Gastrointestinal Vascular Lesions Research Articles

Hereditary hemorrhagic telangiectasia: A rare genetic disorder causing recurrent anaemia

Gastrointestinal (GI) vascular lesions are one of the most common causes of occult bleeding. The term angiodysplasia and telangiectasias

Safety and efficacy of dual emission endoscopic laser treatment in patients with upper or lower gastrointestinal vascular lesions causing chronic anemia: results from the first multicenter cohort study

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.

Cross-Sectional Imaging Evaluation of Vascular Lesions in the Gastrointestinal Tract and Mesentery.

Gastrointestinal (GI) tract and mesenteric vascular lesions can have various clinical presentations, of which GI bleeding is the most common. This collection of pathology is highly variable in etiology ranging from occlusive disease to vascular malformations to trauma to neoplasms which makes for a challenging workup and diagnosis. The advent of multiple imaging modalities and endoscopic techniques makes the diagnosis of these lesions more achievable, and familiarity with their various imaging findings can have a significant impact on patient management. In this article, we review the gamut of GI tract and mesenteric vascular lesions and their associated imaging findings.

Gastrointestinal mucosal abnormalities using videocapsule endoscopy in systemic sclerosis

To date, there are no large studies on videocapsule endoscopy in systemic sclerosis (SSc). Consequently, the prevalence and features of gastrointestinal mucosal abnormalities in SSc have not been determined. To determine both prevalence and characteristics of gastrointestinal mucosal abnormalities in unselected patients with SSc, using videocapsule endoscopy. To predict which SSc patients are at risk of developing potentially bleeding gastrointestinal vascular mucosal abnormalities. Videocapsule endoscopy was performed on 50 patients with SSc. Prevalence of gastrointestinal mucosal abnormalities was 52%. Potentially bleeding vascular mucosal lesions were predominant, including: watermelon stomach (34.6%), gastric and/or small intestinal telangiectasia (26.9%) and gastric and/or small intestinal angiodysplasia (38.5%). SSc patients with gastrointestinal vascular mucosal lesions more often exhibited: limited cutaneous SSc (P = 0.06), digital ulcers (P = 0.05), higher score of nailfold videocapillaroscopy (P = 0.0009), anaemia (P = 0.02), lower levels of ferritin (P < 0.0001) and anti-centromere antibody. Our study identifies a high frequency of gastrointestinal mucosal abnormalities in SSc, with a marked predominance of vascular mucosal damage. Furthermore, our study shows a strong correlation between gastrointestinal vascular mucosal lesions and presence of severe extra-digestive vasculopathy (digital ulcers and higher nailfold videocapillaroscopy scores). This latter supports the theory that SSc-related diffuse vasculopathy is responsible for both cutaneous and digestive vascular lesions. Therefore, we suggest that nailfold videocapillaroscopy may be a helpful test for managing SSc patients. In fact, nailfold videocapillaroscopy score should be calculated routinely, as it may result in identification of SSc patients at higher risk of developing potentially bleeding gastrointestinal vascular mucosal lesions.

917 EUS-Guided Angiotherapy

Interventional endoscopic ultrasound has an increasing role in therapeutic endoscopy, as it has expanded to include drainage of fluid collections, biliary drainage, delivery of local intra-lesional therapies and vascular therapy. EUS-guided angiotherapy is a growing concept which allows for precise delivery of intravascular therapies to afferent vessels and real-time confirmation of thrombosis and hemostasis. Gastrointestinal vascular lesions including varices and bleeding tumors are relatively unexplored targets for EUS-guided angiotherapy.

P945 CLINICAL OUTCOME OF GASTRIC VARICES IN PATIENTS WITH PORTAL HYPERTENSION WITH OR WITHOUT CIRRHOSIS WITHOUT A PREVIOUS HISTORY OF BLEEDING

