Diagnosis and therapeutic strategies for small bowel vascular lesions.

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy's lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

Multicentre, open-label, randomised, parallel-group, superiority study to compare the efficacy of octreotide therapy 40†mg monthly versus standard of care in patients with refractory anaemia due to gastrointestinal bleeding from small bowel angiodysplasias: a protocol of the OCEAN trial.

INTRODUCTION: Gastrointestinal angiodysplasias are an important cause of difficult-to-manage bleeding, especially in older patients. Endoscopic coagulation of angiodysplasias is the mainstay of treatment, but may be difficult for small bowel angiodysplasias because of the inability to reach them for endoscopic intervention. Some patients are red blood cell (RBC) transfusion dependent due to frequent rebleeding despite endoscopic treatment. In small cohort studies, octreotide appears to decrease the number of bleeding episodes in patients with RBC transfusion dependency due to gastrointestinal angiodysplasias. This trial will assess the efficacy of octreotide in decreasing the need for RBC transfusions and parenteral iron in patients with anaemia due to gastrointestinal bleeding of small bowel angiodysplasias despite endoscopic intervention. STUDY DESIGN: Randomised controlled, superiority, open-label multicentre trial. PARTICIPANTS: 62 patients will be included with refractory anaemia due to small bowel angiodysplasias, who are RBC transfusion or iron infusion dependent despite endoscopic intervention and oral iron supplementation. INTERVENTION: Patients will be randomly assigned (1:1) to standard care or 40 mg long-acting octreotide once every 4 weeks for 52 weeks, in addition to standard care. The follow-up period is 8 weeks. MAIN OUTCOME MEASURES: The primary outcome is the difference in the number of blood and iron infusions between the year prior to inclusion and the treatment period of 1 year. Important secondary outcomes are the per cent change in the number of rebleeds from baseline to end point, adverse events and quality of life. ETHICS AND DISSEMINATION: The trial received ethical approval from the Central Committee on Research Involving Human Subjects and from the local accredited Medical Research Ethics Committee of the region Arnhem-Nijmegen, the Netherlands (reference number: 2014-1433). Results will be published in a peer-reviewed journal and presented at international conferences. TRIAL REGISTRATION NUMBER: NCT02384122; Pre-results.

Therapeutic failure with thalidomide in patients with recurrent intestinal bleeding due to angiodysplasias / Fracaso terapéutico a talidomida en paciente con sangrado intestinal recurrente debido a angiodisplasias

Angiodysplasias are one of the reasons of gastrointestinal bleeding, whose origin is usually due to vascular malformations. There are different types of therapies for angiodysplasia such as endoscopic, angiographic and pharmacological techniques. Among the last ones, there is little variety of effective drugs to treat the disease. We describe the therapeutic failure with thalidomide in a male with recurrent gastrointestinal bleeding due to angiodysplasias. A thorough diagnostic work-up, including gastroscopy, enteroscopy, angiography and capsule endoscopy were performed. Despite treatment with high-dose somatostatin analogues and oral iron, the patient continued bleeding. The patient was administered then thalidomide for three months with no clinical response. Thalidomide had to be withdrawn owing to adverse effects (AU)

Una de las causas de sangrado a nivel gastrointestinal son las angiodisplasias, cuyo origen suele deberse a malformaciones a nivel vascular. Existen distintos tipos de terapias para las angiodisplasias, como son las técnicas endoscópicas, angiográficas y farmacológicas. Dentro de estas últimas existe poca variedad de fármacos efectivos para dicha patología. Se describe el fracaso terapéutico con talidomida en un varón con sangrado gastrointestinal recurrente debido a angiodisplasias. Se le realiza un diagnóstico completo, incluyendo gastroscopia, enteroscopia, angiografía y cápsula endoscópica. A pesar del tratamiento con análogos de la somatostatina a altas dosis y hierro oral, el paciente continuó sangrando. El paciente recibió talidomida durante tres meses sin respuesta clínica. La talidomida tuvo que ser retirada debido a los efectos adversos y a la falta de eficacia (AU)

High variation in treatment strategies for gastrointestinal angiodysplasias.

