Less favorable clinical outcome after diagnostic and interventional double balloon enteroscopy in patients with suspected small-bowel bleeding?

Clinical Outcomes of Negative Balloon-Assisted Enteroscopy for Obscure Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis

Background

For patients with obscure gastrointestinal bleeding (OGIB), finding the bleeding site is challenging. Balloon-assisted enteroscopy (BAE) has become the preferred diagnostic modality for OGIB. The long-term outcome of patients with negative BAE remains undefined. The present study aimed to evaluate the long-term outcomes of patients with negative BAE results for OGIB and to clarify the effect of further investigations at the time of rebleeding with a systematic review and meta-analysis of the available cohort studies.

Methods

Studies were searched through the PubMed, EMBASE, and Cochrane library databases. The following indexes were analyzed: rebleeding rate after negative BAE, rebleeding rate after different follow-up periods, the proportion of patients who underwent further evaluation after rebleeding, the percentage of patients with identified rebleeding sources, and the percentage of patients with rebleeding sources in the small intestine. Heterogeneity was assessed using the I² test.

Results

Twelve studies that involved a total of 407 patients were included in the analysis. The pooled rebleeding rate after negative BAE for OGIB was 29.1% (95% CI: 17.2–42.6%). Heterogeneity was significant among the studies (I² = 88%; p < 0.0001). The Chi-squared test did not show a difference in rebleeding rates between the short and long follow-up period groups (p = 0.142). The pooled proportion of patients who underwent further evaluation after rebleeding was 86.1%. Among the patients who underwent further evaluation, rebleeding sources were identified in 73.6% of patients, and 68.8% of the identified rebleeding lesions were in the small intestine.

Conclusion

A negative result of BAE in patients with OGIB indicates a subsequently low risk of rebleeding. Further evaluation should be considered after rebleeding.

The Evolution of Device-Assisted Enteroscopy: From Sonde Enteroscopy to Motorized Spiral Enteroscopy

The introduction of capsule endoscopy in 2001 opened the last "black box" of the gastrointestinal tract enabling complete visualization of the small bowel. Since then, numerous new developments in the field of deep enteroscopy have emerged expanding the diagnostic and therapeutic armamentarium against small bowel diseases. The ability to achieve total enteroscopy and visualize the entire small bowel remains the holy grail in enteroscopy. Our journey in the small bowel started historically with sonde type enteroscopy and ropeway enteroscopy. Currently, double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy are available in clinical practice. Recently, a novel motorized enteroscope has been described with the potential to shorten procedure time and allow for total enteroscopy in one session. In this review, we will present an overview of the currently available techniques, indications, diagnostic yield, and complications of device-assisted enteroscopy.

Therapeutic Impact of Deep Balloon-assisted Small Bowel Enteroscopy on Red Blood Cell Transfusion

Objective Evaluate impact of balloon-assisted deep small bowel enteroscopy on red blood cell transfusion requirement in patients with obscure gastrointestinal (GI) bleeding.

Methods Retrospective study of patients, who underwent balloon-assisted deep enteroscopy with double-balloon enteroscopy (DBE) at two tertiary care academic centers (University of Wisconsin and Aurora St. Luke’s Medical Center) over a 55-month consecutive period. Sixty-nine patients with reliable blood transfusion records were identified during this time period. DBE was preceded by small bowel capsule endoscopy (CE) within 1 year in 38 cases. Transfusion requirements 6 months prior and postintervention were measured to see if DBE had any impact on the need for blood transfusions.

Results Sixty-nine patients (25 females and 44 males) were included. Mean age ± standard deviation (SD) was 63 ± 17 years. Wilcoxon signed rank test statistics were used to find the difference in the rate of blood transfusion. There was a statistically significant decrease in rate of packed red blood cell (pRBC) transfusion post DBE and endoscopic therapy with coagulation (p < 0.001). Argon plasma coagulation was used to ablate all arteriovenous malformations (AVMs) except in one (subepithelial lesion). Those that required > 5 units pRBC transfusions pre-DBE had the most benefit.

Conclusions Our study demonstrates that transfusion requirements are significantly reduced in those undergoing therapy with DBE and coagulation for obscure GI bleed.

