Overview of small bowel angioectasias: clinical presentation and treatment options

An unpredictable gastrointestinal bleed

A 65-year-old male complained of persistent melena for 6 days, and displayed anemia symptoms without hematemesis, vomiting, and abdominal distention. He was diagnosed as ruptured aneurysm of aortic sinus Valsalva, and had received coronary artery occlusion 1 month ago. After the operation, he was continually prescribed clopidogrel 75 mg once daily. The laboratory examination showed blood hemoglobin concentration was 60 g/L without other conspicuous abnormality. Unfortunately, neither esophagogastroduodenoscopy (EGD) nor colonoscopy found no obvious bleeding lesions. And abdominal computed tomography angiography (CTA) and enhanced computed tomography (CT) showed no obvious abnormal findings. Moreover, capsule endoscopy revealed small intestinal with mucosal erosion (Figure 1A). After discontinued clopidogrel, blood transfusion, and support therapy, his symptoms was resolved with negative fecal occult blood, continued clopidogrel 75 mg once daily, and uneventfully discharged 1 week later.

Standard of Care Versus Octreotide in Angiodysplasia-Related Bleeding (the OCEAN Study): A Multicenter Randomized Controlled Trial

BACKGROUND & AIMS

Gastrointestinal angiodysplasias are vascular anomalies that may result in transfusion-dependent anemia despite endoscopic therapy. An individual patient data meta-analysis of cohort studies suggests that octreotide decreases rebleeding rates, but component studies possessed a high risk of bias. We investigated the efficacy of octreotide in reducing the transfusion requirements of patients with angiodysplasia-related anemia in a clinical trial setting.

METHODS

The study was designed as a multicenter, open-label, randomized controlled trial. Patients with angiodysplasia bleeding were required to have had at least 4 red blood cell (RBC) units or parental iron infusions, or both, in the year preceding randomization. Patients were allocated (1:1) to 40-mg octreotide long-acting release intramuscular every 28 days or standard of care, including endoscopic therapy. The treatment duration was 1 year. The primary outcome was the mean difference in the number of transfusion units (RBC + parental iron) between the octreotide and standard of care groups. Patients who received at least 1 octreotide injection or followed standard of care for at least 1 month were included in the intention-to-treat analyses. Analyses of covariance were used to adjust for baseline transfusion requirements and incomplete follow-up.

RESULTS

We enrolled 62 patients (mean age, 72 years; 32 men) from 17 Dutch hospitals in the octreotide (n = 31) and standard of care (n = 31) groups. Patients required a mean number of 20.3 (standard deviation, 15.6) transfusion units and 2.4 (standard deviation, 2.0) endoscopic procedures in the year before enrollment. The total number of transfusions was lower with octreotide (11.0; 95% confidence interval [CI], 5.5-16.5) compared with standard of care (21.2; 95% CI, 15.7-26.7). Octreotide reduced the mean number of transfusion units by 10.2 (95% CI, 2.4-18.1; P = .012). Octreotide reduced the annual volume of endoscopic procedures by 0.9 (95% CI, 0.3-1.5).

CONCLUSIONS

Octreotide effectively reduces transfusion requirements and the need for endoscopic therapy in patients with angiodysplasia-related anemia.

CLINICALTRIALS

gov, NCT02384122.

Endoscopic injection sclerotherapy for treating recurrent bleeding of small bowel angioectasias

BACKGROUND

There is still no consensus on the preferred endoscopic therapy for small bowel angioectasias (SBAs). The aim of this study was to evaluate effectiveness and safety of endoscopic injection sclerotherapy (EIS) for treating recurrent bleeding of SBAs.

METHODS

Sixty-six adult patients diagnosed with SBAs by capsule endoscopy (CE) or double-balloon enterscopy (DBE) examinations were enrolled in this retrospective study from September 2013 to September 2021. The patients were divided into an EIS group (35 cases) and a control group (31 cases) according to whether they underwent EIS treatment. Clinical characteristics, medical histories, lesion characteristics, main laboratory indicators, treatments, and outcomes were collected. The rates of re-bleeding, re-admission, and red blood cell (RBC) transfusion were compared between different groups after discharge. The rates of hospitalization and RBC transfusion were compared between before admission and after discharge in both groups. Odds ratios (ORs) and 95% confidence intervals (CIs) were used in the multivariate logistic regression analysis to assess relative factors for re-bleeding.

