Gastrointestinal Angiodysplasia Research Articles

403 A HIGHLY SENSITIVE AND HIGHLY SPECIFIC CONVOLUTIONAL NEURAL NETWORK-BASED ALGORITHM FOR AUTOMATED DIAGNOSIS OF ANGIODYSPLASIA IN SMALL BOWEL CAPSULE ENDOSCOPY

Capsule endoscopy (CE) has become a standard non-invasive tool for small bowel (SB) examination. However, with an average number of 50,000 SB still frames per CE video, lesions can be missed and CE reading remains a time-consuming activity. Therefore, the development of computer-aided algorithms for lesions’ detection has become an active research area in CE. Gastro-intestinal angiodysplasias (AGD) are the most common SB vascular lesions with an inherent risk of bleeding. This study aimed to develop a computer-assisted diagnosis (CAD) tool for SB-AGD detection in CE. A French national database (CAD-CAP) was created: 5296 deidentified third generation SB-CE videos (Pillcam® SB3 system, Medtronic) were collected from 13 centers; 5427 pathological still frames were extracted from 1369 SB-CE with at least one pathological findings; 20,000 normal (control) still frames were extracted from 200 normal SB-CE videos. Six hundred still images with typical AGD were selected from the database by expert readers. Six hundred normal still frames were randomly extracted as controls. The 600 selected AGD were annotated on each individual pathological frame, as “ground truth” reference. Two sets of 600 SB-CE still frames (300 normal frames and 300 frames with AGD, per set) were created. Different learning-based algorithms were tested including color-based approaches and deep feature extraction. The first set of still frames was used for the machine learning process and the second bank for the validation process. Among the tested algorithms, the one with the best diagnostic performance characteristics used a semantic segmentation images approach associated with an artificial convolutional neural network (CNN) for deep feature extraction (figure 1 from left to right: original image, annotated image, CNN approach, CNN approach on original image). This algorithm reached a 100% sensitivity, a 95,83% specificity, a 96.15% positive predictive value, and a 100% negative predictive value for AGD detection. Reproducibility was perfect (Kappa = 1.0). This study shows that a computed algorithm based on a CNN has very good reproducibility, diagnostic sensitivity (100%), and specificity (95.83%), for detection of AGD on still frames. This study opens the way to automated SB-CE reading softwares, and calls for prospective evaluations of CNN at the video level.

Lenalidomide as a novel therapy for gastrointestinal angiodysplasia in von Willebrand disease.

Lenalidomide is a thalidomide analog with anti-angiogenic properties. Previous case reports suggest its efficacy in preventing gastrointestinal bleeding (GIB) secondary to angiodysplasia (AD) in hereditary haemorrhagic telangiectasia and potentially in reversing AD. We present the first case series to explore lenalidomide as a treatment for AD-related GIB in patients with von Willebrand disease (VWD). A retrospective chart review was conducted to include patients with VWD, who were evaluated from 2010 to 2013 and who had received lenalidomide to treat recurrent GIB secondary to AD. All patients had failed single-agent use of antifibrinolytic agents. Patients were observed for at least 2years on therapy. Five patients (3 males; 68.2±4.9years) with VWD (3 with type 3 and 1 each with types 1 and 2a) and AD were found. Sites of AD included the stomach, duodenum, jejunum and colon. Lenalidomide was started at 5mg oral daily. Uptitration to 10 and 15mg in 1 patient each was necessary due to recurrence of GIB. The mean number of endoscopies performed for control of GIB post lenalidomide was significantly lower compared to pretherapy (0.25 vs 5.50; P=.001). Mean bleed-free duration on lenalidomide was 12.6±4.7months. Three patients have reported no GIB on lenalidomide. This case series demonstrates significantly reduced number of endoscopies and increased bleed-free duration with lenalidomide treatment in selected patients with VWD and recurrent GIB from AD. Prospective multicenter trials are needed to further define the role of lenalidomide in the management of GIB from angiodysplasia and VWD.

Efficacy and safety of pasireotide-LAR for the treatment of refractory bleeding due to gastrointestinal angiodysplasias: results of the ANGIOPAS multicenter phase II noncomparative prospective double-blinded randomized study.