Small Bowel Enteroscopy - A Joint Clinical Guideline from the Spanish and Portuguese Small Bowel Study Groups

The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication and on its diagnostic and therapeutic yields. A set of recommendations were issued accordingly.

Clinical outcome after enteroscopy for small bowel angioectasia bleeding: A Korean Associateion for the Study of Intestinal Disease (KASID) multiceter study

BACKGROUND AND AIMS

Angioectasias are the most common sources of bleeding in the small bowel. They can be treated using balloon-assisted enteroscopy (BAE). This study aimed to identify the rebleeding rate and associated factors after BAE in patients with small bowel angioectasia bleeding.

METHODS

We retrospectively analyzed the records of patients with bleeding due to small bowel vascular lesion in a multicenter enteroscopy database including 1108 BAEs. Finally, in rebleeding analysis, we analyzed 66 patients with angioectasia on the basis of the Yano-Yamamoto classification. Patients who had undergone endotherapy (ET) were divided into ET (n = 45) and non-ET (n = 21) groups. Rebleeding was defined as evidence of bleeding at least 30 days after BAE.

RESULTS

Fifty-three patients (80.4%) underwent only one-side enteroscopy. The most common ET was argon plasma coagulation (87.2%). During a mean follow-up duration of 24.5 months, ET and non-ET groups had rebleeding rates of 15.6% and 38.1% (P = 0.059), respectively. Median rebleeding time of ET and non-ET groups was 32.5 and 62 months, respectively. Liver cirrhosis (LC), low platelet count (< 10⁵ /μL), and transfusions were the rebleeding-associated factors in the univariate analysis. In the multivariate analysis, the presence of LC (HR 4.064, 95% CI 1.098-15.045; P = 0.036) was the only independent rebleeding-associated risk factor.

CONCLUSIONS

ET using BAE did not significantly affect the rebleeding rate in patients with small bowel angioectasia bleeding. An independent rebleeding risk factor was the presence of LC. Regardless of ET, careful long-term follow-up may be needed, especially in LC patients with small bowel angioectasia bleeding.

Deep enteroscopy - indications, diagnostic yield and complications

Since its introduction in 2001 capsule endoscopy opened up the small bowel for diagnostic approaches followed by double balloon enteroscopy which enabled the endoscopic community to perform therapeutic interventions in the whole small intestine. In this review the scientific developments related to indications, diagnostic yield and complications of the last years between the competing devices double ballon enteroscopy, single balloon enteroscopy and spiral enteroscopy are illustrated.

Impact of balloon-assisted enteroscopy on the diagnosis and management of suspected and established small-bowel Crohn's disease

BACKGROUND AND AIMS

The role of recently developed balloon-assisted enteroscopy (BAE) in small-bowel Crohn's disease (CD) is not well established. The purpose of this study is to determine the clinical impact of BAE on patients with suspected and established small-bowel CD.

METHODS

This study included 22 patients (group A) with suspected small-bowel CD and 43 patients (group B) with established small-bowel CD with or without previous surgery, who underwent BAE, in a prospective BAE registry of a US academic medical institution. All underwent abdominal imaging studies including computed tomography (CT) or magnetic resonance (MR) enterography before BAE. The main outcome measurements were diagnostic yield and clinical outcomes.

RESULTS

In total, 78 BAE procedures were carried out in 65 patients. In group A (n = 22, 25 BAE procedures), enteroscopy led to a diagnosis of CD in six patients (27.3 %). Non-steroidal anti-inflammatory drug-related enteropathy was diagnosed in three patients (13.6 %), whereas no lesions were found in the remaining 13 patients. In group B (n = 43, 53 BAE procedures) enteroscopy revealed active intestinal inflammation with ulcers and/or luminal stenosis in 18 patients (41.9 %), which led to a change and escalation of medical therapy. Five patients without active ulcers underwent successful dilation of small-bowel strictures with resulting resolution of obstructive symptoms. Of the 78 BAE procedures, two patients (2.6 %) had bleeding complications which were successfully treated conservatively. One patient (1.3 %) underwent surgery due to procedure-related perforation.

CONCLUSIONS

The use of BAE may help improve management in patients with suspected and established small-bowel CD.

Double-balloon endoscopy in clinical practice: where are we now?