RESULTS

All the rates of re-bleeding, re-admission and RBC transfusion after discharge in the EIS group were significantly lower than those in the control group (all P < 0.05). The rates of hospitalization and RBC transfusion after discharge were significantly lower than those before admission in the EIS group (both P < 0.05), while those did not reach significant differences in the control group (both P > 0.05). Multivariate logistic regression analysis showed that RBC transfusion before admission (OR, 5.655; 95% CI, 1.007-31.758, P = 0.049) and multiple lesions (≥ 3) (OR, 17.672; 95% CI, 2.246-139.060, P = 0.006) were significant risk factors of re-bleeding, while EIS treatment (OR, 0.037; 95% CI, 0.005-0.260, P < 0.001) was a significant protective factor. No endoscopic adverse events were observed during hospitalization and none of the enrolled patients died within 12 months after discharge.

CONCLUSION

EIS treatment had good effectiveness and safety for treating recurrent bleeding of SBAs, which could be considered as one of the first-line endoscopic treatment options for SBAs.

Diagnosis and management of small-bowel bleeding

Small-bowel (SB) bleeding is a challenging problem for the clinician, presenting many pitfalls in both diagnosis and subsequent treatment. Videocapsule endoscopy (VCE) and device-assisted enteroscopy (DAE) have revolutionized the approach to the patient with SB bleeding, allowing for the endoscopic diagnosis and management of what was previously only a surgical matter. The patients' assessment in SB bleeding is of foremost importance, as treatment success relies on a detailed evaluation of clinical history, suspicion for underlying lesions, and a careful selection and timing of diagnostic and therapeutic tools. This review will summarize current state-of-the-art evidence and practice points, to provide the clinician with a comprehensive guide towards the management of SB bleeding.

Efficacy of pharmacologic treatment for treating gastrointestinal angiodysplasias-related bleeding: a systematic review and meta-analysis

INTRODUCTION

We evaluated the efficacy of pharmacologic treatments for patients with overt or occult bleeding due to gastrointestinal angiodysplasias (GIADs).

METHODS

A systematic computer-aided literature search across Medline, Cochrane, Scopus and Embase databases was performed. Studies evaluating pharmacologic treatments for patients presenting with GIADs-related overt or occult bleeding were included. Post-treatment rebleeding was the primary outcome. Need for red blood cells (RBC) transfusion, post-treatment hemoglobin levels and adverse events rate comprised secondary outcomes. Results are presented as odds ratio (OR), mean difference (MD) or pooled rates (%) with 95% confidence intervals (95%CI).

RESULTS

Four types of pharmacologic treatment were identified (25 studies): somatostatin analogs, hormonal therapy, thalidomide and angiogenesis inhibitors. Pharmacologic treatment of any kind led to significantly reduced bleeding episodes [OR (95% CI), 0.08 (0.04-0.18)]. No pharmacologic treatment was superior to others ( P  = 0.46). Overall, pooled rebleeding rate post-treatment was 34% (26-43%). Similarly, significantly fewer patients required RBC transfusion during the post-treatment period [0.03 (0.03-0.07)], with no differences among various treatments ( P  = 0.83), yielding an overall pooled transfusion rate of 33% (19-46%). Administration of pharmacological treatment led to significant improvement in terms of hemoglobin levels [MD (95% CI), 3.21 g/dL (2.42-3.99)]. The pooled rate of adverse events was 32% (22-42%).

CONCLUSION

In patients with GIADs administration of any pharmacologic treatment significantly decreases rebleeding episodes and transfusions leading to higher hemoglobin values. One-third of them experience at least one adverse event related to the treatment.

