemical evaluation. CLINICAL OTOLARYNGOLOGY AND ALLIED SCIENCES 2000; 25:547-50. [PMID: 11122297 DOI: 10.1046/j.1365-2273.2000.00415.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Systemic and topical oestrogen can provoke squamous metaplasia of epithelium. In Hereditary Haemorrhagic Telangiectasia (HHT) the underlying telangiectasia may be protected from trauma and epistaxis reduced. Oestrogens have been advocated but their efficacy is unclear. Recent advances have now identified two oestrogen and one progesterone receptors. The aim of this study is to analyse the sex receptor status of HHT nasal mucosa to determine if oestrogen therapy is biochemically justified. Five HHT patients (three men, two women) and eight controls (four men, four women) underwent nasal mucosa biopsy. Samples were fixed in formalin and paraffin embedded. Alpha oestrogen (ERalpha) and beta oestrogen (ERss) and progesterone (PgR) receptors were identified using mouse monoclonal antibodies by the Streptavidin-biotin peroxidase method. ERss was detected in two HHT subjects (1 M: 1F) and two control subjects. ERalpha and PgR was absent in HHT subjects. This pilot study demonstrated that a subgroup of HHT patients were ERss positive. Oestrogen therapy therefore has a potential therapeutic role on a biochemical basis in these patients. ERss status should be determined before considering oestrogen therapy.
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Affiliation(s)
- H Pau
- Department of Otorhinolaryngology, Leicester Royal Infirmary and The Breast Cancer Research Unit, Glenfield General Hospital, Leicester, UK.
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Tran A, Villeneuve JP, Bilodeau M, Willems B, Marleau D, Fenyves D, Parent R, Pomier-Layrargues G. Treatment of chronic bleeding from gastric antral vascular ectasia (GAVE) with estrogen-progesterone in cirrhotic patients: an open pilot study. Am J Gastroenterol 1999; 94:2909-11. [PMID: 10520843 DOI: 10.1111/j.1572-0241.1999.01436.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Gastric antral vascular ectasia (GAVE) is a rare cause of chronic bleeding in cirrhotic patients. Treatment of GAVE with surgical or nonsurgical portal decompression, beta-blockers, or endoscopic therapy provides disappointing results. In the present study, we evaluated the efficacy of estrogen-progesterone therapy, which has been reported to control chronic bleeding in gastrointestinal vascular malformations, such as Osler-Weber Rendu disease or angiodysplasia, in GAVE-related chronic bleeding. METHODS Six cirrhotic patients who bled chronically from GAVE were included. Three had alcoholic cirrhosis, two cryptogenic cirrhosis, and one primary biliary cirrhosis. Grade 1 esophageal varices were noted in four patients. Bleeding could not be controlled by beta-blockers, and endoscopic therapy was not considered given the extension of the antral vascular lesions. RESULTS Before the start of therapy, transfusion requirements averaged 3.5 units/month over a 1.5-11 month period of observation. Patients were then treated with a combination of ethynil estradiol 30 microg and noretisterone 1.5 mg daily. During follow-up (range 3-12 months), bleeding did not recur in four patients; in one patient, treatment with estrogen progesterone decreased the need for transfusions from 4 units/month to 1.4 unit/month; this patient stopped the treatment inadvertently after 6 months and severe anemia recurred with a need for 4 units of blood in the following month; reintroduction of the treatment resulted in an increase of hemoglobin levels without the need for blood transfusions during the following 4 months. In the last patient, a 5-month treatment did not improve chronic bleeding. CONCLUSIONS The present study suggests that estrogen-progesterone therapy is useful in the treatment of chronic bleeding related to GAVE; however, these findings require confirmation by a controlled trial.
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Affiliation(s)
- A Tran
- Liver Unit, Saint-Luc Hospital, and University of Montreal, Canada
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24
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Abstract
Severe gastrointestinal bleeding is a rare complication of radiation therapy that requires frequent transfusions. This case report describes a patient with severe bleeding from radiation colitis after treatment of bladder cancer. During 5 months of therapy with multiple drugs, the patient needed 26 units of packed red cells. A subsequent hormone therapy consisting of an estrogen-progesterone combination significantly reduced the need for blood transfusions and hospitalization. We conclude that hormones might provide a promising new additional symptomatic therapy for bleeding radiogenic colitis.