Double-balloon endoscopy (DBE) was developed in 2000 for the diagnosis and treatment of small bowel diseases. Although use rates still differ between Eastern and Western countries, DBE quickly reached a broad global diffusion. Together with capsule endoscopy (CE), DBE represented 'a revolution' for the management of small bowel diseases because of its therapeutic capabilities. At present, the main indications for DBE in clinical practice are obscure gastrointestinal bleeding, Crohn's disease and familial polyposis. In the setting of obscure gastrointestinal bleeding, DBE seems to have similar diagnostic performances as capsule endoscopy, but it allows for a more definitive diagnosis and the treatment of identified lesions. The main contribution of DBE in the management of Crohn's disease patients is its therapeutic capabilities. Indeed, several recently published studies have suggested that endoscopic dilation of small bowel strictures can delay or, in the near future, could even replace surgical interventions. Also, for patients with familial polyposis syndromes, DBE can represent a viable alternative to small bowel surgery. The complication rate of DBE appears to be low; major complications, such as pancreatitis, bleeding and perforation, have been reported in approximately 1% of all diagnostic DBE whereas the complication rate for therapeutic procedures is about 5%.

Outcome of patients who have undergone total enteroscopy for obscure gastrointestinal bleeding

AIM: To assess the diagnostic success and outcome among patients with obscure gastrointestinal bleeding who underwent total enteroscopy with double-balloon endoscopy.

METHODS: Total enteroscopy was attempted in 156 patients between August 2003 and June 2008 at Hiroshima University Hospital and achieved in 75 (48.1%). It is assessed whether sources of bleeding were identified, treatment methods, complications, and 1-year outcomes (including re-bleeding) after treatment, and we compared re-bleeding rates among patients.

RESULTS: The source of small bowel bleeding was identified in 36 (48.0%) of the 75 total enteroscopy patients; the source was outside the small bowel in 11 patients (14.7%) and not identified in 28 patients (37.3%). Sixty-one of the 75 patients were followed up for more than 1 year (27.2 ± 13.3 mo). Four (6.6%) of these patients showed signs of re-bleeding during the first year, but bleeding did not recur after treatment. Although statistical significance was not reached, a marked difference was found in the re-bleeding rate between patients in whom total enteroscopy findings were positive (8.6%, 3/35) and negative (3.8%, 1/26) (3/35 vs 1/26, P = 0.63).

CONCLUSION: A good outcome can be expected for patients who undergo total enteroscopy and receive proper treatment for the source of bleeding in the small bowel.

Long-term outcome of patients treated with double balloon enteroscopy for small bowel vascular lesions

OBJECTIVES

Early rebleeding rate after endoscopic therapy with double balloon enteroscopy (DBE) of hemorrhagic small bowel vascular lesions (SBVL) varies between 10 and 50%. In recent reports, long-term follow-up of patients have been described but rebleeding risk factors are still not well established. The aim of the current study was to identify long-term treatment success rate and rebleeding risk factors after DBE therapy in a large cohort.

METHODS

We conducted a single-center, retrospective cohort study in a large French tertiary-referral center between January 2004 and December 2007.

RESULTS

Among 261 patients presenting with obscure gastrointestinal bleeding (OGIB), SBVL was present in 133 patients and was treated successfully in 129 (97%) using mainly argon plasma coagulation. Ninety-eight patients were followed up for a mean period of 22.6±13.9 months (range 1-52). Rebleeding rate was 46% (45/98 patients) at 36 months. On multivariate analysis, the total number of observed lesions (hazard ratio (HR): 1.15, 95% confidence interval (CI): 1.06-1.25, P=0.001) and the presence of a valvular and/or arrhythmic cardiac disease (HR: 2.50, 95% CI: 1.29-4.87, P=0.007) were significantly associated with the risk of rebleeding. Complication rate of therapeutic DBE was 2.3% with no mortality.

CONCLUSIONS

Endoscopic therapy using DBE for SBVL in patients with recurrent OGIB allows a long-term remission in more than half of the patients. Independent rebleeding risk factors after a first endoscopic therapy are an increased number of SBVL and an associated valvular/arrhythmic heart disease.

