Presence Of Angiodysplasia Research Articles

Heydeho syndróm

Gastrointestinal bleeding is a severe and potentially life-threatening condition associated with significant morbidity and mortality. In clinical practice, its differential dia­gnosis can sometimes be complicated, especially when bleeding is recurrent. One of the lesser-known reasons for recurrent gastrointestinal bleeding is the so called Heyde’s syndrome. It is a combination of bleeding from gastrointestinal angiodysplasia, aortic stenosis and acquired type 2A von Willebrand syndrome. In the submitted article, authors present a summary of the current knowledge on etiology and pathogenesis of the disease. The degenerative aortic valve disease, typically present in elderly patients, causes changes in the blood flow through stenotic opening. This results in elongation of otherwise globular von Willebrand’s factor (vWF) molecules, resulting in its reduced efficacy in hemostasis. According to new scientific discoveries, vWF also plays a role in angiogenesis and therefore in gastrointestinal angiodysplasia formation. This combination of factors results in recurrent bleeding typical for Heyde’s syndrome. Surgical aortic valve replacement is the gold standard treatment. A vicious circle can often be created between the gastroenterologist, who refers the patient for cardiac surgery procedures, and the cardiothoracic surgeon, who is waiting for a time when the patient will stop bleeding. A close communication and cooperation between the gastroenterologist, hematologist and cardiothoracic surgeon is required to properly manage the patient. The presence of angiodysplasia in an elderly patient, associated with recurrent gastrointestinal bleeding, should lead clinicians to look for aortic stenosis and consider Heyde’s syndrome as a potential dia­gnosis. Its interesting etiopathogenesis and rare occurrence led the authors to further investigate this topic. They also present a short summary of their own group of patients. Key words: Heyde’s syndrome – aortic stenosis – angiodysplasia – von Willebrand’s syndrome

Prevalence of Angiodysplasia Detected in Upper Gastrointestinal Endoscopic Examinations.

BackgroundThis study was performed to examine the prevalence of asymptomatic angiodysplasia detected in upper gastrointestinal endoscopic examinations and of hereditary hemorrhagic telangiectasia (HHT) suspected cases.MethodologyThe study participants were 5,034 individuals (3,206 males, 1,828 females; mean age 53.5 ± 9.8 years) who underwent an upper gastrointestinal endoscopic examination as part of a medical check-up. The presence of angiodysplasia was examined endoscopically from the pharynx to duodenal second portion. HHT suspected cases were diagnosed based on the presence of both upper gastrointestinal angiodysplasia and recurrent nasal bleeding episodes occurring in the subject as well as a first-degree relative.ResultsAngiodysplasia was endoscopically detected in 494 (9.8%) of the 5,061 subjects. Those with angiodysplasia lesions in the pharynx, larynx, esophagus, stomach, and duodenum numbered 44, 4, 155, 322, and 12, respectively. None had symptoms of upper gastrointestinal bleeding or severe anemia. Subjects with angiodysplasia showed significant male predominance and were significantly older than those without. A total of 11 (0.2%) were diagnosed as HHT suspected cases by the presence of upper gastrointestinal angiodysplasia and recurrent epistaxis episodes from childhood in the subject as well as a first-degree relative.ConclusionsAsymptomatic angiodysplasia was detected in 9.8% of the subjects who underwent screening upper gastrointestinal endoscopic examinations.

Arteriovenous malformations within jejunal diverticulosis: case report and literature review

BackgroundJejunal diverticula are the rarest of all small bowel diverticula. Most patients with jejunal diverticula are asymptomatic. Major complications include diverticulitis, gastrointestinal hemorrhage, intestinal obstruction and perforation. The hemorrhage has been attributed to diverticulitis with ulceration, diverticulosis associated with trauma and irritation disorder. However, only six cases reported the arteriovenous malformations within jejunal diverticulosis to be the cause of hemorrhage.Case presentationWe present a case of arteriovenous malformations within jejunal diverticulosis in a 68-year-old male presented with lower gastrointestinal bleeding. After admission and stabilization, upper and lower endoscopies were performed without demonstrating the bleeding site. They only revealed clotted and red blood throughout the colon. Technetium-labeled red blood cell bleeding scan, endoscopic capsule, and selective angiography were performed to localize the site of bleeding without significant findings. As the clinical status of the patient deteriorated, exploratory laparotomy was performed urgently. Extensive jejunal saccular pouches were found 10 cm distal to duodenojejunal junction extending 1.6 m distally. Segmental resection was performed with side to side primary anastomosis. Microscopic examination of the specimen revealed many diverticula. He was followed up 2 years after that without complications.ConclusionWe report yet the seventh case jejunal diverticulosis with the presence of angiodysplasia, in hope of expanding the knowledge of a rare occurrence and increasing the demand for further research about the etiology, clinical impact and treatment of such anomalies coexistence. This case also highlights the importance of considering the diagnosis of AVMs within jejunal diverticulosis in the presence of uncontrollable blood loss in the pre- or intra- operatively diagnosed jejunal diverticulosis and the urgent need for surgical intervention. In addition, the diagnostic tests should be performed close to the bleeding episode.

