Recent or Current GI Bleeding: AVMs Must Be Obliterated When Detected on Endoscopy. A Long-Term Follow-Up Study

Abstract

Introduction. The long-term natural history of GI AVMs is not known. Should an innocent-appearing non-bleeding AVM be obliterated when it is discovered during endoscopy for work-up of recent or current GI bleeding? “After all, I guess it's not bleeding now”. We hypothesized the following: Given sufficient time, untreated AVMs in the gut will eventually bleed. With more people living longer, and as more cardioprotective meds are used for aches, pains and blood thinning, the number of individuals at risk for massive GI bleed will increase. An AVM left in the gut may be a ticking time bomb, subject to the whim of a cardioprotective med. We sought to determine whether untreated AVMs resulted in increased morbidity and mortality over time in patients (Pts) who were hospitalized with recent or current GI bleeding. Methods. We analyzed our large GI endoscopic database, which includes all Pts with AVMs found during endoscopic procedures. The VA database storage system (DHCP) was used to store all endoscopy data, all labs, and all prescription meds since 1985. An AVM was defined by the endoscopist as an abnormal-appearing aberrant blood vessel(s) in the GI mucosa. Recent or current bleeding was defined as the event necessitating hospitalization. The Index AVM was defined as the first AVM to be diagnosed during endoscopy. Results: From 1998 through 2001, index AVMs in the GI tract were diagnosed in 23 Pts with recent or current GI bleeding: 4 in the colon (3 coagulated) and 19 in the upper gut (13 coagulated). The most common reason for neglecting the Index AVM was the thought that it was not the cause of the GI bleed. Bad outcomes (multiple GI bleeds, transfusion-dependant anemia, and multiple admissions) occurred in all 8 (100%) neglected-AVM-Pts. In these 8 Pts, bleeding was associated with the use of NSAIDs+ASA (1 Pt), ASA alone (1 Pt), clopidogrel (1 Pt) and coumadin (4 Pts). In the coagulated-AVM-Pts, bad outcomes occurred in 7 of 15 (47%), with one death directly related to the coagulation process. Thus, failure to coagulate AVMs when initially discovered resulted in significantly increased morbidity compared to similar Pts in whom AVMs were obliterated. Conclusion: AVMs discovered in Pts with recent or current GI bleeding should be completely obliterated, regardless of whether they appear to be the cause of the bleeding.