Therapeutic management options for patients with obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) is one of the most challenging disorders faced by gastroenterologists because of its evasive nature and difficulty in identifying the exact source of bleeding. Recent technological advances such as video capsule endoscopy and small bowel deep enteroscopy have revolutionized the diagnosis and management of patients with OGIB. In this paper, we review the various diagnostic and therapeutic options available for the management of patients with OGIB.

Primary balloon-assisted enteroscopy in patients with obscure gastrointestinal bleeding: findings and outcome of therapy

GOALS

The aim of this study was to evaluate the diagnostic and therapeutic outcome of a primary balloon-assisted enteroscopy (BAE) approach in obscure gastrointestinal bleeding (OGIB) patients.

BACKGROUND

In the diagnostic approach of OGIB, both wireless capsule endoscopy (WCE) and BAE are used. The advantage of the primary wireless capsule endoscopy approach is its noninvasiveness. The main advantage of the primary BAE approach is the excellent diagnostic accuracy and the possibility to perform treatment during the same procedure.

STUDY

A retrospective analysis of our BAE database with patients evaluated for OGIB was performed. BAE data, findings, and follow-up were obtained and evaluated.

RESULTS

One hundred and thirty-two patients (81 male, mean age 62 (11-88) years) were included. In 60 (45%) patients with follow-up, a likely cause for OGIB was found in the small bowel during BAE: angiodysplasia or vascular malformations in 42 (70%), ulcerative lesions in 7 (12%), tumors in 3 (5%), and other findings in 8 (13%) patients. Follow-up was available in 118 (89%) patients; mean time of follow-up was 18 (1-47) months. Thirty-eight (76%) patients with findings at BAE received endoscopic treatment, 27 (71%) of them improved, but anemia also improved spontaneously in 34 patients (63%) with normal findings during BAE. The total number of angiodysplasia per patient was not related to the outcome after treatment.

CONCLUSIONS

The primary BAE approach in OGIB patients has an acceptable diagnostic yield. Therapy seems successful at mid-term follow-up. A high frequency of spontaneous resolution of anemia in patients with normal findings during BAE was observed.

A comparative evaluation of single-balloon enteroscopy and spiral enteroscopy for patients with mid-gut disorders

BACKGROUND

Single-balloon enteroscopy (SBE) and spiral enteroscopy (SE) are recently described device-assisted techniques in endoluminal evaluation of the small bowel. No studies comparing SBE and SE in patients with suspected small-bowel disorders have previously been reported.

OBJECTIVE

The aims of this study were to compare SBE and SE in terms of diagnostic yield, procedure time, depth of maximal insertion, and complications.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care referral center.

PATIENTS

A retrospective analysis was performed on all patients at our institution undergoing anterograde SBE or SE between 2007 and 2009. Patients with altered anatomy or prior small-bowel surgery were excluded.

INTERVENTION

Deep enteroscopy.

MAIN OUTCOME MEASUREMENT

Diagnostic yield.

RESULTS

During the study period, 92 patients underwent 105 procedures (52 SBE, 53 SE). The most common indication for small-bowel endoscopy was obscure GI bleeding (n = 42). The diagnostic yield was not statistically different between SBE and SE (59.6% and 43.4%, respectively, P = .12). The overall diagnostic yield in patients with obscure GI bleeding was 67%. There was no significant difference between mean SBE and SE procedure times (53 minutes [range 15-99 minutes] vs 47 minutes [range 20-125 minutes], respectively; P = .2). The mean depth of maximal insertion beyond the ligament of Treitz for SE was significantly higher than that for SBE (301 cm [range 175-400 cm] vs 222 cm [range 110-400 cm], respectively; P < .001). Perforation occurred in one SBE procedure.

LIMITATIONS

Retrospective design and nonstandardized gas insufflation.

CONCLUSION

This is the first report comparing SE and SBE. Although SE yielded greater depth of maximal insertion than SBE, both techniques had similar diagnostic yields and procedure times. In addition, both techniques were safe and were particularly useful in patients with obscure GI bleeding.

The clinical utility of single-balloon enteroscopy: a single-center experience of 172 procedures

BACKGROUND

Single-balloon enteroscopy (SBE) is a novel endoscopic technique designed to evaluate and treat small-bowel disease. Although there is substantial literature addressing double-balloon enteroscopy and its impact on the diagnosis and management of small-bowel disease, there are limited data available on the clinical utility of SBE.