Background and Aims: Gastrointestinal vascular anomalies can cause chronic anaemia, a clinical challenge in terms of endoscopic therapy, transfusion and hospital admissions. Evidence suggests Thalidomide as a therapeutic option for such patients. We aim to determine the efficacy and side-effect profile of Thalidomide in patients with gastrointestinal vascular anomalies. Methods: A retrospective case-note review 12-months preand post-Thalidomide therapy. Results: Patients on Thalidomide due to failed standard therapy between the years 2004 and 2013 were included. 17 patients comprising 7 women and 10 men with a median age of 68.5 years (range 48–87 years) were identified. Endoscopic diagnoses were; portal hypertensive gastropathy (PHG) (n =5), Gastric Antral Vascular Ectasia (GAVE) (n = 9), PHG/GAVE (n =4), upper gastrointestinal vascular malformation (GIVM) (n =5) and lower GIVM (n=2). 11 patients continued treatment beyond 3 months and 5 out of 11 took Thalidomide for atleast 12 months. There was reduction in transfusion frequency by 65% (p < 0.05), number of red cell concentrate units by 71% (p < 0.05), number of OGDs by 81% (p < 0.05), number of argon treatments by 75% (p < 0.05), and number of hospital admissions by 71% (p < 0.05) for the 11 patients. No statistically significant improvement was seen in patients who received less than 3 months of therapy. 27% developed side effects (3/11). The side effects reported were peripheral neuropathy, fatigue and pancytopenia, which lead to cessation of therapy. Conclusions: Thalidomide has a role in the management of gastrointestinal vascular lesions resistant to conventional treatment, drug side effects are common and require monitoring. P945 CLINICAL OUTCOME OF GASTRIC VARICES IN PATIENTS WITH PORTAL HYPERTENSION WITH OR WITHOUT CIRRHOSIS WITHOUT A PREVIOUS HISTORY OF BLEEDING E. Ahn, P. Kortan, G. May, N. Marcon, G. Kandel, Y.I. Kim, S. Grover, M. Cirocco, F. Wong. Division of Gastroenterology, Toronto General Hospital & University of Toronto, Division of Gastroenterology, St. Michael’s Hospital, Toronto, ON, Canada E-mail: eric.ahn@mail.utoronto.ca

Vascular targeted photodynamic therapy for bleeding gastrointestinal mucosal vascular lesions: A preliminary study

Vascular-targeted photodynamic therapy (V-PDT) has shown good selectivity and efficacy in the treatment of certain types of vascular disease, including port wine stains, age-related macular degeneration, and esophageal varices. This study was conducted to test the efficacy and safety of V-PDT in the treatment of gastrointestinal (GI) bleeding caused by the abnormal dilatation of capillaries. Patients with bleeding GI mucosal vascular lesions treated with V-PDT were included in this retrospective study. The efficiency of V-PDT was analyzed by comparing the documented endoscopy results, hemoglobin levels, and transfusion requirements before and at 6 months after the last V-PDT. Side effects during and after V-PDT and follow-up results were also analyzed. Seven patients with bleeding GI mucosal vascular lesions were treated with V-PDT. After 1-4 V-PDT sessions, all patients no longer needed transfusions to maintain a stable hemoglobin level during the follow-up period of 6 months. The mean hemoglobin level of the seven patients improved from 6.21±1.48 g/dl to 11.66±1.21 g/dl (p<0.001), and the GI bleeding and melena of all the patients disappeared. No perforations, strictures, scars, or episodes of photosensitization occurred in the seven patients, and there were no recurrences of GI bleeding during the 1-21 months of further follow-up. This preliminary study indicated that V-PDT is a highly selective, safe, well-tolerated, and effective treatment modality for bleeding GI mucosal vascular lesions. However, prospective studies with larger sample sizes are needed to confirm this finding.

Effective Pharmacological Management of Gastrointestinal Vascular Lesions With Long Acting Octreotide: A Case Series

Effective Pharmacological Management of Gastrointestinal Vascular Lesions With Long Acting Octreotide: A Case Series

Utilidad de la gammagrafía con hematíes marcados en el síndrome de Blue Rubber Bleb Nevus

Blue Rubber Bleb Nevus syndrome is a rare disorder characterized by distinctive cutaneous and gastrointestinal venous malformations that usually cause episodes of occult gastrointestinal haemorrhage and iron deficiency anaemia. We describe an 8-year-old girl who had multiple cutaneous venous malformations since birth. She also suffered from several episodes of severe chronic iron deficiency anaemia and required blood transfusions. To evaluate the presence of gastrointestinal bleeding secondary to intestinal angiomatosis, we decided to perform 99mTc-labelled red blood cell scintigraphy, which confirmed cutaneous venous malformations and also showed gastrointestinal vascular lesions that suggested the diagnosis of Blue Rubber Bleb Nevus Syndrome.