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Affiliation(s)
- H Wurzer
- General Hospital of Graz, 2nd Medical Department, University Clinic of Surgery, Austria
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25
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Lee JY, Korzenik JR, DeMasi R, Lih-Brody L, White RI. Transjugular intrahepatic portosystemic shunts in patients with hereditary hemorrhagic telangiectasia: failure to palliate gastrointestinal bleeding. J Vasc Interv Radiol 1998; 9:994-7. [PMID: 9840048 DOI: 10.1016/s1051-0443(98)70439-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- J Y Lee
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT 06520, USA
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26
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Abstract
OBJECTIVE The aim of this study was to evaluate the effectiveness and safety of combined hormonal therapy in patients with recurring occult gastrointestinal bleeding of obscure origin. METHODS This was a prospective longitudinal observational study. The setting was an outpatient private practice affiliated with a large university-based hospital. A total of 43 patients, comprising 14 men and 29 women with a mean age of 74 yr (range 48-86 yr), were included. They had a history of recurrent gastrointestinal bleeding of unknown origin for a period of > 1 yr and had required multiple hospitalizations and transfusions. Patients were initially treated with one Enovid 5-mg tablet containing 5 mg norethynodrel and 75 microg of mestranol. Enovid became commercially unavailable and treatment was changed to Ortho-Novum 1/50, containing 1 mg norethindrone and 0.05 milligrams of mestranol, given one tablet b.i.d. Patients were treated and followed for a mean time of 535 days (range 25-1551 days). All patients acted as their own controls and were followed for compliant behavior with periodic hematocrit, serial stool hemoccults, medication counts, and clinical histories regarding transfusion requirements or hospitalization for bleeding or anemia. RESULTS Of 43 patients who initially entered the study, 38 were treated with combination hormonal therapy. The remaining five patients were treated with estrogen alone. In 25 patients, initial enteroscopy revealed AVMs in the stomach or proximal small bowel and these were cauterized. In the remaining 18 patients no source of bleeding was found. None of the 38 patients who were treated with combination hormonal therapy rebled as long as they continued their prescribed dosage. All five of the patients treated with estrogen alone had rebleeding episodes. There was no statistical difference with respect to AVM cauterization in the rebleeding rate between those patients who underwent cauterization of their AVMs and those who did not. Side effects of combination hormonal therapy occurred in 11 patients and all were considered to be mild. Seven of these 11 patients (64%) elected to continue treatment. CONCLUSION In this long-term observational study, combination hormonal therapy was shown to stop rebleeding in patients with occult gastrointestinal bleeding of obscure origin.
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Affiliation(s)
- J S Barkin
- University of Miami, School of Medicine/Mt. Sinai Medical Center, Division of Gastroenterology, Florida 33140, USA
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27
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Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med 1998; 158:643-61. [PMID: 9700146 DOI: 10.1164/ajrccm.158.2.9711041] [Citation(s) in RCA: 378] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- J R Gossage
- Section of Pulmonary Diseases, Department of Medicine, Medical College of Georgia, Augusta, Georgia, USA.
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28
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MESH Headings
- Activin Receptors
- Antigens, CD
- Chromosome Mapping
- Chromosomes, Human, Pair 12
- Chromosomes, Human, Pair 9
- Endoglin
- Genetic Linkage
- Humans
- Mutation
- Protein Serine-Threonine Kinases/genetics
- Receptors, Cell Surface
- Receptors, Transforming Growth Factor beta/genetics
- Telangiectasia, Hereditary Hemorrhagic/epidemiology
- Telangiectasia, Hereditary Hemorrhagic/genetics
- Telangiectasia, Hereditary Hemorrhagic/physiopathology
- Vascular Cell Adhesion Molecule-1/genetics
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Affiliation(s)
- D A Marchuk
- Department of Genetics, Duke University Medical Center, Durham, NC, USA
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29
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Lund VJ, Howard DJ. Closure of the nasal cavities in the treatment of refractory hereditary haemorrhagic telangiectasia. J Laryngol Otol 1997; 111:30-3. [PMID: 9292127 DOI: 10.1017/s0022215100136369] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
From a cohort of 35 patients with hereditary haemorrhagic telangiectasia (HHT), 12 patients have undergone closure of the one or both nasal cavities during the last three years for refractory epistaxis. All had failed other forms of treatment including hormone therapy, laser coagulation and septodermoplasty. All patients were available for follow-up at six months or longer. In all patients where complete closure was achieved (11 out of 12) bleeding ceased completely from the operated side.