Mo1662 - Presence of Angiodysplasia is Associated with a Decreased Quality of Life: A Cross-Sectional Cohort

Mo1662 - Presence of Angiodysplasia is Associated with a Decreased Quality of Life: A Cross-Sectional Cohort

Small Bowel Endoscopy in End-Stage Heart Failure Patients With Obscure Gastrointestinal Bleeding After HeartMate II Implantation

Introduction: The HeartMate II (HMII) axial continuous flow left ventricular assist device (LVAD) has been approved for end-stage heart failure (ESHF) patients as bridge-to-transplant (BTT) or destination therapy (DT) in recent years. However, a higher rate of post-implantation bleeding, including gastrointestinal bleeding, has been observed. The causes remain undetermined. Although upper and lower GI lesions in HMII patients were sparsely reported in small series recently, the occurrence of obscure GI bleeding (OGIB) and risk of a small bowel lesion have not been assessed. The best strategies for managing OGIB in HMII patients are still lacking. Methods: In a large U.S. academic heart and vascular institute, we used video small bowel capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE) besides radiology to investigate OGIB in HMII patients. A total of 296 HMII LVADs were implanted in 280 patients from 2004 to 2013. OGIB was defined according to the AGA position statement. Patient characteristics, details of HMII implantation, perioperative data, and details of bleeding complications were prospectively collected in the institutional databases. Twenty-five patients who presented with OGIB after HMII implantation and underwent enteroscopy (CE and/or BAE) were recruited for the study. Clinical information including duration of HMII support prior to OGIB episode, medication use, lab data, and enteroscopic findings were analyzed. Results: Upon presentation of OGIB (25 patients, 8.9% of this cohort), the median duration of HMII support was 6.1 months. There were 21 men and 4 women with a mean (±sd) age of 60.1 (±13.2) years. The causes of ESHF were mostly related to ischemic (n=13) and dilated (n=10) cardiomyopathy. The most common co-morbidity was type 2 diabetes (DM) (n=13). The mean (±sd) body mass index (BMI) was 28.2 (±5.4) kg/m2. Eleven patients received HMII as DT, while 14 did as BTT. All patients received post-operative therapy including aspirin, dipyridamole, and warfarin with a goal INR of 1.7 to 2.5 and prophylactic use of a proton pump inhibitor. The enteroscopic investigation revealed angiodysplasias in jejunum and/or ileum in 9 patients, which were treated successfully by BAE with argon plasma coagulation, and medication-related erosions and/or ulceration in 8 patients. Four patients were diagnosed with anemia of undetermined source. Four patients had supratherapeutic INR related to warfarin use. The presence of angiodysplasias was unrelated to age, sex, type of ESHF, BMI, DM, BUN, Cr, pump thrombosis, DT, or BTT. There was no procedure-related complication. Conclusion: Our study reveals that angiodysplasia and medication-related small bowel bleed is a significant but manageable complication in HMII patients. CE and BAE are useful and safe in HMII patients.

PTH-093 Small bowel angiodysplasia and lymphangiectasia: a positive association. A novel clinical marker or a shared pathophysiology?: Abstract PTH-093

Introduction The cause of sporadic angiodysplasia is unknown and the natural history poorly understood. Many lesions are thought to arise from a degenerative process associated with ageing. Most cases of hereditary haemorrhagic telangiectasia appear to result from mutations in two genes, ENG and ACVRL1. These mutations alter the function of 2 key endothelial receptor proteins, endoglin and ALK-1 (part of the transforming growth factor β super-family), which ordinarily play a key role in maintaining vascular integrity. It has been observed that endoglin is over expressed in smooth muscle cells in atherosclerotic plaques, suggesting a role for this protein in plaque progression, atherosclerosis and associated cardiovascular disease. Methods To determine if there is an association between angiodysplasia, lymphangiectasias and conditions traditionally associated with atherosclerosis. Consecutive patients referred to a single tertiary referral centre for a capsule endoscopy (CE) over a 3-year period were identified from a dedicated CE database. Indications, findings, demographic information, and the presence of diabetes, ischaemic heart disease, hypertension, hyperlipidaemia were recorded, along with body mass index. Only patients with a complete CE were included for analysis. Logistic regression analysis (LRA) was employed to examine associations between angiodysplasia, lymphangiectasia, patient demographics, obesity and the diseases described. Results In all 180 patients were identified, 46 (25%) had angiodysplasia and 47 (26%) lymphangiectasia. Lymphangiectasias were seen in 24 (52%) of 46 with angiodysplasia, in 16 (19%) of 84 with obscure GI bleeding without angiodysplasia and in 7 (14%) of 50 without GI bleeding. LRA confirmed a strong positive association between angiodysplasia and lymphangiectasia, OR 4.42, p Conclusion This study reveals a strong association between small bowel angiodysplasia, lymphangiectasia and ageing, but not between angiodysplasia and conditions associated with increased risk of atherosclerosis. Lymphangiectasias may represent a useful clinical marker for the presence of angiodysplasia.

The clinical impact of capsule endoscopy: to believe or not to believe

The study by Estevez et al., 'Diagnostic yield and clinical outcomes after capsule endoscopy in 100 consecutive patients with obscure gastrointestinal bleeding' published in this issue of the journal on a large patient cohort refined a subgroup of patients who could best benefit from capsule endoscopy (CE), e.g. patients with overt bleeding and a requirement for transfusion, and a subgroup of patients in whom CE is clearly not indicated, e.g. patients with overt bleeding and no transfusion requirement. Although the results are promising, some further comments on limitations appear appropriate. The entire small intestine was accessible only in a subgroup of patients and there is a necessity for further technical improvement. A large proportion of the significant lesions detected by CE may also have been detected by conventional diagnostic work-up. The clinical relevance of potentially bleeding lesions that were detected by CE is unresolved. For example, the presence of angiodysplasias per se does not imply a significant bleeding source because their natural history, morphological criteria to characterize the bleeding risk, and occurrence in asymptomatic populations are still unknown. Most of the treatment modifications after CE did not reflect a specific impact of CE on changes in treatment modalities (iron supplementation, eradication of Helicobacter pylori, gluten-free diet, suspension of non-steroidal anti-inflammatory drugs). The authors merit credits for their contribution to our understanding on how to put CE into a rational diagnostic algorithm. It seems to be clear that this decision will not be made by the believer or non-believer in CE alone, but also by health insurance companies.