OBJECTIVE: Angiodysplasias (ADs) are the second leading cause of gastrointestinal bleeding in the elderly. The impact extends from no symptoms to chronic anaemia. Treatment guidelines are lacking. The aim of this study was to assess the current practice of gastrointestinal ADs and explore possible new research areas. On the basis of existing evidence, we would like to propose a treatment algorithm. METHODS: We administered a 19-item web-based survey to gastroenterologists in the Netherlands between February and April of 2015. RESULTS: A total of 111 (response rate 28%) gastroenterologists completed the survey (mean age=47 years; 24% women). The respondents identified Von Willebrand disease (17%), chronic kidney disease (21%) and aortic stenosis (77%) as risk factors for the development of ADs. Colonoscopy (54%) and esophagogastroduodenoscopy (43%) were the preferred first tools to screen for ADs. The favoured (77%) first treatment option is endoscopic argon plasma coagulation, whereas 20% start iron supplementation or blood transfusions. Treatment strategy is mostly (65%) based on the location of the ADs. Small bowel ADs are considered the most difficult to treat, because of the need for balloon enteroscopy. Of the gastroenterologists, 13% would treat ADs as a coincident finding during endoscopy. Medical therapy is mostly started in refractory ADs, and thalidomide (40%) is preferred over octreotide (19%). Thalidomide is more preferred by gastroenterologists working in a teaching hospital. CONCLUSION: Identification of risk factors and treatment of ADs vary widely between gastroenterologists in the Netherlands. Further research is needed to create an evidence-based guideline and thereby optimize the management of symptomatic ADs.

Therapeutic failure with thalidomide in patients with recurrent intestinal bleeding due to angiodysplasias.

Angiodysplasias are one of the reasons of gastrointestinal bleeding, whose origin is usually due to vascular malformations. There are different types of therapies for angiodysplasia such as endoscopic, angiographic and pharmacological techniques. Among the last ones, there is little variety of effective drugs to treat the disease. We describe the therapeutic failure with thalidomide in a male with recurrent gastrointestinal bleeding due to angiodysplasias. A thorough diagnostic work-up, including gastroscopy, enteroscopy, angiography and capsule endoscopy were performed. Despite treatment with high-dose somatostatin analogues and oral iron, the patient continued bleeding. The patient was administered then thalidomide for three months with no clinical response. Thalidomide had to be withdrawn owing to adverse effects.

Una de las causas de sangrado a nivel gastrointestinal son las angiodisplasias, cuyo origen suele deberse a malformaciones a nivel vascular. Existen distintos tipos de terapias para las angiodisplasias, como son las técnicas endoscópicas, angiográficas y farmacológicas. Dentro de estas últimas existe poca variedad de fármacos efectivos para dicha patología. Se describe el fracaso terapéutico con talidomida en un varón con sangrado gastrointestinal recurrente debido a angiodisplasias. Se le realiza un diagnóstico completo, incluyendo gastroscopia, enteroscopia, angiografía y cápsula endoscópica. A pesar del tratamiento con análogos de la somatostatina a altas dosis y hierro oral, el paciente continuó sangrando. El paciente recibió talidomida durante tres meses sin respuesta clínica. La talidomida tuvo que ser retirada debido a los efectos adversos y a la falta de eficacia.

URGENT COLONOSCOPY IN LOWER INTESTINAL BLEEDING.

The aim of the study was to compare the diagnostic efficacy and safety of emergency colonoscopy without colon preparation at patients with intestinal bleeding. MATERIAL AND METHODS: In a comparative cohort study included 252 patients admitted due to intestinal bleeding in 2006- 2015. 118 men, women 134. The average age was 60.15 ± 15,7 years. Patients with explicit anal / hemorrhoidal bleeding at admission or manifestations of gastroesophageal bleeding were excluded. Randomization was performed by alternating days of hospitalization. In Hospital N~ 29 colonoscopy was performed at admission without prior colon preparation, patients of Hospital N~ 1 performed lavage or enema preparation prior to colonoscopy within 24-48hours of hospitalization. RESULTS: Significant differences in the structure of intestinal bleeding source were identified. In patients without bowel preparation most frequently detected bleeding diverticula and cancer - 17%, ulcerative colitis - 1096, intestinal bleeding - 1696, upper bleeding - 16%. At preliminary colon preparation most often as likely causes bleeding source detected cancers - 22%, ulcerative colitis - 15%, angiodysplasia - 13%. Analysis of the dependence of bleeding sources structure from bowel preparation revealed differences only in women. The number of endoscopic findings at colon preparation was 1.5 times higher versus emergency colonoscopy without colon preparation. The number and structure of the observed changes were significantly different between groups, and depending on the sex of patients. There were no complications. CONCLUSION: Colonoscopy at intestinal bleeding without colon preparation is safe and highly informative in identifying of.