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Affiliation(s)
- V J Lund
- Institute of Laryngology and Otology, London, UK
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30
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Bauer T, Britton P, Lomas D, Wight DG, Friend PJ, Alexander GJ. Liver transplantation for hepatic arteriovenous malformation in hereditary haemorrhagic telangiectasia. J Hepatol 1995; 22:586-90. [PMID: 7650340 DOI: 10.1016/0168-8278(95)80455-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Symptomatic hepatic involvement is a rare complication of hereditary hemorrhagic telangiectasia and most commonly consists of fibrosis or cirrhosis. We describe a 33-year-old woman in whom multiple hepatic arteriovenous malformations led to high output cardiac failure and liver failure due to biliary necrosis with refractory biliary sepsis, requiring orthotopic liver transplantation. Hepatic arteriovenous malformations were the first manifestation of the disease and a similar asymptomatic hepatic tumour was subsequently detected in her 60-year-old father who also had the classical cutaneous stigmata of the syndrome. Unrecognised genetic factors may determine the clinical spectrum of hereditary haemorrhagic telangiectasia including the hepatic manifestations.
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Affiliation(s)
- T Bauer
- Department of Medicine, Clinical School of Medicine, University of Cambridge, Addenbrooke's NHS Trust, UK
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31
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McAllister KA, Grogg KM, Johnson DW, Gallione CJ, Baldwin MA, Jackson CE, Helmbold EA, Markel DS, McKinnon WC, Murrell J. Endoglin, a TGF-beta binding protein of endothelial cells, is the gene for hereditary haemorrhagic telangiectasia type 1. Nat Genet 1994; 8:345-51. [PMID: 7894484 DOI: 10.1038/ng1294-345] [Citation(s) in RCA: 1018] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by multisystemic vascular dysplasia and recurrent haemorrhage. Linkage for some families has been established to chromosome 9q33-q34. In the present study, endoglin, a transforming growth factor beta (TGF-beta) binding protein, was analysed as a candidate gene for the disorder based on chromosomal location, expression pattern and function. We have identified mutations in three affected individuals: a C to G substitution converting a tyrosine to a termination codon, a 39 base pair deletion and a 2 basepair deletion which creates a premature termination codon. We have identified endoglin as the HHT gene mapping to 9q3 and have established HHT as the first human disease defined by a mutation in a member of the TGF-beta receptor complex.
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Affiliation(s)
- K A McAllister
- Department of Genetics, Duke University Medical Center, Durham, North Carolina 27710
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32
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Panés J, Casadevall M, Fernández M, Piqué JM, Bosch J, Casamitjana R, Cirera I, Bombí JA, Terés J, Rodés J. Gastric microcirculatory changes of portal-hypertensive rats can be attenuated by long-term estrogen-progestagen treatment. Hepatology 1994; 20:1261-70. [PMID: 7927261 DOI: 10.1002/hep.1840200525] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
It has been suggested that estrogen-progestagen therapy may be useful in preventing bleeding from gastric angiodysplasia, a vascular lesion similar to that described in portal-hypertensive gastropathy. In this study we assessed the effects of estrogen-progestagen therapy on gastric microcirculation and systemic and splanchnic hemodynamics in portal-hypertensive and sham-operated rats. One week after the surgical procedure (partial portal vein ligation or sham surgery), animals were given an intramuscular injection of a slow-release preparation of estrogen-progestagen or its vehicle. Two weeks later, gastric mucosal blood flow was measured by means of hydrogen gas clearance, a morphometrical analysis of gastric mucosal blood vessels was performed and systemic and splanchnic hemodynamics were evaluated with a radiolabeled-microspheres technique. In portal-hypertensive rats, estrogen-progestagen therapy induced a significant reduction in gastric mucosal blood flow, number of blood vessels and relative area of vessels. Similar changes, although of lesser magnitude, were achieved with estrogen or progestagen given separately and with the low dose of combined estrogen-progestagen. Estrogen-progestagen treatment also induced significant reductions in portal pressure and porto-collateral resistance without changing systemic or splanchnic hemodynamics. In contrast, estrogen-progestagen treatment did not induce changes in any of the parameters studied in sham-operated rats. We conclude that long-term estrogen-progestagen therapy reduces the gastric hyperemia, increased mucosal vessel density and portal pressure in portal-hypertensive rats.