Background:Gastrointestinal angiodysplasias (GIADs) could be responsible for recurrent bleeding and severe anemia. Somatostatin analogs could reduce transfusion requirements in these patients but no randomized controlled study is available. The main objective of the ANGIOPAS phase II double-blinded randomized, noncomparative study was to assess the effectiveness of pasireotide-LAR in reducing transfusion requirements in patients with refractory GIADs bleeding.Methods:A total of 22 patients with transfusion requirements ⩾6 units of packed red blood cells (pRBCs) during the 6 months prior to inclusion were randomized to receive pasireotide-LAR 60 mg (n = 10) or placebo (n = 12) every 28 days for 6 months. Patients were then followed for an additional 6 months after stopping treatment.Results:The pasireotide-LAR and placebo groups were equivalent for age, sex, comorbidities and transfusion requirement during the reference period (median 13 and 9.5 pRBCs). A 50 and 83% success rate (success defined as a decrease of at least 30% of transfused pRBCs) was observed in the pasireotide-LAR arm in the Intent to Treat (ITT) and per protocol (PP) analysis respectively. The need for transfusion during the intervention period was 3 pRBC units in the pasireotide-LAR group (range 0–26) and 11.5 pRBC units in the placebo group (range 0–23). Overall, three cases with glycemic control impairment were observed in the pasireotide-LAR group including one de novo diabetes.Conclusion:This double-blinded noncomparative randomized phase II study suggests, for the first time, the effectiveness of pasireotide-LAR 60 mg every 28 days to decrease the transfusion requirement in patients with recurrent bleeding due to GIADs.

Emergency transcatheter arterial embolization for massive gastrointestinal arterial hemorrhage.

To evaluate the different arteriographic manifestations of acute arterial massive hemorrhage of the gastrointestinal (GI) tract and the efficacy of emergency transcatheter arterial embolization (ETAE).A total of 88 patients with acute massive GI bleeding who experienced failure of initial endoscopy and/or conservative treatment were referred to our interventional department for acute GI arteriography from January 2007 to June 2015. After locating the source of bleeding, appropriate embolic agents, such as spring coil, hydroxyl methyl acrylic acid gelatin microspheres, polyvinyl alcohol (PVA) particles, etc., were used to embolize the targeted vessels. The angiographic manifestations and the effects of embolization of acute arterial massive hemorrhage of the GI tract were retrospectively analyzed.Of the 88 patients, 54 were diagnosed with arterial hemorrhage of the upper GI tract and 34 with arterial hemorrhage of the lower GI tract. Eighty cases were associated with positive angiography, which showed the following: contrast extravasation (only); gastroduodenal artery stenosis; pseudoaneurysm (only); pseudoaneurysm rupture with contrast extravasation; pseudoaneurysms merged with intestinal artery stenosis; GI angiodysplasia; and tumor vascular bleeding. Eight cases were diagnosed with negative angiography. Seven-two patients underwent successful hemostasis, and a total of 81 arteries were embolized. The technical and clinical success rates (no rebleeding within 30 days) in performing transcatheter embolization on patients with active bleeding were 100% and 84.71%, respectively (72 of 85). Within 30 days, the postoperative rebleeding rate was 15.29% (13/85). Of these rebleeding cases, 2 patients were formerly treated with “blind embolization,” 7 underwent interventional embolic retreatment, and 3 had surgical operations. All cases were followed-up for 1 month, and 3 patients died from multiple organ failure. No serious complications such as bowel ischemia necrosis were observed.ETAE is a safe, effective, and minimally invasive treatment; because of the diversified arteriographic manifestations of acute GI hemorrhage, the proper selection of embolic agents and the choice of reasonable embolization method are essential for successful hemostasis.

Tranexamic acid in treatment-resistant chronic transfusion-dependent gastrointestinal angiodysplasia bleeding

A small proportion of gastrointestinal angiodysplasia bleeding leads to chronic blood cell transfusion dependency. There are no guidelines supporting decision-making among various treatments in patients with gastrointestinal angiodysplasia bleeding. When...