Argon plasma coagulation is a safe and effective treatment for gastrointestinal vascular lesions

Argon plasma coagulation is a safe and effective treatment for gastrointestinal vascular lesions

Argon Plasma Coagulation in the Management of Symptomatic Gastrointestinal Vascular Lesions: Experience in 100 Consecutive Patients with Long-Term Follow-Up

The long-term efficacy of argon plasma coagulation (APC) in the management of gastrointestinal vascular lesions has not been evaluated in a large and well-defined series. The impact of APC on transfusion requirements and hemoglobin, and technical parameters including complications and number of treatment sessions, is assessed in this series. Patients who underwent APC for bleeding gastrointestinal vascular lesions were identified via interrogation of an established endoscopic database, excluding patients with radiation proctitis, tumors, residual polypectomy tissue and acute ulcer bleeding. Follow-up data were collected via interview with patients and referring doctors, review of medical records, and follow-up blood tests. One hundred patients were enrolled, males = 46, median age = 74 yr (range: 19-99 yr). Median follow-up time was 16 months (range: 4-47 months). Lesions treated were arteriovenous malformations (n = 74) and gastric antral vascular ectasia (n = 26). Fifty-three patients required transfusion. In this group, median hemoglobin improved from 66 g/L (range: 35-114) to 111 g/L (range: 55-155, p < 0.001). Median transfusion velocity fell from 2 units/month (range: 0.1-6) to 0 units/month (range: 0-4, p < 0.001). Transfusion requirement was abolished in 77%. In non-transfusion-requiring patients, median hemoglobin improved from 105 g/L (range: 58-143) to 123 g/L (range: 79-158, p < 0.001). No complications occurred. APC is effective and safe in the management of gastrointestinal vascular lesions.

Maffucci's syndrome with extensive gastrointestinal involvement

A 10-year-old girl with cutaneous, oral and gastrointestinal vascular lesions was referred for consideration of laser treatment of her skin lesions. She was noted to have multiple venous malformations predominantly affecting the hands and feet, some of which had been present from birth. Her right hand was deformed by multiple venous malformations, and X-rays of this hand revealed enchondromata within metacarpal and phalangeal bones. She was known to have extensive involvement of her gastrointestinal tract by venous malformations, resulting in refractory iron-deficiency anaemia. In view of the multiple cutaneous and gastrointestinal vascular lesions, a diagnosis of blue rubber bleb naevus syndrome had been made many years earlier. However, after recognition of the characteristic enchondromata, this diagnosis has been revised to Maffucci's syndrome. In addition to her ongoing dermatological and paediatric follow up, she has now been referred to the orthopaedic surgeons for surveillance of her skeletal lesions.

A Novel Diagnostic Method for Evaluation of Vascular Lesions in the Digestive Tract Using Infrared Fluorescence Endoscopy

We have developed an infrared fluorescence endoscope to evaluate gastrointestinal vascular lesions. Infrared endoscopy (IRE) after intravenous administration of indocyanine green (ICG) is used at present to examine vascular lesions such as esophageal varices. However, no previous study has compared the sensitivity of infrared fluorescence endoscopy (IRFE) with that of IRE. In this study, we compared the usefulness of IRFE and IRE. For IRFE we used an infrared endoscope equipped with excitation and barrier filters and an intensified charge-coupled device camera. In preliminary experiments, the observable tissue depth was assessed by wrapping increasing numbers of layers of commercially available pork around a syringe containing a uniform concentration of ICG or by changing the concentration of ICG in a syringe covered by a piece of pork of uniform thickness. In the clinical part of the study, ICG was administered intravenously at different concentrations to patients with esophageal varices and the resulting infrared fluorescent images were evaluated. The preliminary experiments revealed that the depth of tissue that could be visualized was significantly greater in IRFE than it was in IRE (11.2 mm in IRFE vs. approximately 3.2 mm in IRE). Clear infrared fluorescence was obtained by IRFE at lower concentrations of ICG than the concentrations required to obtain clear images using IRE. In the clinical part of the study, clear infrared fluorescence was observed in a region where esophageal varices had been detected by conventional endoscopy when ICG was administered in doses of 0.005 mg/kg to 0.01 mg/kg, which was lower than the doses used in IRE. Compared with conventional IRE, IRFE facilitated the observation of deeper layers, and esophageal varices were observed by IRFE following the intravenous administration of a markedly reduced dose of ICG. IRFE, in combining the characteristics of reflected infrared light and fluorescence, may be a useful novel procedure in the diagnosis of vascular lesions in the gastrointestinal tract.

Angiodisplasia múltiple de intestino delgado. Un reto diagnóstico y terapéutico

Small bowel bleeding is infrequent and presents a challenge to the clinician. Approximately 30-40% of gastrointestinal bleeding localized in the small bowel is due to angiodysplasia, a vascular malformation. We present the case of a patient with multiple angiodysplasia of the small bowel who required push enteroscopy and capsule endoscopy to establish the diagnosis. Treatment with subcutaneous octreotide was successful. In conclusion, in doubtful cases or in patients with persistent hemorrhage, capsule endoscopy can improve the diagnostic yield of enteroscopy in bleeding gastrointestinal vascular lesions such as angiodysplasia. Endoscopic treatment (laser coagulation) and drug therapy (somatostatin or analogs) are valid alternatives in inoperable or non-resectable cases.