Jejunal angiodysplasia causing recurrent gastrointestinal bleeding presenting as severe anaemia and melena.

Angiodysplasia of the gastrointestinal (GI) tract consists of ectasia of the submucosal vessels of the bowel. The evaluation of such patients needs proctoscopy, colonoscopy, small bowel enema, enteroscopy, capsule enteroscopy and angiography. Capsule enteroscopy has come up as an alternative to GI enteroscopy and colonoscopy in patients with occult GI bleeding; up to 52% cases of small bowel angiodysplasia in patients with occult GI bleed with negative upper GI and colonoscopy have been reported. The use of capsule enteroscopy potentially limits the hazard of radiation exposure from angiography and is less invasive than double balloon endoscopy. The treatment options for angiodysplasias include intra-arterial vasopressin injection, selective gel foam embolisation, endoscopic electrocoagulation and injection of sclerosants, with each of these being technically demanding, and requiring centres with good access to enteroscopy technology and trained gastroenterologists. Operative intervention has been indicated for refractory bleeding or lesions in sites not accessible to endoscopic interventions.

[A woman in her 60s with multifactorial anaemia]. / En kvinne i 60-årene med kombinert anemi.

Anaemia may be multifactorial in origin. We present a woman with autoimmune hepatitis and secondary warm autoimmune haemolytic anaemia and most likely also concomitant anaemia of chronic disease. A relapse of autoimmune haemolysis was successfully treated with steroids and high-dose intravenous immunoglobulin. At the same time, bleeding from angiodysplasia in the coecum was masked by unauthorised perorally administrated iron. No other cause of bleeding was found. During that period, she required extensive blood transfusions, up to several times per month. Surgical or endoscopic treatment of the bleeding angiodysplasia was not possible. Alloimmunisation developed as a complication to the large number of transfusions, despite the use of steroids. Treatment with somatostatin analogue markedly reduced the need of our patient for blood transfusions for a follow-up period of more than one year, and she has not experienced any side effects. We do not know how long the haemostasis achieved will last, however, we believe that this treatment may be an alternative for other patients as bleeding from angiodysplasia is not uncommon and is often difficult to eradicate.

Unexplained iron deficiency anaemia: Is it worthwhile to perform capsule endoscopy?

BACKGROUND: In around 30% of iron deficiency anaemia (IDA) cases a definite diagnosis cannot be made. AIM: To investigate the role of capsule endoscopy (CE) in detecting lesions in patients with unexplained IDA after a negative endoscopic, serologic and haematologic diagnostic work up and its possible role in influencing clinical outcome. METHODS: 138 patients suffering from IDA were identified among 650 consecutive patients undergoing CE at our unit. RESULTS: CE revealed the following positive findings in 91/138 patients: angiodysplasias in 51 patients; jejunal and/or ileal micro-ulcerations in 12; tumours/polyps in 9; erosive gastritis in 4; Crohn's disease in 5; jejunal villous atrophy in 5; a solitary ileal ulcer in 1 and active bleeding in the last 4 patients. Follow up data were available for 80/91 patients (87.9%). In 15 out of 46 patients with angiodysplasias IDA spontaneously resolved without any treatment; 9 patients required iron supplementation; 10 patients healed after lanreotide administration; APC was performed in 9 out of 46 patients and 3 patients underwent regular blood transfusion without any success on IDA. 10 out of the 12 patients with small bowel micro-ulcers spontaneously recovered from IDA whilst 2 patients after iron supplementation. All 9 patients affected by tumours/polyps were surgically addressed. In all erosive gastritis cases, patients recovered from IDA after PPI and Helicobacter pylori eradication. Four patients with Crohn's disease diagnosis restored to health with medical therapy. One out of the 4 patients with jejunal villous atrophy and the sole patient with a solitary ileal ulcer spontaneously healed. In 1 out of 3 patients with active bleeding IDA resolved without further treatment after blood transfusion whilst 2 patients were referred for surgical treatment. At follow up, complete resolution of IDA was achieved in 96.25%. CONCLUSIONS: Small bowel investigation is a matter of great importance in IDA patients after negative upper and lower gastrointestinal endoscopy.

