Idiopathic gastrointestinal bleeding and aortic stenosis

Inpatient Outcomes of Gastric Antral Vascular Ectasia in Those With Aortic Stenosis: A Retrospective Study of 85,000 Hospitalizations

GOALS

To investigate the outcomes of hospitalized patients with gastric antral vascular ectasia (GAVE) in the setting of aortic stenosis (AS).

BACKGROUND

Although AS is associated with gastrointestinal arteriovenous malformations, its association with GAVE, a rare cause of upper gastrointestinal bleeding, remains unknown.

STUDY

The National Inpatient Sample database from the years 2016 to 2019 was searched for patients admitted with a diagnosis of GAVE, with and without a history of AS. Univariate and multivariate logistic regression analysis was performed to determine the risk of mortality and in-hospital complications in the GAVE/AS group compared with the GAVE-only group.

RESULTS

Patients with AS had a 2-fold increase in the risk of GAVE [odds ratio (OR): 2.08, P < 0.001], with no statistically significant difference in inpatient mortality between the study groups (OR: 1.36, P = 0.268). Patients with GAVE-AS had a higher risk of hypovolemic shock (OR: 2.00, P = 0.001) and acute coronary syndromes (OR: 2.25, P < 0.001) with no difference in risk of cardiogenic shock ( P = 0.695), acute kidney injury ( P = 0.550), blood transfusion ( P = 0.270), sepsis ( P = 0.598), respiratory failure ( P = 0.200), or in-hospital cardiac arrest ( P = 0.638). The cost of care in patients with GAVE-AS was increased by a mean of $4729 ( P = 0.022), with no increase in length of stay ( P = 0.320) when compared with patients with GAVE-only.

CONCLUSIONS

Patients with AS have a 2-fold increase in the risk of development of GAVE. Patients with AS admitted for GAVE-related bleeding are at higher rates of hypovolemic shock, acute coronary syndrome, and higher resource utilization when compared with admitted patients with GAVE without AS.

Aortic stenosis and Heyde’s syndrome: A comprehensive review

Heyde’s syndrome is an under reported systemic disease of gastrointestinal and cardiac manifestation in older adults. It is characterized by a triad of aortic stenosis, angiodysplasia with bleeding and acquired von Willebrand syndrome. It is characterized by proteolysis of high molecular weight multimers of von Willebrand Factor and loss of platelet mediated homeostasis. Heyde’s syndrome is a treatable condition in most cases, especially in the current era of evolution in interventional cardiology and gastroenterology. There are currently no established guidelines in the management of this condition due to paucity of high quality studies, which warrant future trials. High index of suspicion and increasing the awareness of the syndrome among the general practitioners and sub-specialists will improve the diagnostic potential of Heyde’s syndrome. Future studies may change the management aspect of Heyde's syndrome and pave a path for drawing specific guidelines and algorithms. The aim of our review article is to summarize the basic pathophysiology, diagnostics and management of Heyde’s syndrome with a special attention to Transcatheter aortic valve replacement.

Medical Management of Heyde Syndrome

Heyde syndrome is a triad of bleeding colonic angiodysplasia, aortic stenosis, and acquired coagulopathy. It is most commonly seen in the elderly between 60-80 years of age. We present a case of Heyde syndrome presenting with severe anemia secondary to bleeding angiodysplasia or arteriovenous malformations (AVM) in the lower gastrointestinal (GI) tract.

Heyde Syndrome: Aortic Stenosis and Beyond

Heyde described aortic stenosis and gastrointestinal bleeding in the 1950s. Since then, a link with intestinal angiodysplasia and abnormalities of von Willebrand factor (VWF) has been noted. Loss of the highest-molecular-weight multimers of VWF and bleeding also have been described in subaortic stenosis in hypertrophic cardiomyopathy, in isolated mitral and aortic insufficiency, in endocarditis, in patients with prosthetic valve stenosis or regurgitation, and in patients with left ventricular assist devices (LVADs). Bleeding tends to recur with local treatment of angiodysplasias, whereas cardiac repair or removal of LVAD eliminates VWF dysfunction is curative of bleeding in the majority.

Alarming Increasing Trends in Hospitalizations and Mortality With Heyde's Syndrome: A Nationwide Inpatient Perspective (2007 to 2014)

We studied the trends and outcomes of patients with intestinal angiodysplasia-associated gastrointestinal bleeding (Heyde's syndrome [HS]) with aortic stenosis (AS) who underwent surgical aortic valve replacement (SAVR) versus transcatheter aortic valve implantation (TAVI). The National Inpatient Sample (2007 to 2014) and International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify HS hospitalizations, pertinent co-morbidities, and outcomes of SAVR versus TAVI from 2011 to 2014. The incidence of HS with AS was 3.1%. The trends in hospitalizations and all-cause inpatient mortality showed relative surges of 29.16% (from 48 to 62 per 100,000) and 22.7% (from 3.7 to 4.54 per 100,000) from 2007 to 2014. HS patients were older (mean age ∼80 vs 77 years) females (54.3% vs 52.2%) compared with AS without HS. The all-cause mortality (6.9% vs 4.1%), length of stay (LOS) (∼7.0 vs 5.8 days), and hospitalization charges ($58,519.31 vs $57,598.67) were higher in HS (p<0.001). No differences were reported in all-cause mortality and hospital charges in HS patients who underwent either SAVR or TAVI. However, the TAVI cohort showed lower rates of stroke (1.7% vs 10.0%) and blood transfusion (1.7% vs 11.7%), a shorter LOS (18.3 vs 23.9 days; p<0.001), and more routine discharges (21.7% vs 14.8%, p = 0.01). An older age, male gender, Asian race, congestive heart failure, coagulopathy, fluid and/or electrolytes disorders, chronic pulmonary disease, and renal failure raised the odds of mortality in HS patients. In conclusion, we observed increasing rates of hospitalizations with HS and higher inpatient mortality from 2007 to 2014. The HS patients who underwent TAVI had fewer complications without any difference in the all-cause mortality compared with SAVR.