Lower gastrointestinal vascular lesions: current concepts in diagnosis and treatment

Lower gastrointestinal vascular lesions: current concepts in diagnosis and treatment

Laparoscopic localization and management of lower gastrointestinal vascular lesions

Laparoscopic localization and management of lower gastrointestinal vascular lesions

7087 Argon plasma coagulation in endoscopic therapy.

The goal of the study was to review the experience of a single institution in using Argon Plasma Coagulation (APC) to obliterate gastrointestinal vascular and mass lesions. Background: APC is a non-contact electrocoagulation in which current is applied to tissues by means of ionized argon gas.The maximum coagulation depth is 3-4 mm. The absence of adhesion between the coagulation electrode and the tissue as well as symmetric spread of the coagulation through surrounding mucosa provide a theoretical advantage over standard electrocoagulation. Methods: The medical records, endoscopic findings, and complications for all patients treated with APC between April 1997 and October 1999 were reviewed. Results: During this period, APC was performed on 36 patients in 61 sessions. Argon flow was set at 0.4 L/min and electrical power at 55 Watts (mean; range 40-60 Watts).The diameter of the probe was 2.3 mm (manufactured by ERBE Inc, Marietta, GA).Treated lesions were Gasric antral vascular ectasia (GAVE; 14 sessions; 8 patients),AVM (13 sessions; 9 patients), radiation proctitis (16 sessions; 8 patients), radiation enteritis (1 session), esophageal tumor (2 sessions; 1 patient), base of a large polyp post polypectomy (7 sessions; 6 patients), flat sessile polyps (2 sessions; 2 patients), 3 cm villous adenoma (1 session), and malignant colon cancer in a non-surgical candidate (1 session). Hemostasis was observed and lesions obliterated after all sessions, although mass lesions were not rebiopsied. There were no immediate complications. Three months after treatment, one patient with AVM and one with radiation proctitis had ulcers at the site of APC application.Conclusion:AVM s and the lesions in GAVE and radiation proctitis were effectively obliterated by APC,but often required more than one treatment session. Preliminary results of APC treatment in mass lesions are encouraging, but more data are required.APC is safe and easy to perform.

Bleeding in children caused by gastrointestinal vascular lesions.

Intestinal vascular malformations in infants and children are rare but must be considered in the differential diagnosis of gastrointestinal bleeding. Many vascular malformation syndromes have associated intestinal lesions. Localization of vascular lesions is essential for successful management. A variety of treatment options including laser photoablation, surgical resection, and other nonoperative therapies have been utilized to treat these disorders.

Vascular Malformations of the Gastrointestinal Tract

The advent of fiberoptic endoscopy, which became widespread in the evaluation of gastrointestinal bleeding throughout the late 1970s and 1980s, has dramatically changed both our understanding of the extent to which vascular malformations account for gastrointestinal blood loss and our ability to treat these lesions at the time of diagnosis. Colonic vascular malformations appear to be the single most common cause of acute or recurrent gastrointestinal bleeding episodes in patients over 60 years of age, being responsible for the bleeding in as many as 35% of such patients. Although less common as a cause of upper gastrointestinal bleeding, these lesions still account for 2% to 5% of bleeding lesions in older patients. Diagnosis is accomplished by endoscopy, and the vascular malformations can then be coagulated via the endoscope using one of a number of thermal systems. The argon laser, the heater probe, and the BICAP system are all effective and safe throughout the gastrointestinal tract, especially in the cecum and right colon, where the majority of sporadic vascular malformations occur. Monopolar cautery and the Nd:YAG laser are equally efficacious, but their greater and less predictable depth of coagulation make them much less safe in the cecum and right colon. There are no apparent advantages in terms of efficacy and safety between laser treatment and the other thermal modalities. The laser has the advantage of being quicker, which is especially important when treating large or multiple lesions. The other modalities have the advantages of portability and low relative cost. Endoscopic therapy with lasers or other thermal devices is nonspecific. The effects are achieved by thermally coagulating the mucosal vascular lesions, allowing the coagulated tissue to slough, and leaving a mucosal ulceration that subsequently heals with re-epithelialization. Endoscopic coagulation has thus been reported effective in the treatment of gastrointestinal mucosal vascular lesions regardless of their etiology or characteristics. It has been effective for sporadic vascular malformations, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), radiation proctocolitis, the blue rubber-bleb nevus syndrome, and diffuse gastric antral vascular ectasia (the watermelon stomach). As we move through the 1990s and beyond, these endoscopic modalities offer an effective, relatively safe, and clearly less invasive treatment option for the many patients who experience acute, recurrent, or chronic gastrointestinal bleeding from any of these lesions.