OBJECTIVES

To evaluate the clinical utility and diagnostic impact of SBE in a large cohort of patients at a single tertiary center.

DESIGN

Single-center, retrospective study.

SETTING

Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.

PATIENTS

A total of 161 patients were referred for SBE from January 2006 to August 2008.

MAIN OUTCOME MEASUREMENTS

Demographic, clinical, procedural, and outcome data were collected and analyzed.

RESULTS

A total of 161 patients underwent a total of 172 procedures. Antegrade and retrograde approaches were used in 83% and 17% of subjects, respectively. The average insertion depth using the antegrade approach was 132 cm beyond the ligament of Treitz (range 20-400 cm). The average insertion depth using the retrograde approach was 73 cm above the ileocecal valve (range 10-160 cm). The average procedure time was 40 minutes overall, 38 minutes (range 12-90) antegrade and 48 minutes (range 28-89) retrograde. Fluoroscopy was used in 20 cases (12%). Diagnostic yield was 58% (99/172); 42% (72/172) were therapeutic cases. There were no significant complications.

LIMITATIONS

Single-center, retrospective study.

CONCLUSIONS

SBE demonstrated a high diagnostic yield and frequently provided useful therapeutic intervention. It seems to be a safe and effective method for performing deep enteroscopy.

Double-balloon enteroscopy in the elderly: safety, findings, and diagnostic and therapeutic success

BACKGROUND

Double-balloon enteroscopy (DBE) is an important tool in the evaluation and management of small-bowel disease. Limited data are available on the safety, findings, and outcomes of DBE in elderly patients.

OBJECTIVE

To determine the safety and efficacy of DBE in elderly patients.

DESIGN

Single-center, retrospective analysis of prospectively collected database.

SETTING

Open-access, tertiary care referral center.

PATIENTS

A total of 176 patients undergoing DBE (216 procedures) for evaluation of small-bowel disease between August 2007 and August 2008.

INTERVENTIONS

Argon plasma coagulation of bleeding small-bowel lesions.

MAIN OUTCOME MEASUREMENTS

DBE complication rate, diagnostic/therapeutic success of DBE.

METHODS

An age cutoff of 75 years and older was used to designate patients as elderly. Data on complications, indications, findings, and diagnostic and therapeutic success of DBE were compared between age groups.

RESULTS

The mean age of patients was 66 +/- 16.4 years (range 20-95 years). DBE was performed in 185 patients, including 60 patients age 75 years and older and 110 patients younger than age 75. An overall complication rate of 0.9% was seen for DBE in this study, with no significant difference between age groups. No major complications were observed in elderly patients. Elderly patients were more likely to have angioectasias (39% vs 23%; P = .01) and were more likely to require endoscopic therapy during DBE (46.8% vs 29.2%; P = .01).

LIMITATIONS

Single-center, retrospective study.

CONCLUSIONS

DBE is safe in elderly patients. Elderly patients are more likely to have angioectasias and to require endoscopic therapy during DBE.

Enteroscopy in the diagnosis and management of obscure gastrointestinal bleeding

Capsule endoscopy and balloon-assisted enteroscopy, have revolutionized our approach to the diagnosis and management of patients with obscure gastrointestinal bleeding, largely replacing intraoperative enteroscopy and conventional barium studies. Despite its limitations, capsule endoscopy may well be the most reasonable initial diagnostic strategy to evaluate most patients with obscure gastrointestinal bleeding, leaving balloon-assisted enteroscopy in reserve as a complementary tool. This article reviews the data on enteroscopy, with particular emphasis on the use of capsule endoscopy and balloon-assisted enteroscopy for the diagnosis and management of patients with obscure gastrointestinal bleeding.