Multifocal Small Bowel Angioectasias: Managed with Innovative, Nonresectional Surgical Procedure

Gastrointestinal (GI) angioectasias/angiodysplasias are the most frequent vascular lesions of GI tract, responsible for ∼5 to 6% of GI bleedings. It commonly involves the small bowel, making it difficult to diagnose and manage endoscopically. Though medical management has been used to prevent bleeding, it has only a limited role in acute severe hemorrhage. In such cases, surgical resection remains the only practical option. However, multiple lesions pose a unique challenge, as resection may not be advisable for long length of bowel involvement. Here, we report a case of recurrent GI bleeding due to multifocal small bowel angioectasias who was managed by a novel technique of full-thickness transmural sutures under intraoperative enteroscopic guidance. At 6 months follow-up, no new bleeding episodes were observed.

[Not Available]

Objectives and study aims  Recent pilot studies have assessed the feasibility of a novel 1.9-/1.5-μm dual emission endoscopic laser treatment ( _1.9-/1.5-μm DEELT) for endoscopic hemostasis, ablation and resection. In this study, we investigated the safety and efficacy of _1.9-/1.5-μm DEELT in patients with chronic anemia due to gastrointestinal vascular lesions in a real-life multicenter cohort setting.

Patients and methods  Consecutive patients with moderate/severe iron-deficiency anemia undergoing _1.9-/1.5-μm DEELT for upper and lower gastrointestinal bleeding due to vascular lesions were enrolled in three academic referral centers. Safety and successful ablation of vascular lesions were the primary outcomes. Long-term hemoglobin level, blood transfusion requirements, endoscopic severity scores of complex vascular disorders and technical lasing parameters were also assessed. Long-term hemoglobin variations have been further assessed, with repeated measure analysis of variance and univariate analyses.

Results  Fifty patients (median age 74; range 47 to 91 years) with gastric antral vascular ectasia (GAVE) (22), angioectasia (22) and radiation proctopathy (6) underwent 58 _1.9-/1.5-μm DEELT between 2016 and 2020. All procedures were technically feasible leading to successful ablation of the targeted lesion/s, with no incident or adverse event potentially related to the _1.9-/1.5-μm DEELT technique. Within a 6-month follow-up, hemoglobin values significantly rose (+ 1.77 at 1 month and + 1.70 g/dL at 6 months, P  < 0.01), the blood supply requirement decreased (at least one transfusion in 32 versus 13 patients, P  < 0.01), and GAVE lesions showed a clear endoscopic improvement (from 5 points to 1 points, P  < 0.01).

Conclusions  The 1.9-/1.5-μm laser system is a safe and effective endoscopic tool for haemostatic ablation of bleeding vascular lesions within the gastrointestinal tract in tertiary referral centers.

RHEMITT score: Predicting the risk of mid gastrointestinal rebleeding after small bowel capsule endoscopy: A prospective validation

BACKGROUND AND AIM

The RHEMITT score (Renal disease; Heart failure; Endoscopic findings; Major bleeding; Incomplete SBCE; Tobacco; Treatment by enteroscopy) was the first score to accurately predict the individual risk of small bowel rebleeding after capsule endoscopy (SBCE). The aim of the study is on the prospective validation of the RHEMITT score.

METHODS

Cohort of consecutive patients with mid-gastrointestinal bleeding (MGIB) submitted to SBCE and followed prospectively, during at least 12 months, since 2017 until 2020. Rebleeding was defined as an overt bleeding event (melena or hematochezia) or a hemoglobin decrease of at least 2 g/dL. The RHEMITT score was calculated for each patient and the rebleeding rates compared. The performance of the score was tested by calculating the area under curve of the receiver operator characteristic curve. A rebleeding-free survival was assessed, corresponding to the period between the date of SBCE and the date of the first post-SBCE rebleeding event.

RESULTS

We included 162 patients, 102 (62.9%) were female, with a mean age of 64 years old. The sensitivities and specificities of the score grades for predicting rebleeding were as following: for low-risk patients, 0% (0-10%) and 28.8% (21.1-36.5%); for intermediate-risk patients, 23.3% (8.2-38.4%) and 72% (64.3-79.7%); for high-risk patients, 76.7% (61.6-91.8%) and 99.2% (97.7-100%), corresponding to an area under curve of the receiver operator characteristic of 0.988 (P < 0.001). Kaplan-Meyer plots were statistically different according to the attributed risk (log-rank P value <0.001; Breslow-Wilcoxon P value <0.001).