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Affiliation(s)
- J Panés
- Gastroenterology Department, Hospital Clínic, Barcelona, Spain
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33
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Abstract
Bleeding from the small intestine may be difficult to diagnose, because of the organ's length and free intraperitoneal location. Although there is a variety of causes of intestinal bleeding, angiodysplasia is the most common. Several different tests can be used to identify the bleeding site preoperatively or intraoperatively, including enteroscopy.
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Affiliation(s)
- B S Lewis
- Mount Sinai School of Medicine, New York, New York
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34
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Shovlin CL, Hughes JM, Tuddenham EG, Temperley I, Perembelon YF, Scott J, Seidman CE, Seidman JG. A gene for hereditary haemorrhagic telangiectasia maps to chromosome 9q3. Nat Genet 1994; 6:205-9. [PMID: 8162076 DOI: 10.1038/ng0294-205] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disorder that is characterized by frequent nosebleeds, mucocutaneous telangiectases and vascular malformations that cause recurrent haemorrhage and arteriovenous shunting. Linkage analyses in one kindred identified an HHT locus on the long arm of chromosome 9 (maximum multipoint lod score = 6.20 between D9S60 and D9S61). Analyses in two other unrelated HHT families demonstrated that the disease in one was not linked to the locus on chromosome 9q3. We conclude that HHT is a genetically heterogeneous disorder. Based on its map location (9q3) and expression in vascular tissues, type V collagen is a possible candidate gene for HHT.
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Affiliation(s)
- C L Shovlin
- Medical Research Council Molecular Medicine Group, Hammersmith Hospital, London, UK
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35
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Abstract
Since the first report of pulmonary endometriosis as a cause of catamenial haemoptysis all cases have been assumed to be due to pulmonary endometriosis, even in the absence of histopathological proof. A case is presented where the histological findings were of a pulmonary arteriovenous malformation.
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Affiliation(s)
- D J Wood
- Department of Medicine, Kings Mill Hospital, Sutton in Ashfield
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36
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Moshkowitz M, Arber N, Amir N, Gilat T. Success of estrogen-progesterone therapy in long-standing bleeding gastrointestinal angiodysplasia. Report of a case. Dis Colon Rectum 1993; 36:194-6. [PMID: 8425426 DOI: 10.1007/bf02051180] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Gastrointestinal angiodysplasia is a common cause of occult bleeding. Surgical and endoscopic treatments are often ineffective. Recently, estrogen-progesterone therapy proved to be effective in these patients. We describe herein an 84-year-old man who presented with prolonged gastrointestinal bleeding, in whom treatment with estrogen-progesterone stopped the bleeding. We suggest that hormonal therapy should be considered in cases of prolonged obscure gastrointestinal bleeding thought to be due to angiodysplasia. This therapy should be instituted intermittently for a prolonged period. The role of progesterone, especially in men, should be reconsidered.
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Affiliation(s)
- M Moshkowitz
- Department of Gastroenterology, Sourasky Medical Center, Ichilov Hospital, Tel Aviv, Israel
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37
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Rhodus NL, Kuba R. Hereditary hemorrhagic telangiectasia with florid osseous dysplasia. Report of a case with differential diagnostic considerations. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1993; 75:48-53. [PMID: 8419874 DOI: 10.1016/0030-4220(93)90405-s] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The clinical presentation of hereditary hemorrhagic telangiectasia with various manifestations has been well described as has florid osseous dysplasia. There have been no cases reported of the two pathologic entities in the same patient. We present a case with the simultaneous occurrence of hereditary hemorrhagic telangiectasia and florid osseous dysplasia with important considerations for differential diagnosis, and we discuss whether this case presents a potential syndrome.
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Affiliation(s)
- N L Rhodus
- Department of Oral Diagnosis and Radiology, University of Minnesota School of Dentistry, Minneapolis
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38
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Radu C, Reich DL, Tamman R. Anesthetic considerations in a cardiac surgical patient with Osler-Weber-Rendu disease. J Cardiothorac Vasc Anesth 1992; 6:461-4. [PMID: 1498304 DOI: 10.1016/1053-0770(92)90016-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- C Radu
- Department of Anesthesiology, Mount Sinai Medical Center, New York, NY 10029-6574
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39
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Tandan R, Mohire MD, Dorwart RH. Intracranial arteriovenous malformations in two brothers with myotonic dystrophy. Clin Neurol Neurosurg 1991; 93:143-7. [PMID: 1652396 DOI: 10.1016/0303-8467(91)90056-u] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We describe two brothers with myotonic muscular dystrophy and intracranial arteriovenous malformations who developed acute vascular neurological syndromes. The simultaneous occurrence of these two disorders in brothers could either be due to chance association, or due to a common causative mechanism, possibly a membrane abnormality.