Readmission Rates and Follow-up Outcomes of Patients Found to Have Gastrointestinal Angiodysplasia on Double Balloon Enteroscopy

Readmission Rates and Follow-up Outcomes of Patients Found to Have Gastrointestinal Angiodysplasia on Double Balloon Enteroscopy

How Accurate Is Endoscopy in Diagnosing Gastrointestinal Angiodysplasia?

How Accurate Is Endoscopy in Diagnosing Gastrointestinal Angiodysplasia?

Continuous-Flow LVAD Support Causes a Distinct Form of Intestinal Angiodysplasia.

The objective of this autopsy study was to determine whether gastrointestinal angiodysplasia develops during continuous-flow left ventricular assist device (LVAD) support. LVAD support causes pathologic degradation of von Willebrand factor (vWF) and bleeding from gastrointestinal angiodysplasia at an alarming rate. It has been speculated that LVAD support itself may cause angiodysplasia. The relationship to abnormal vWF metabolism is unknown. We tested the hypothesis that abnormal gastrointestinal vascularity develops during continuous-flow LVAD support. Small bowel was obtained from deceased humans, cows, and sheep supported with a continuous-flow LVAD (n=9 LVAD, n=11 control). Transmural sections of jejunum were stained with fluorescein isothiocyanate-conjugated isolectin-B4 for endothelium to demarcate vascular structures and quantify intestinal vascularity. Paired plasma samples were obtained from humans before LVAD implantation and during LVAD support (n=41). vWF multimers and degradation fragments were quantified with agarose and polyacrylamide gel electrophoresis and immunoblotting. Abnormal vascular architecture was observed in the submucosa of the jejunum of human patients, cows, and sheep supported with a continuous-flow LVAD. Intestinal vascularity was significantly higher after LVAD support versus controls (5.2±1.0% versus 2.1±0.4%, P=0.004). LVAD support caused significant degradation of high-molecular-weight vWF multimers (-9±1%, P<0.0001) and accumulation of low-molecular-weight vWF multimers (+40±5%, P<0.0001) and vWF degradation fragments (+53±6%, P<0.0001). Abnormal intestinal vascular architecture and LVAD-associated vWF degradation were consistent findings in multiple species supported with a continuous-flow LVAD. These are the first direct evidence that LVAD support causes gastrointestinal angiodysplasia. Pathologic vWF metabolism may be a mechanistic link between LVAD support, abnormal angiogenesis, gastrointestinal angiodysplasia, and bleeding.

Decreased health-related quality of life in angiodysplasia patients: A cross-sectional cohort.

Gastrointestinal angiodysplasias may cause anemia. Quality of life (QoL) is a valid patient reported outcome and improvement of QoL represents an important treatment goal. There is a paucity of data on the effect of angiodysplasias on QoL. Therefore, we aim to evaluate QoL and fatigue in angiodysplasia patients. We performed a cross-sectional patient-reported outcome study. We included patients with endoscopy proven angiodysplasias and measured QoL with Short Form-36 and level of fatigue using Multi Fatigue Inventory-20. We distinguished three subgroups of patients according to disease severity: 1) with treatment for angiodysplasias, 2) without treatment for angiodysplasias and 3) without recent hospital visits. The primary outcome was the physical component summary (PCS) score on the SF-36. Multivariate regression analysis were performed to correct for differences at baseline. A total of 144 patients completed the questionnaires (response rate = 62%; mean age 68 years; 65% men). Angiodysplasia patients have a significant lower PCS compared to the age-matched general population (respectively 41.0 vs. 43.3, p = 0.01). Disease severity is independently associated with a negative outcome on QoL (ß -4.6, 95% CI -7.8–-1.3). Similarly patients score lower on multiple QoL subdomains, i.e. role limitations due to physical health problems (40.8 vs. 44.0, p<0.01), general health (39.7 vs. 47.3, p<0.01). Angiodysplasia patients are more fatigued compared to the general population (male 56.1 vs. 48.5, p<0.01, female 59.2 vs. 51.5, p = 0.01). In conclusion, angiodysplasias are independently associated with clinically significant impairments in multiple domains of health-related QoL, especially in measures of functional limitation.