CONCLUSION

The RHEMITT score performed with excellent discriminative power in predicting rebleeding risk, and we herewith propose a surveillance of MGIB patients guided by the RHEMITT score.

Clinical management and patient outcomes of acute lower gastrointestinal bleeding. A multicenter, prospective, cohort study

BACKGROUND & AIM

Although acute lower GI bleeding (LGIB) represents a significant healthcare burden, prospective real-life data on management and outcomes are scanty. Present multicentre, prospective cohort study was aimed at evaluating mortality and associated risk factors and at describing patient management.

METHODS

Adult outpatients acutely admitted for or developing LGIB during hospitalization were consecutively enrolled in 15 high-volume referral centers. Demographics, comorbidities, medications, interventions and outcomes were recorded.

RESULTS

Overall 1,198 patients (1060 new admissions;138 inpatients) were included. Most patients were elderly (mean-age 74±15 years), 31% had a Charlson-Comorbidity-Index ≥3, 58% were on antithrombotic therapy. In-hospital mortality (primary outcome) was 3.4% (95%CI 2.5-4.6). At logistic regression analysis, independent predictors of mortality were increasing age, comorbidity, inpatient status, hemodynamic instability at presentation, and ICU-admission. Colonoscopy had a 78.8% diagnostic yield, with significantly higher hemostasis rate when performed within 24-hours than later (21.3% vs.10.8%, p = 0.027). Endoscopic hemostasis was associated with neither in-hospital mortality nor rebleeding. A definite or presumptive source of bleeding was disclosed in 90.4% of investigated patients.

CONCLUSION

Mortality in LGIB patients is mainly related to age and comorbidities. Although early colonoscopy has a relevant diagnostic yield and is associated with higher therapeutic intervention rate, endoscopic hemostasis is not associated with improved clinical outcomes [ClinicalTrial.gov number: NCT04364412].

Kvasir-Capsule, a video capsule endoscopy dataset

Artificial intelligence (AI) is predicted to have profound effects on the future of video capsule endoscopy (VCE) technology. The potential lies in improving anomaly detection while reducing manual labour. Existing work demonstrates the promising benefits of AI-based computer-assisted diagnosis systems for VCE. They also show great potential for improvements to achieve even better results. Also, medical data is often sparse and unavailable to the research community, and qualified medical personnel rarely have time for the tedious labelling work. We present Kvasir-Capsule, a large VCE dataset collected from examinations at a Norwegian Hospital. Kvasir-Capsule consists of 117 videos which can be used to extract a total of 4,741,504 image frames. We have labelled and medically verified 47,238 frames with a bounding box around findings from 14 different classes. In addition to these labelled images, there are 4,694,266 unlabelled frames included in the dataset. The Kvasir-Capsule dataset can play a valuable role in developing better algorithms in order to reach true potential of VCE technology.

Evaluation and Validation of a New Score to Measure the Severity of Small Bowel Angiodysplasia on Video Capsule Endoscopy

INTRODUCTION

Angiodysplasias are responsible of 50% of small bowel bleeding. An endoscopic method that allows measuring its severity is not available.

AIMS

The aim of the study was to validate a new endoscopic score with VCE to measure the severity of small bowel angiodysplasias (SBAD).

METHODS

Four endoscopists independently reviewed VCE videos of 22 patients with SBAD. The score graded 3 variables: A - extent of lesions: E1, located in one half of the intestine and E2, in both halves; B - number of lesions: N1, <5; N2, 5-10; and N3, >10 lesions; C - probability of bleeding: P1, pale red spots; P2, bright red spots; P3, bleeding stigmata; and P4, active bleeding. Capsule Endoscopy Small Bowel Angiodysplasia Activity Index (CESBAI) was calculated as follows: E × 1 + N × 2 + P × 3. Interobserver variability was analyzed by Spearman's correlation and agreement Kappa statistic tests.