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Affiliation(s)
- R Tandan
- Department of Neurology, University of Vermont College of Medicine, Burlington 05405
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40
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Braverman IM, Keh A, Jacobson BS. Ultrastructure and three-dimensional organization of the telangiectases of hereditary hemorrhagic telangiectasia. J Invest Dermatol 1990; 95:422-7. [PMID: 2212727 DOI: 10.1111/1523-1747.ep12555569] [Citation(s) in RCA: 165] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We studied 10 cutaneous telangiectatic lesions of hereditary hemorrhagic telangiectasia (HHT), ranging in size from pinpoint to 2 mm, by light and electron microscopy. Four representative lesions were reconstructed by computer from serial 1- or 2-mm plastic embedded sections. The earliest clinically detectable lesion of HHT is a focal dilatation of postcapillary venules, which continue to enlarge and eventually connect with dilated arterioles through capillaries. As the vascular lesion increases in size, the capillary segments disappear and a direct arterio-venous communication is formed. This entire sequence of morphologic events is associated with a perivascular mononuclear cell infiltrate in which the majority of cells are lymphocytes and the minority are monocytes/macrophages by ultrastructure. Comparison of these findings with the telangiectatic mats of scleroderma and cherry angiomas revealed that the former, previously shown to be composed of dilated postcapillary venules, are also associated with perivascular infiltrates, but the latter, which are produced by capillary loop aneurysms, are not.
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Affiliation(s)
- I M Braverman
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
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41
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van Cutsem E, Rutgeerts P, Vantrappen G. Treatment of bleeding gastrointestinal vascular malformations with oestrogen-progesterone. Lancet 1990; 335:953-5. [PMID: 1970032 DOI: 10.1016/0140-6736(90)91010-8] [Citation(s) in RCA: 209] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
10 patients with frequent and severe bleeding from gastrointestinal vascular malformations took part in a double-blind, placebo-controlled, cross-over trial of a daily dose of 0.05 mg ethinyloestradiol plus 1 mg norethisterone given by mouth. Each arm of the trial lasted 6 months. Oestrogen-progesterone significantly decreased the transfusion need from 10.9 to 1.1 units packed cells (p less than 0.003). While on oestrogen-progesterone 2 of 9 patients required transfusions (mean 1.1 units packed cells per patient over 6 months), whereas all patients had to be transfused while on placebo (mean 10.9 units per patient over 6 months; p = 0.002 for number of patients). No significant excess of side-effects was noted with the active agents. The findings indicate that oestrogen-progesterone is an effective treatment for severely bleeding gastrointestinal vascular malformations.
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Affiliation(s)
- E van Cutsem
- Department of Internal Medicine, University Hospital Gasthuisberg, Leuven, Belgium
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42
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Braverman IM. Ultrastructure and organization of the cutaneous microvasculature in normal and pathologic states. J Invest Dermatol 1989; 93:2S-9S. [PMID: 2666519 DOI: 10.1111/1523-1747.ep12580893] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The cutaneous microvasculature is organized into upper and lower horizontal plexuses with the dermal capillary loops arising from the upper plexus. The arteriolar and venular sides of the microvasculature can be identified by the ultrastructure of the mural basement membrane material. Collecting venules present in the lower dermis contain valves. Periadventitial cells (veil cells) are present around all microvessels. Their size and number appear to correlate with the quantity of mural basement membrane material found in cutaneous vessels in diabetes, actinic damage, and chronological aging. The contractile cells of the vascular wall surround the endothelial cell tube in a manner suggesting specific functions. The smooth muscle cells in the arteriolar segment form a sleeve, whereas each pericyte in the postcapillary venular simultaneously makes many contacts with several underlying endothelial cells. The common telangiectases can be explained by abnormalities in this organization and ultrastructure rather than by neovascularization or random anastomoses. The macular telangiectases seen in scleroderma, generalized essential telangiectasia, and nevus flammeus are produced by dilatation of the postcapillary venules of the upper horizontal plexus. Cherry angiomas are produced by spherical and tubular dilatations of capillary loops in dermal papillae with tortuous cross-connections between individual loops. Angiokeratomas of Fabry and Fordyce have the ultrastructure of collecting venules that contain valves, and appear to represent the ectopic development or placement of small valve-containing collecting veins. The cutaneous lesions of hereditary hemorrhagic telangiectasia represent arteriovenous communications.