Sa1219 Rebleeding and Transfusions Rates Are Higher in Patients With Gastrointestinal Angiodysplasia Who Present With Moderate to Severe Aortic Stenosis

Sa1219 Rebleeding and Transfusions Rates Are Higher in Patients With Gastrointestinal Angiodysplasia Who Present With Moderate to Severe Aortic Stenosis

Evaluation of the efficacy of therapeutic endoscopy in gastrointestinal bleeding secondary to angiodysplasias.

Gastrointestinal angiodysplasias are defined as vascular dilations that communicate capillaries and veins in the walls of the digestive tract. The clinical presentation of these lesions varies from chronic occult bleeding to severe gastrointestinal hemorrhage. The primary aim of our study was to analyze lesion location, the efficacy of therapeutic endoscopy with argon plasma coagulation, and the factors associated with rebleeding in patients with gastrointestinal angiodysplasias. A retrospective study of 32,042 endoscopies was carried out within the time frame of January 2012 and December 2013 at our hospital center. Gastrointestinal angiodysplasia was the diagnosis in 331 of the endoscopies. The procedures included upper gastrointestinal endoscopy, colonoscopy, sigmoidoscopy, and enteroscopy. The most frequent location of the angiodysplasias was the cecum (49%), followed by the ascending colon (17%) and the sigmoid colon (16%). They were most frequently found in the duodenum (60%) and gastric body (49%) at upper gastrointestinal endoscopy. Therapeutic endoscopy was performed in 163 cases (49.8%) and the most predominant methods were fulguration with argon (90%) and combination treatment (argon plasma coagulation and injection sclerotherapy) (6.7%). The macroscopic rebleeding rate after therapeutic endoscopy was 7.4%. Patients that had rebleeding presented with a lower hemoglobin concentration, higher mean age, and the presence of multiple angiodysplasias at endoscopy (P<.05). Therapeutic endoscopy was performed in 49.8% of the patients with angiodysplasias. The macroscopic rebleeding rate after treatment was 7.4%. There were statistically significant differences in the patients with rebleeding in relation to mean age, hemoglobin values, and the presence of multiple angiodysplasias.

Evaluation of the efficacy of therapeutic endoscopy in gastrointestinal bleeding secondary to angiodysplasias

IntroductionGastrointestinal angiodysplasias are defined as vascular dilations that communicate capillaries and veins in the walls of the digestive tract. The clinical presentation of these lesions varies from chronic occult bleeding to severe gastrointestinal hemorrhage. AimThe primary aim of our study was to analyze lesion location, the efficacy of therapeutic endoscopy with argon plasma coagulation, and the factors associated with rebleeding in patients with gastrointestinal angiodysplasias. Material and methodsA retrospective study of 32,042 endoscopies was carried out within the time frame of January 2012 and December 2013 at our hospital center. Gastrointestinal angiodysplasia was the diagnosis in 331 of the endoscopies. The procedures included upper gastrointestinal endoscopy, colonoscopy, sigmoidoscopy, and enteroscopy. ResultsThe most frequent location of the angiodysplasias was the cecum (49%), followed by the ascending colon (17%) and the sigmoid colon (16%). They were most frequently found in the duodenum (60%) and gastric body (49%) at upper gastrointestinal endoscopy. Therapeutic endoscopy was performed in 163 cases (49.8%) and the most predominant methods were fulguration with argon (90%) and combination treatment (argon plasma coagulation and injection sclerotherapy) (6.7%).The macroscopic rebleeding rate after therapeutic endoscopy was 7.4%.Patients that had rebleeding presented with a lower hemoglobin concentration, higher mean age, and the presence of multiple angiodysplasias at endoscopy (P<.05). ConclusionsTherapeutic endoscopy was performed in 49.8% of the patients with angiodysplasias. The macroscopic rebleeding rate after treatment was 7.4%. There were statistically significant differences in the patients with rebleeding in relation to mean age, hemoglobin values, and the presence of multiple angiodysplasias.

