An overview of angiodysplasia: management and patient prospects

Advances in gastrointestinal vascular bleeding disorders: Successful sirolimus treatment in colonic angioectasia

BACKGROUND

Gastrointestinal (GI) vascular bleeding disorders pose significant clinical challenges due to their complex pathogenesis and varied treatment responses. Despite advancements in diagnostic and therapeutic techniques, optimal management strategies remain elusive, necessitating further research.

AIM

To assess research trends and clinical advancements in GI vascular bleeding disorders, highlighting key themes and therapeutic progress.

METHODS

A bibliometric analysis was conducted using the Web of Science Core Collection database, reviewing publications from 2000 to 2024 to identify trends, high-frequency keywords, and key contributions from leading research institutions. In addition, a case study highlighted the effective application of sirolimus in managing colonic angioectasia in a patient with recurrent GI bleeding who had not responded to previous treatments.

RESULTS

The analysis reviewed 470 scholarly articles from 203 countries, involving 2817 authors across 1502 institutions. The United States led in publication contributions, with strong collaborations with countries like China, England, and Germany. A significant trend was observed in the shift from traditional endoscopic interventions to pharmacological therapies, particularly highlighting the successful use of sirolimus in treating colonic angioectasia. High-frequency keywords such as "angiodysplasia", "colon", and "management" were identified, indicating key research themes. The study also noted a growing interest in drug therapies, as evidenced by the increasing prominence of keywords like "thalidomide" since 2018.

CONCLUSION

This study links bibliometric analysis and clinical insights, highlighting the shift to pharmacological management in GI vascular bleeding disorders to improve patient outcomes.

Jejunal angiodysplasia: surgery can be life-saving - a case report

Introduction

Angiodysplasia, a rare cause of gastrointestinal (GI) bleeding, presents a spectrum of clinical manifestations from anemia to life-threatening hemorrhage. This case study emphasizes the significance of considering intestinal vascular malformations as a differential diagnosis, especially in the context of chronic anemia and GI bleeding. Jejunal angiodysplasia, though infrequent, poses diagnostic challenges due to the hidden nature of the small bowel in the GI system.

Case presentation

A 23-year-old male presented with acute hematochezia and melena, necessitating prompt intervention. Despite a normal esophagogastroduodenoscopy, colonoscopy was hindered, CT angiography could not be performed due to the patient's unstable condition, leading to a planned exploratory laparotomy. Surgical exploration revealed a mucosal vascular lesion in the jejunum, prompting resection, and anastomosis. The patient's postoperative course was uneventful, reinforcing the importance of swift diagnosis and intervention.

Clinical discussion

Angiodysplasia's pathogenesis remains unclear, with hypotheses implicating vascular endothelial growth factor and submucosal changes. Challenges in management revolve around lesion localization and stabilizing hemodynamics, necessitating a multidisciplinary approach. While endoscopy is often diagnostic and therapeutic, advanced modalities such as CT angiography may be required. Literature review highlights diverse presentations and successful interventions, including embolization and surgical resection.

Conclusion

Jejunal angiodysplasia demands a comprehensive diagnostic and therapeutic strategy. The presented case underscores the pivotal role of endoscopy, embolization, and surgery in managing this condition. Timely diagnosis and intervention are crucial for mitigating the impact of angiodysplasia, necessitating further research and collaborative efforts for improved management of this rare condition.

Clinical features and bleeding risk factors of angiodysplasia lesions in a Tunisian population

INTRODUCTION

Gastrointestinal angiodysplasia (GIAD) is the most common vascular anomaly in the gastrointestinal (GI) tract, yet little is known about the factors favoring their bleeding. Our study aim was to determine the characteristics of patients with GIAD lesions in a Tunisian population and identify the risk factors of bleeding.

PATIENTS AND METHODS

A retrospective study was carried out from January 2010 to February 2020 at a tertiary care medical center in Tunisia. Clinical and endoscopic data were collected from each patient's medical reports. We divided the patients into two groups: group A, patients with symptomatic GIAD; and group B, patients with incidental lesions. Group A was subsequently divided into two subgroups, according to the presence or absence of recurrent bleeding. The groups were compared by clinical, laboratory, and endoscopic features.

RESULTS

GIAD was diagnosed in 114 patients, with a mean age of 70 ± 13.3 years. GIAD lesions were mainly located in the colon (n = 72, 63%). Fifty-four patients (47%) presented with GIAD-related bleeding. The bleeding diagnosis was made during endoscopic procedures by visualizing active bleeding and the stigmata of recent hemorrhage in 10 (18.5%) and 12 (22.2%) cases, respectively. Most of the patients were treated by argon plasma coagulation (93%). Predictive factors of bleeding were age > 75 years, number of lesions >10, chronic kidney disease, diabetes mellitus, and coronary artery disease (p: 0.008; 0.002; 0.016; 0.048; and 0.039, respectively).

CONCLUSION

Knowledge of the predictive factors of bleeding aids endoscopists in the decision-making process in cases of angiodysplasia.

Endovascular management of severe lower gastrointestinal bleeding from angiodysplasia in the cecum: A case report

Gastrointestinal angiodysplasias (GIADs) are rare disorder but can cause noticeable issue clinically. Their clinical characteristics can range from being an asymptomatic incidental finding to causing life-threatening bleeding. Many modalities are applied for treating bleeding GIADs include endoscopic therapies, angiography with embolization, surgical resection, and pharmacologic therapy. However, since patients with GIADs are often aged and have many comorbidities, endoscopic therapies may not be the best initial option. Angiography is suitable method for hemodynamically unstable patients with active bleeding, patients with an unknown active bleeding source, and patients who are poor surgical candidates. Angiography not only diagnose the bleeding point but also provide therapeutic endovascular intervention at the same time. We report a case of endovascular management of severe lower gastrointestinal bleeding from a GIAD in the cecum using a mixture of n-butyl cyanoacrylate and lipiodol to embolize the bleeding source. Clinical symptoms improved without prominent complications.