RESULTS

The mean CESBAI scores by observers were O1= 11.6 ± 4.1; O2 = 11.3 ± 4.8; O3 = 11.1 ± 4.9; and O4 = 11.8 ± 4.2 (p > 0.05). Spearman's correlation values of CESBAI between every 2 observers were from 0.61 to 0.94 (p < 0.001) with a global correlation of 0.73 among all observers. Kappa values of CESBAI between every 2 observers ranged from 0.42 to 0.87 (p < 0.001) with a global agreement of 0.57 among all observers. All evaluators stated that the method was easy to use.

CONCLUSIONS

CESBAI is a reliable and reproducible score. Nevertheless, these results must be validated in other studies with larger population before assessing its power for predicting bleeding recurrence.

Small Bowel Angioectasias Rebleeding and the Identification of Higher Risk Patients

BACKGROUND

Small bowel capsule endoscopy (SBCE) is the gold standard for suspected small bowel bleeding (SBB). Angioectasias are the most common vascular anomalies in the gastrointestinal tract and have been reported as the source of SBB in up to 80% of patients. Considering their frequency, their usual intermittent bleeding nature, and their risk of rebleeding, the aim of this study was to identify some features and possible predictors of rebleeding in the presence of these lesions.

METHODS

This is a retrospective study, which included consecutive SBCE with angioectasias between April 2008 and December 2017 with a minimum follow-up of 12 months. Rebleeding was defined as a drop of hemoglobin ≥ 2 g/dl and/or in the presence of hematochezia or melenas with negative esophagogastroduodenoscopy and ileocolonoscopy. Data were collected from medical records, and angioectasias were classified by number, location, size, and type. Univariate and multivariable statistical analysis was performed to identify possible predictors of rebleeding.

RESULTS

From a total of 630 patients submitted to SBCE for suspected SBB, 129 with angioectasias were included; 59.7% were female, with a median age of 72 (19-91) years old and a mean follow-up of 44.0 ± 31.9 months. In 32.6% (n = 42) of the patients, at least one episode of rebleeding was documented. The presence of heart failure (OR 3.41; IC95% 1.18-9.89; p = 0.024), the size of the angioectasias (OR 5.41; IC95% 2.15-13.6; p < 0.001), and smoking status (OR 3.15; IC95% 1.07-9.27; p = 0.038) were independent predictor factors of rebleeding.

CONCLUSION

Heart failure, smoking status, and angioectasias with a size superior to 5 mm are independent predictor factors of rebleeding in a population with angioectasias diagnosed by SBCE.

Intra-operative enteroscopy for the identification of obscure bleeding source caused by gastrointestinal angiodysplasias: through a balloon-tip trocar is better

AIM

Intra-operative enteroscopy (IE) is a valid diagnostic tool which can be adopted in order to identify the precise location of bleeding gastrointestinal angiodysplasias (GIADs) of the small bowel. We describe a novel IE technique that may increase the diagnostic yield by maintaining a steady distension of the bowel and that prevents microtrauma to the intestinal mucosa and spillage of enteric content into the operative field.

METHODS

After laparotomy, a centimetric transverse enterotomy is performed approximately at the middle of the small bowel. A 12-mm trocar with balloon is then introduced and insufflated. The small bowel is gently distended by carbon dioxide insufflation. Through the trocar, a paediatric colonscope is then inserted and the enteroscopy is performed either retrogradely to the duodenum or anterogradely to the caecum. Once located, surgery is tailored to the precise site of bleeding, with a consequent sparing of intestinal resection.

RESULTS

IE with 12-mm trocar with balloon was adopted in four elderly patients undergoing surgery for bleeding GIADs. The length of small bowel resection ranged from 10 to 200 cm, depending on the number of GIADs. Operating time ranged from 210 to 275 min. Intra-operative blood loss was nil. No patient developed organ-space or wound infections. There was no recurrence of bleeding from the midgut.