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Affiliation(s)
- I M Braverman
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut 06510
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43
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Flint SR, Keith O, Scully C. Hereditary hemorrhagic telangiectasia: family study and review. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1988; 66:440-4. [PMID: 2972984 DOI: 10.1016/0030-4220(88)90263-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Hereditary hemorrhagic telangiectasia is reviewed, and the orofacial features of the condition are illustrated by details of an affected family and in particular a male patient who is now 63 years old. The nature of the disease from its insidious onset in the second and third decades to involve not only the mucous membranes but all cutaneous and visceral structures is noted, together with medical complications. Aspects of general and dental management are summarized.
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Affiliation(s)
- S R Flint
- University Department of Oral Medicine, Bristol Dental School and Hospital, England
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44
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Shelley WB, Shelley ED, Burmeister V. The laminate capillary and its wall of multiple basement membranes. Br J Dermatol 1988; 118:327-31. [PMID: 3355776 DOI: 10.1111/j.1365-2133.1988.tb02424.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Cutaneous telangiectatic vessels from two cases of unilateral dermatomal superficial telangiectasia were shown under electron microscopy to be venular capillaries with thick walls composed of multiple basement membranes. We suggest that this special capillary structure, seen in a variety of telangiectatic and disease states, should be called the 'laminate capillary'.
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Affiliation(s)
- W B Shelley
- Department of Medicine, Medical College of Ohio, Toledo 43699
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45
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Abstract
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) is an autosomal dominant, systemic fibrovascular dysplasia in which telangiectases, arteriovenous malformations, and aneurysms may be widely distributed throughout the body vasculature. Major clinical manifestations include: recurrent bleeding from mucosal telangiectases and arteriovenous malformations; hypoxemia, cerebral embolism, and brain abscess due to pulmonary arteriovenous fistulas; high-output congestive heart failure and portosystemic encephalopathy from hepatic arteriovenous malformations; and a variety of neurologic symptoms due to central nervous system angiodysplasia. Therapy is primarily supportive, consisting of iron supplementation and blood transfusion. Septal dermoplasty and oral estrogens may allow prolonged remission of epistaxis, but permanent surgical cure of gastrointestinal bleeding is rarely feasible because of diffuse angiodysplasia of the alimentary tract. Ligation, resection, or embolization may be indicated for pulmonary arteriovenous fistulas. The prognosis and survival of patients with hereditary hemorrhagic telangiectasia are favorable, providing treatable complications are accurately diagnosed.
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46
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Odell JM, Haas JE, Tapper D, Nugent D. Infantile hemorrhagic angiodysplasia. PEDIATRIC PATHOLOGY 1987; 7:629-36. [PMID: 3502423 DOI: 10.3109/15513818709161426] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
We report a female infant who presented at birth with an unusual syndrome of disseminated cutaneous and gastrointestinal vascular malformations associated with severe thrombocytopenia and chronic gastrointestinal hemorrhage. The infant required extensive blood-product support and expired at 7 months of age. Postmortem examination confirmed the presence of numerous flat vascular lesions, descriptively classified as angiodysplastic, and composed of congeries of dilated capillaries, arterioles, and postcapillary venules. No visceral space-occupying hemangiomas were found. The case is discussed in relation to a spectrum of congenital vascular malformation syndromes including disseminated neonatal hemangiomatosis and hereditary hemorrhagic telangiectasia (HHT). Some pathologic characteristics appear to link it to the latter entity. However, other clinical and pathologic features distinguish it from the reported spectrum of congenital HHT, prompting its essentially descriptive designation.