Gastrointestinal bleeding of undetermined origin: What diagnostic strategy to propose?

Gastrointestinal bleeding of undetermined origin (GBUO) is defined as gastrointestinal bleeding without an identified cause or location despite an endoscopic assessment including an esogastroduodenal endoscopy (EOGD) and a total colonoscopy. A distinction is made between exteriorized GBUO and non-exteriorized occult GBUO. The causes in the majority of cases (vascular, inflammatory and tumoral) are located in the small intestine. The diagnostic strategy aiming to locate the origin of the GBUO is a real challenge. Innovation in endoscopic and imaging techniques has enabled minimally invasive exploration of the small intestine. In Europe, there is a strong consensus to recommend a video-capsule endoscopy (VCE) as the first-intention study. If there is reason to suspect intestinal obstruction, VCE is contraindicated and a CT-enteroscopy is then performed as first intention. Enteroscopy is performed as a second-line treatment, either for therapeutic purposes after a positive VCE or CT-enteroclysis, or for diagnostic purposes after a negative VCE. Finally, intraoperative enteroscopy (IOE) coupled with surgical exploration should be reserved either for therapeutic purposes in the event of impossibility or failure of preoperative enteroscopy, or for diagnostic purposes in the event of recurrent GBUO after failure of all other studies and explorations of the small intestine.

Epidemiología, diagnóstico y tratamiento de las angiectasias gastrointestinales

Las angiectasias son las malformaciones vasculares mas comunes en el tracto gastrointestinal en la población general. Hasta el momento, la patogénesis de este tipo de malformaciones vasculares no ha esclarecida totalmente. Su incidencia ha venido en aumento debido a la mayor disponibilidad de métodos diagnósticos en gastroenterología, principalmente la videocápsula endoscópica (VCE) y la enteroscopia profunda asistida para el estudio del intestino delgado. La terapia endoscópica es la estrategia de tratamiento inicial más efectiva, sin embargo existen otras alternativas terapéuticas como lo son la terapia farmacológica, la angiografía más embolización selectiva o la resección quirúrgica.

Clinical characteristics and risk factors for rebleeding in uremic patients with obscure gastrointestinal bleeding undergoing deep enteroscopy: A multi-center retrospective study in Taiwan

BACKGROUND/PURPOSE

Recurrent obscure gastrointestinal bleeding (OGIB) in patients with chronic kidney disease is a challenge often faced by physicians, given the need for repeated hospitalizations, multiple extensive examinations, limited treatment options, and high medical costs. The purpose of this study was to identify the clinical characteristics of uremic patients undergoing deep enteroscopy for OGIB and analyze the risk factors for rebleeding in these patients after undergoing single-balloon enteroscopy (SBE).

METHODS

Out of 765 patients with OGIB who underwent 1004 procedures of SBE in four teaching hospitals, 78 uremic patients with OGIB were enrolled. Clinical characteristics and endoscopic findings were collected, and multiple variables were analyzed to determine the risk of rebleeding after SBE.

RESULTS

The diagnostic yield was 75.6%, and the rebleeding rate was 29.5% in the enrolled uremic patients. The most common etiology was angiodysplasia (74.6%) and the most common site was the jejunum (50.8%). The endoscopic intervention rate was 62.8% and most patients were treated with argon plasma coagulation (75.6%). Among the eight patients with valvular heart disease (VHD), four (50%) had severe aortic stenosis, and the remaining had non-aortic stenosis-VHD. VHD (p < 0.05) and angiodysplasia (p < 0.05) were both associated with a higher rebleeding rate.

CONCLUSION

VHD may be an independent risk factor associated with rebleeding after SBE in uremic patients with OGIB. Moreover, uremic patients with angiodysplasia-related bleeding appear to have a higher rebleeding rate than those with alternative causes of bleeding.

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.

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.

Analysis of small bowel angioectasia in asymptomatic individuals depending on patients' age and gender

Objectives: Small bowel angioectasia (SBA) plays an important role in the etiologies of obscure gastrointestinal haemorrhage. But the exact prevalence of the disease is unknown, especially in asymptomatic populations. Therefore, we aimed to evaluate the prevalence of asymptomatic angioectasia in the small bowel (SB) with magnetically controlled capsule gastroscopy (MCCG).Methods: We retrospectively collected a multicentre clinical data of 508 asymptomatic patients who underwent MCCG from June 2018 to May 2019. Bowel cleanliness was rated as four grades according to the criteria, and the excellent or good preparation was classified as the adequate group. The detection rates of small bowel lesions were analysed according to the ages, genders and bowel preparations.Results: A total of 508 individuals have completed the examination. There were 316 men and 192 women with an average age of 44.5 years old. The prevalence of SBA was 11.8% (95% CI: 9.0-14.6%). 70.0% of them were over 40 years old and 73.3% were male although there was no obvious disparity found in age and gender for the SBA. Most findings were located in the proximal small bowel (jejunum). The incidence of small bowel lesions was not related to bowel preparations (p > .05).Conclusions: SBA is not uncommon in asymptomatic individuals. Age and gender may be risk factors for bleeding of angioectasia in the small bowel, but they seem to have little to do with the occurrence of it. MCCG showed no difference in ages, genders or bowel preparations of small bowel lesions among our study population.

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.