[Utility of single- and double-balloon enteroscopy]

Single- and double-balloon enteroscopes have similar efficacy. The entire small bowel can be examined through the oral route in 60-90minutes in 25-40% of patients. Using the oral and rectal routes, complete examinations can be performed in 75% of patients The diagnostic indications are mid-gastrointestinal bleeding tumors, Crohn's disease, intestinal obstruction and atypical malabsorption. Therapeutic indications include access to enterostomy, hemostasis, foreign body withdrawal, dilatation and polypectomy in the small bowel. This procedure is also useful to place enteral feeding tubes in patients with an excluded stomach. Hemostatic efficacy is high in patients with elevated transfusional requirements. For polypectomy, this technique has not been demonstrated to have the same efficacy/risk as colonoscopy. Complications include pancreatitis (0.34%) and perforation (0.34-6.4%). The level of evidence for almost all indications is low, since few prospective and homogeneous studies have been performed.

Long-term outcomes after double-balloon enteroscopy for obscure gastrointestinal bleeding

BACKGROUND & AIMS

Long-term outcomes after doubleballoon enteroscopy (DBE), performed for the evaluation of obscure gastrointestinal bleeding, have not been determined.

METHODS

We invited 274 patients undergoing DBE at Stanford University or the University of Chicago between 2004 and 2006 to participate in the study; 135 (49%) agreed (mean age, 64 +/- 14.8; range, 23-90 years). Telephone interviews were conducted at a mean of 11 and 30 months after DBE.

RESULTS

Arteriovenous malformations (AVMs) were detected in 43% of the cohort. One hundred one patients (37%; 56 with overt, 45 with occult bleeding) were interviewed 12 +/- 5 (range, 6-26) months after DBE. At 12 months, 43% reported no further overt bleeding or iron/transfusion needs, 23% reported overt bleeding, and 35% reported ongoing iron and/or transfusions. Eighty-five patients (31%) participated in the second survey, conducted 30 +/- 5.7 (range, 19-51) months after DBE. Fifty (59%) reported no overt bleeding or iron/transfusion needs, 20 (24%) reported overt bleeding, and 15 (18%) reported ongoing iron and/or transfusions. In the 40 patients evaluated after endoscopic treatment for AVMs, 17 (43%) reported no bleeding or iron therapy at 12 months and 16 of 29 (55%) at 30 months. Of the 40 patients with normal DBE examinations to the depth of insertion, 19 of 40 (48%) reported no bleeding or iron/transfusion needs at 12 months and 25 of 43 (58%) at 30 months.

CONCLUSIONS

At 30 months after DBE, up to 60% of patients report no further bleeding. Patients with AVMs or normal examinations to the depth of insertion are most likely to report recurrent hemorrhage.

Small bowel enteroscopy: territory conquered, future horizons

PURPOSE OF REVIEW

To review recent advances in small bowel enteroscopy, focusing on indications, modifications to improve imaging and techniques, pitfalls, and clinical applications.

RECENT FINDINGS

The need for endoscopic access to improve diagnosis and treatment of small bowel disease has led to the development of novel technologies, video capsule, and double balloon endoscopy. Newer devices, single balloon and spiral endoscopy, are just entering clinical use. With new technologies come the trials and tribulations of learning new endoscopic skills and determining their role in the diagnosis and treatment of small bowel disease. Identification of small bowel lesions has dramatically improved. However, small bowel angulations, peristalsis, and bilious fluid in the lumen can result in false readings or missed lesions. Studies are underway to determine the best strategy to apply new enteroscopy technologies for the diagnosis and management of small bowel disease, particularly bleeding.

SUMMARY

Complete enteroscopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and therapeutic maneuvers require patience and significant skill. Prospective randomized studies are needed to guide diagnostic testing and therapy with these new endoscopic techniques.

Gastrointestinal angiodysplasia

Angiodysplasia of the gastrointestinal tract is common in the population 60 years of age and older and may be the cause of acute and/or chronic bleeding. Colonic angiodysplastic lesions are presumed to be degenerative in nature, secondary to either intermittent obstruction of the submucosal veins or hypoxemia. The pathogenesis of upper intestinal angiodysplasia is most likely related to a degenerative process. The clinical presentation varies from an incidental finding in an otherwise asymptomatic person to occult bleeding or an acute massive hemorrhage. Endoscopy and angiography are useful diagnostic modalities. Management options include surgery, endoscopic obliteration, or angiographic embolization of an identified bleeding angiodysplastic lesion(s). In a subset of patients who have angiodysplasia associated with Osler-Rendu-Weber disease or chronic renal failure, hormonal therapy with estrogen-progesterone may be efficacious.