[Bleeding in digestive tract caused by jejunal angiodysplasia: complementary value of capsule endoscopy and double-balloon enteroscopy]. / Hemorragia digestiva oscura por angiodisplasia yeyunal: valor complementario de la cápsula endoscópica y la enteroscopia de doble balón.

We report the case of a 35-year-old male patient, with a history of six months of pallor and dyspnea associated with severe iron deficiency anemia and positive fecal occult blood tests. Endoscopy of the lower and upper gastrointestinal tract, and a small bowel follow-through were performed, but did not reveal the origin of the bledding. Later, a capsule endoscopy study were performed and detected an elevated area - not well defined - with active bleeding in the jejunal portion of the small bowel, for that reason we decided to complement the study with a double balloon enteroscopy, that allowed us to see more clearly the jejunal lesion: an elevated and ulcerated lesion; the area was marked with India ink to guide the surgeon. In the surgical intervention a resection of the involved jejunal segment was performed; the study of pathological anatomy established the diagnosis of jejunal angiodysplasia. We present this case of obscure gastrointestinal bleeding to emphasize the diagnostic utility of capsule endoscopy and double balloon enteroscopy.

Long-acting octreotide as rescue therapy in chronic bleeding from gastrointestinal angiodysplasia.

BACKGROUND: Octreotide has shown to be effective against rebleeding from gastrointestinal angiodysplasias, but a long-term daily parenteral administration is recommended. Long-acting octreotide (LAR-OCT) could overcome such a limitation, but it has not been studied extensively. AIM: To investigate the usefulness of long-acting octreotide in the control of chronic bleeding from gastrointestinal angiodysplasias. METHODS: Thirteen patients with chronic gastrointestinal bleeding because of angiodysplasias were enrolled. Diagnosis was made by endoscopy and wireless video capsule. Long-acting octreotide was administered intramuscularly at a dosage of 10 mg/monthly for 1 year. Patients were followed up for a minimum period of 1 year, and haemoglobin levels, blood transfusions, iron supplementation and hospitalizations were recorded 1 year before and after starting long-acting octreotide therapy. RESULTS: Follow-up ranged from 12 to 60 months. Nine of 13 patients (69%) did not need blood transfusions and iron supplementation any longer; a partial improvement was observed in one patient; no effect was found in the others. No side effect was recorded in any patient. CONCLUSIONS: Long-acting octreotide for 1 year may be beneficial as a rescue therapy for controlling chronic bleeding from gastrointestinal angiodysplasias in patients not eligible for surgery. Its monthly administration represents an advantage, which makes such a formulation the choice when a long-term treatment is mandatory.

[Value of 99mTc-Sulphur colloid scintigraphy in the diagnosis of intermittent digestive bleeding secondary to a case of jejunal angiodysplasia]. / Valor de la gammagrafía 99mTc-sulfuro coloidal en el diagnóstico de hemorragia digestiva intermitente secundaria a un caso de angiodisplasia en yeyuno.