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Affiliation(s)
- J M Odell
- Division of Laboratories, Children's Hospital and Medical Center, Seattle, Washington 98105
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47
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O'Hare JP, Hamilton M, Davies JD, Corrall RJ, Mountford R. Oestrogen Deficiency and Bleeding from Large Bowel Telangiectasia in Turner's Syndrome. Med Chir Trans 1986; 79:746-7. [PMID: 3492603 PMCID: PMC1290580 DOI: 10.1177/014107688607901221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lesser BA, Wendt D, Miks VM, Norum RA. Identical twins with hereditary hemorrhagic telangiectasia concordant for cerebrovascular arteriovenous malformations. Am J Med 1986; 81:931-4. [PMID: 3777000 DOI: 10.1016/0002-9343(86)90372-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Central nervous system arteriovenous malformations are uncommon in hereditary hemorrhagic telangiectasia. Identical twins are described with hereditary hemorrhagic telangiectasia and concordance for central nervous system arteriovenous malformations identified by angiography. One twin had a central nervous system hemorrhage in the seventh month of pregnancy and also had a pulmonary arteriovenous malformation. The other was asymptomatic. A previously reported association between HLA type A2 BW17 and hereditary hemorrhagic telangiectasia was not confirmed. Two recombinations were identified between the loci for HLA and hereditary hemorrhagic telangiectasia. The loci for HLA and hereditary hemorrhagic telangiectasia are not closely linked. Stroke in a young person should prompt an inspection for manifestations of hereditary hemorrhagic telangiectasia.
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Johansson BR, Beran M, Petrusson B. Light and electron microscopy of varicose vessels and telangiomas in the nasal mucosa of habitual nosebleeders. Acta Otolaryngol 1985; 99:620-9. [PMID: 4024913 DOI: 10.3109/00016488509182269] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Biopsy specimens of abnormal vessels in the nasal mucosa of 42 habitual nosebleeders (22 with telangiomas, 20 with varicose vessels) were examined with light and electron microscopy. There were no specific morphologic features that distinguished the wall structure of solitary varicose vessels from that of telangiomatous lesions consisting of multiple vessel branches. Thus, in both categories of vascular malformations a disproportionately thin and simple wall lined the large lumina. Mostly, the endothelium was the only component in the wall. The endothelium could consist of extremely thin, seemingly degenerating, cells that at some points even failed to form a continuous tunic. At other areas of the same vessel circumference patches of thick, organelle-rich, 'active' endothelial cells could be seen and endothelial cells with intermediate structural characteristics were also found. It is suggested that these endothelial cell appearances represent different stages of cellular proliferation, maturation, and ageing, i.e. turnover. The periendothelial lamina was occasionally multilayered. The large, thin-walled abnormal vessels were covered with scarce connective tissue and a rather thin epithelium. For simple mechanical reasons it is obvious that bleeding, i.e. vessel wall rupture, is easily elicited in these vascular channels and that control of hemorrhage is defect due to the absence of a true muscular media. The findings give rise to interesting questions as to the initiation and control of the abnormal angiogenic response(s) in the nasal mucosa manifested clinically as recurrent epistaxis.
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Shelley WB, Fierer JA. Focal intravascular coagulation in progressive ascending telangiectasia: ultrastructural studies of ketoconazole-induced involution of vessels. J Am Acad Dermatol 1984; 10:876-87. [PMID: 6327785 DOI: 10.1016/s0190-9622(84)80439-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
We describe a unique form of telangiectasia that we have called progressive ascending telangiectasia. It is a noninflammatory process, characterized by the presence of greatly dilated venous capillaries in the upper dermis. By means of scanning electron microscopy, focal fibrin clots were observed in some of the dilated vessels in the skin of a patient with this disease. These were not apparent with either light microscopy or transmission electron microscopy. Immunofluorescent microscopy revealed deposition of complement and IgM in the vessel walls. The endothelial cells showed ultrastructural evidence of heightened metabolic activity (numerous pinocytotic vesicles, increased number and size of mitochondria, convoluted nuclei, and prominent rough endoplasmic reticulum). Around the dilated vessels there was a thick laminar wall of multiple basement membranes embedded in mucopolysaccharide. The electron microscopic appearance of the endothelial cells and their investments showed them to be dilated venous capillary channels. Ketoconazole therapy induced disappearance of many of the dilated vessels within 1 month. After 5 months of this treatment, skin biopsies of the cleared areas showed an absence of dilated vessels. The thick laminar walls and intravascular clots had disappeared. It is postulated that microbially induced focal intravascular coagulation plays a role in the pathogenesis of progressive ascending telangiectasia. Stasis factors would seem to account for the dependent, ascending nature of the loci of coagulation.
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