Gastrointestinal Angiodysplasia

Aka: Gastrointestinal Angiodysplasia, Gastrointestinal Arteriovenous Malformation, Gastrointestinal Angioectasia, Vascular Ectasia of the Gastrointestinal Tract, Angiodysplasia of the Colon, Intestinal Angiodysplasia, Gastrointestinal Angiodysplasia Hemorrhage, Gastrointestinal Telangiectasia, Dieulafoy Vascular Malformation, Gastrointestinal Vascular Malformation

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II. Definitions

  1. Gastrointestinal Angiodysplasia or Arteriovenous Malformation
    1. Abnormal vascular structures (arteries, veins, capillaries) in the Gastrointestinal Tract
  2. Dieulafoy Vascular Malformation
    1. Tortuous arteriole in the submucosa of the Stomach which may result in upper gastrointestinal Hemorrhage

III. Epidemiology

  1. Relatively rare cause of Gastrointestinal Bleeding
  2. Most common in age over 60 years
    1. Chronic Kidney Disease may predispose to earlier onset

IV. Pathophysiology

  1. Abnormal vascular structures form in response to chronic low grade intermittent submucosal vein obstruction
  2. Increased Vascular Endothelial Growth Factor dependent proliferation also contrubutes

V. Types

  1. Upper Gastrointestinal Bleeding
    1. Responsible for 4 to 7% of non-variceal Upper Gastrointestinal Bleeding
  2. Lower Gastrointestinal Bleeding (most common)
    1. Cecum and ascending colon (>54% of lesions)

VI. Causes

  1. Aortic Stenosis (Heyde's Syndrome)
  2. Von Willebrand Disease
  3. Chronic Renal Failure

VII. Symptoms

  1. Recurrent painless Gastrointestinal Bleeding
  2. May present as acute Gastrointestinal Bleeding or chronic Gastrointestinal Bleeding
  3. May present as Upper Gastrointestinal Bleeding or lower Gastrintestinal bleeding

VIII. Diagnosis: Colonoscopy

  1. Abnormal ectatic, dilated or tortuous blood vessels lined by endothelium (but no Smooth Muscle)
  2. Vessels are small (typically <10 mm)
  3. Abnormal vessels lie within the intestinal mucosa and submucosa
  4. More than one lesion is seen in 40-60% of patients

IX. Management

  1. See Gastrointestinal Bleeding
  2. See Lower Gastrointestinal Bleeding
  3. Treatment of nonbleading lesions is not typically recommended
  4. Persistent bleeding
    1. Endoscopic argon plasma coagulation (first-line)
      1. Associated with 7-15% recurrence rate
    2. Endoscopic direct contact thermal electrocautery and possible endoclip placement
  5. Longterm bleeding prevention
    1. Lanreotide (Somatuline)
      1. Improves Hemoglobin, and decreases hospitalizations, transfusions and endoscopies
      2. Frago (2018) Scand J Gastroenterol 53(12):1496-502 [PubMed]
      3. Chetcuti (2017) Scand J Gastroenterol 52(9): 962-8 [PubMed]
    2. Hormonal management (e.g. Ethinyl Estradiol and norethisterone)
      1. Does not appear to decrease bleeding episodes or transfusions
      2. Junquera (2001) Gastroenterology 121(5): 1073-9 [PubMed]

X. Course

  1. Self-resolves in 40-45% of cases

XI. References

  1. Hawks (2020) Am Fam Physician 101(4): 206-12 [PubMed]
  2. Sami (2014) Aliment Pharmacol Ther 39:15-34 [PubMed]

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