Efficacy of thalidomide in management of bleeding from gastrointestinal angiodysplasia

Efficacy of thalidomide in management of bleeding from gastrointestinal angiodysplasia

Severe Gastrointestinal Bleeding due to Angiodysplasia after Transcatheter Aortic Valve Implantation in a Patient with High Frailty; What about Antiplatelet and Anticoagulant Therapy

&lt;p style="margin: 0cm 0cm 0pt; text-align: justify; line-height: 200%; text-indent: 35.4pt;"&gt;&lt;span style="font-family: 'Times New Roman','serif';"&gt;&lt;span style="font-size: medium;"&gt;Severe aortic stenosis is associated with significant morbidity and mortality if untreated. The transcatheter aortic valve implantation(TAVI) is now feasable and effective gold standart treatment option in patients with severe aortic valve stenosis(AS) and associated with similar rate of major adverse events compared to the surgery. The relation between &lt;/span&gt;&lt;span style="font-size: medium;"&gt;aortic stenosis and gastrointestinal angiodysplasia was known as Heyde’s Syndrome since 1958. High fluid shear stress through the narrowed valve is thought to be the underlying mechanism leads to the mechanical disruption of the large von Willebrand factor multimers. Aortic valve replacement either surgical or with TAVI seems to reduce gastrointestinal bleeding in approximately 80% in patients with Heyde syndrome in whom gastrointestinal bleeding is associated with intestinal angiodysplasia due to acquired von Willebrand’s disease (type 2A) and aortic valve stenosis. The patients especially with atrial fibrillation who need anticoagulant therapy may have bleeding risk despite aortic valve replacement. We report a case of patient presenting with a massive intestinal bleeding originating from intestinal angiodysplasia after percutaneous aortic valve replacement. &lt;/span&gt;&lt;/span&gt;&lt;/p&gt;

Presence, Location, or Bleeding of Gastrointestinal Angiodysplasia Does Not Vary by Race or Ethnicity in a Veteran Population

Presence, Location, or Bleeding of Gastrointestinal Angiodysplasia Does Not Vary by Race or Ethnicity in a Veteran Population

Colonoscopy in the diagnosis of acute lower gastrointestinal bleeding

Lower gastrointestinal bleeding is defined as a bleeding originated from a source distal to the Treitz ligament and the colonoscopy is well established as the diagnostic procedure of choice. ObjectiveTo evaluate the results of colonoscopies performed to diagnose the cause of acute lower gastrointestinal bleeding in a general hospital at Mato Grosso do Sul. Material and methodsColonoscopy procedures performed in the Endoscopy service of the Hospital Regional de Mato Grosso do Sul in those patients admitted due to an acute lower gastrointestinal bleeding from January 2014 to December 2015 were analyzed retrospectively. The studied variables were age, gender, diagnosis and localization of the lesion. ResultsThe mean age was 66 years, and there was a little predominance of the male gender. Diverticular disease was the main cause of lower gastrointestinal bleeding in this study, followed by cancer, inflammatory gastrointestinal disease, polyps, and angiodysplasia. ConclusionThe colonoscopy showed to be an effective diagnostic method in the case of acute lower gastrointestinal bleeding and a good therapeutic tool in the case of diverticular disease and angiodysplasia.

High variation in treatment strategies for gastrointestinal angiodysplasias.

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. We administered a 19-item web-based survey to gastroenterologists in the Netherlands between February and April of 2015. 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. 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.

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

IntroductionGastrointestinal 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 designRandomised controlled, superiority, open-label multicentre trial.Participants62 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.InterventionPatients 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 measuresThe 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 disseminationThe 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 numberNCT02384122; Pre-results.

Su1062 Transfusion Rates Are Higher in Patients With Small Bowel Gastrointestinal Angiodysplasias Who Present With Melena and Vascular Disease

Su1062 Transfusion Rates Are Higher in Patients With Small Bowel Gastrointestinal Angiodysplasias Who Present With Melena and Vascular Disease

Su1061 Peripheral Vascular Disease Is Significantly Associated With Non-Isolated Gastrointestinal Angiodysplasia

Su1061 Peripheral Vascular Disease Is Significantly Associated With Non-Isolated Gastrointestinal Angiodysplasia