We present the case of a 74 year old female patient, with clinical criteria of liver cirrhosis caused by hepatic C virus who required several admissions in our hospital over a five month period. She was given several blood transfusions because of repeated clinical manifestation of gastrointestinal bleeding without a clear origin. Her last admission was due to intermittent melenas, secondary anemia and hemodynamic angina. The patient's study included clinical analysis, fibrogastroscopy, colonoscopy, opaque enema, spiral CT and supraortic vessels arteriography. Because all the results to diagnose and locate the patient's disease were negative, she was referred to our service for a scintigraphy study. As it was an emergency case because of the patient's serious hemodynamic condition, a 99mTc-sulphur colloid scintigraphy was chosen, the results of which showed and located active gastrointestinal bleeding requiring urgent surgical intervention. The laparotomy with intrasurgical enterotomy and fibrogastroscopy undertaken ratified gastrointestinal bleeding, and the result of the biopsy of the jejunum removed in the intervention confirmed bowel angiodysplasia. Given the low incidence of gastrointestinal bleeding secondary to bowel angiodysplasia and absence of bibliographic references regarding the diagnosis of this disease in the above mentioned site by means of 99mTc-sulphur colloid scintigraphy in particular, we consider it interesting to highlight this case, in which the capability of this nuclear medicine technique for quick and non-invasive detection and location of gastrointestinal bleeding has been highly proven.

Multiple jejunal angiodysplasia detected by enema-helical CT.

The small bowel angiodysplasia is a rare entity that causes lower intestinal bleeding; the diagnosis is difficult and based on selective angiogram. In our case, an 85-year-old woman was hospitalized after frequent episodes of melena. We performed an enema-helical CT abdominal examination before and after contrast medium administration per venam, detecting some increased intensity areas that surgery confirmed to be a vascular dysplasia on the jejunal first loop. We found the source of hemorrhage without performing an angiographic examination.

An unusual case of colonic angiodysplasia.

An unusual case of a colonic vascular anomaly resembling angiodysplasia associated with right sided diverticular disease is presented. The patient, a 74 year old man, presented with a four day history of rectal bleeding and subsequently underwent hemicolectomy. The resected specimen was flushed out with heparin-saline solution and injected with a barium-gelatine mixture. Preoperative barium enema revealed right sided diverticula, whereas post-resection angioradiography revealed the "coral reef" vascular anomaly consistent with angiodysplasia. Histology confirmed the presence of both diverticular disease and angiodysplasia. This case report highlights the importance of considering a vascular anomaly in patients presenting with rectal bleeding despite the presence of another radiologically demonstrable anatomical lesion.

Angiodysplasia of the colon in children.

Angiodysplasia of the colon as a cause of lower intestinal bleeding is diagnosed frequently in the elderly, with defined clinical characteristics. In the pediatric population there is little experience; only six cases have been reported. The present study evaluates the clinical, radiological, and surgical aspects of nine children with angiodysplasia of the colon who were treated at the National Institute of Pediatrics in Mexico City between 1970 and 1993. The mean age of clinical onset was 2.3 years. In six patients, symptoms appeared before the first year of life. Lower intestinal bleeding and severe anemia were present in all cases. The diagnosis and localization of the lesions were established by selective visceral angiography. Six patients were treated by operative resection of the affected colonic segments. For four patients with lesions in the rectum and sigmoid, a Swenson pull-through was performed. In one patient the lesion was recurrent because of incomplete resection. Follow-up ranges from 8 months to 4 years; all patients have had normal hemoglobin levels and negative stool results. Unlike in the elderly and the cases reported in the literature, the left hemicolon was the most frequently involved area.

Angiodysplasia as a source of intestinal bleeding: report of seven cases.

From October 1978 to April 1991, seven patients presenting at the National Taiwan University Hospital with gastrointestinal tract hemorrhage were diagnosed by colonofibroscopy or angiography as having angiodysplasia of the colon and small intestine. There were two men and five women; their ages ranged from 23 to 65 years, with a mean age of 50.3 years. None of these patients were diagnosed by barium enema. Only two patients were diagnosed by colonofibroscopy, and six patients were diagnosed by angiography. Therefore, angiography was the most effective method for diagnosing angiodysplasia. A vascular tuft was the most frequent finding. Six patients with lesions on the right side of the colon underwent a right hemicolectomy, one patient with a lesion on the jejunum underwent a right hemicolectomy initially with segmental resection of the jejunum later. The postoperative courses were smooth, and there has been no further evidence of gastrointestinal blood loss or anemia in the follow-up period. A right hemicolectomy is the treatment of choice because these lesions are frequently multiple; the lesions are found primarily on the right side of the colon.