CONCLUSION

Performing IE through a balloon trocar may increase the diagnostic accuracy of the procedure with the benefit of reducing the risk of traumatic injury to the bowel and the risk of surgical site infection.

Causes and Clinical Characteristics of Small Bowel Bleeding in Northern Vietnam

AIM

Causes, clinical features, and diagnostic approaches for small bowel (SB) bleeding were analyzed to derive recommendations in dealing with this clinical condition.

METHODS

We included 54 patients undergoing surgical treatment for SB bleeding, from January 2009 to December 2019. Detailed clinical data, diagnosis procedures, and causes of bleeding were collected.

RESULTS

Among 54 cases with SB bleeding, the most common causes were tumors (64.8%), followed by angiopathy (14.8%), ulcers (9.3%), diverticula (5.6%), tuberculosis (3.7%), and enteritis (1.9%). Most tumors (32/35 cases, 91.4%) and vascular lesions (8/8 cases, 100%) were located in the jejunum. The incidence of tumors was higher in the older (30/41 cases, 73.1%) than that in patients younger than 40 years of age (5/13 cases, 38.5%, P < 0.01). Common initial findings were melena (68.5%) and hematochezia (31.5%). The overall diagnostic yield of computed tomographic enterography (CTE) was 57.4% (31/54 cases), with the figures for tumors, vascular lesions, and inflammatory lesions being 71.4% (25/35 cases), 62.5% (5/8 cases), and 12.5% (1/8 cases), respectively. Double-balloon enteroscopy (DBE) definitively identified SB bleeding sources in 16/22 (72.7%) patients.

CONCLUSION

Tumors, angiopathy, ulcers, and diverticula were the most common causes of SB bleeding in Northern Vietnamese population. CTE has a high detection rate for tumors in patients with SB bleeding. CTE as a triage tool may identify patients before double-balloon enteroscopy because of the high prevalence of SB tumors.

Thalidomide for the treatment of angiodysplasia-related recurrent gastrointestinal hemorrhage: Is low dose a safe and viable option?

Thalidomide is often used for the management of refractory gastrointestinal angiodysplasia (GIAD). The tolerance, toxic profile, and compliance of thalidomide are dose-dependent. The low-dose thalidomide (50 mg) is safe and a viable option for bleeding related to GIAD.

Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points

Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient's quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.

Mapping the distribution of small bowel angioectasias

Background: Angioectasias are a prominent cause of small bowel (SB) bleeding frequently identified during capsule endoscopy (CE). Subsequent management depends upon grade/severity and location. There is increasing evidence that the location of SB angioectasias is not random. We aimed to map the distribution of SB angioectasias, and assess whether this impacted clinical outcomes. Materials and methods: Retrospective study examining CEs performed over a 10-year period at a tertiary referral centre. Information regarding number, location, and Saurin classification (P0-2) of SB angioectasias was collected. Clinically significant angioectasias (P1/P2) and active SB bleeding were analysed further. Outcomes of patients with P2 angioectasias or active SB bleeding were recorded. Results: 164 SBCE examinations reported angioectasias. 554 P1-2 angioectasias and active bleeds were seen, 435 (78.52%) within the first tertile of SB transit time (SBTT). 277 (50%) angioectasias were identified within the first 10% of SBTT. 40/75 (53.3%) patients with >1 P2 angioectasia and/or active bleed were referred for intervention. Of initial interventions, 24 patients underwent upper GI endoscopy; 13 underwent double balloon enteroscopy (DBE). 9/37(24.3%) had no identifiable angioectasias on endoscopy. Of those receiving ablative therapy, 20/28 (71.4%) re-presented with iron-deficiency anaemia or bleeding. In this group, average angioectasia position was 15.6% of SBTT, compared with 7.9% in those who did not re-represent (p = 0.344). Patients who re-presented had an average 1.6 additional P1 angioectasias, compared with 7.6 amongst those who did not return (p = 0.017). Conclusions: Clinically significant angioectasias are overwhelmingly located within the proximal SB. The majority are within reach of conventional endoscopy. However, AEs are often multiple and many patients re-present following intervention.