New onset Heyde’s syndrome presenting after total aortic valve replacement

Heyde’s syndrome is a well-documented entity in the medical literature that can result in life-threatening gastrointestinal (GI) bleeding. It is a syndrome that is characterized by the combination of GI angioectasias and aortic stenosis. In most cases, the GI angioectasias resolve entirely with correction of the stenotic valve by way of total aortic valve replacement (TAVR). Rarely will cases recur after TAVR. Our case consists of an 84-year-old woman who presented with three new gastric angioectasias several months after undergoing TAVR. This is an exceedingly rare presentation of Heyde’s syndrome. To our knowledge this is the first such case reported in the medical literature.

A Case of Heyde Syndrome with Resolution of Gastrointestinal Bleeding Two Weeks After Aortic Valve Replacement

Patient: Female, 56

Final Diagnosis: Heyde syndrome

Symptoms: Anemia • gastrointesinal haemorrhage

Medication: —

Clinical Procedure: Colonoscopy • EGD • TAVR

Specialty: Gastroenterology and Hepatology

Gastrointestinal Bleeding in Native and Prosthetic Valve Disease

Gastrointestinal bleeding with severe aortic stenosis was originally described in the 1950s by Heyde, although for years, the association was debated. Further discovery of mechanisms and the ubiquity and severity of acquired von Willebrand syndrome in the left ventricular assist device therapy have removed any doubts. At this time, gastrointestinal bleeding from intestinal angiodysplasia in patients with turbulence-related proteolysis of the highest molecular weight multimers of von Willebrand factor is now known to occur in patients with aortic stenosis, and also subaortic obstruction and associated mitral insufficiency in hypertrophic cardiomyopathy, isolated mitral and aortic insufficiency, endocarditis, and in patients with prosthetic valve dysfunction, either from stenosis or insufficiency. The degree of loss of high molecular weight multimers correlates with lesion severity, and tests of von Willebrand factor function have been proposed as important biomarkers of the severity of valve dysfunction, including in-lab testing for paravalvular leak during transcatheter aortic valve replacement. Bleeding tends to recur after endoscopic or surgical therapy, but cardiac repair is curative in the great majority.

Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management

BACKGROUND

Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality.

AIM

To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors.

METHODS

A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract.

RESULTS

Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively.

CONCLUSIONS

Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.

Left ventricular assist devices and gastrointestinal bleeding: a narrative review of case reports and case series

BACKGROUND

The use of left ventricular assist devices (LVADs) has become a state-of-the-art therapy for advanced cardiac heart failure; however, multiple reports in the literature describe an increased risk for gastrointestinal (GI) bleeding in these patients. We characterized this association by reviewing recent studies on this topic.

HYPOTHESIS

GI bleeding occurs frequently in patients with LVADs, especially with devices with nonpulsatile flow patterns.

METHODS

We performed a comprehensive literature review to identify articles that reported GI bleeding in patients with LVADs. Databases used included PubMed, EMBASE, Scopus, Web of Knowledge, and Ovid. Baseline and outcome data were then ed from these reports.

RESULTS

We identified 10 case reports and 22 case series with 1543 patients. The mean age was 54.2 years. Most patients had nonpulsatile LVADs (1316, 85.3%). Three hundred and seventeen patients (20.5%) developed GI bleeding; this occurred more frequently in patients with nonpulsatile LVADs. Multiple procedures were performed without complications but often did not identify a definite bleeding site. Suspect lesions occurred throughout the GI tract but were more frequent in the upper GI tract. Many patients had arteriovenous malformations. All patients received medical therapy. None of the patients had their LVAD replaced. The use of anticoagulation did not appear to predispose these patients to more GI bleeding episodes.

CONCLUSIONS

Patients with LVADs have frequent GI bleeds, especially from arteriovenous malformations, which can occur throughout the GI tract. Most diagnostic and therapeutic interventions can be used safely in these patients. The pathogenesis of the GI bleeding in these patients may involve the use of anticoagulant medications, the formation of arteriovenous malformations, loss of von Willebrand factor activity, and mucosal ischemia.

Left ventricular assist devices and gastrointestinal bleeding: a narrative review of case reports and case series

BACKGROUND

The use of left ventricular assist devices (LVADs) has become a state-of-the-art therapy for advanced cardiac heart failure; however, multiple reports in the literature describe an increased risk for gastrointestinal (GI) bleeding in these patients. We characterized this association by reviewing recent studies on this topic.

HYPOTHESIS

GI bleeding occurs frequently in patients with LVADs, especially with devices with nonpulsatile flow patterns.

METHODS

We performed a comprehensive literature review to identify articles that reported GI bleeding in patients with LVADs. Databases used included PubMed, EMBASE, Scopus, Web of Knowledge, and Ovid. Baseline and outcome data were then ed from these reports.

RESULTS

We identified 10 case reports and 22 case series with 1543 patients. The mean age was 54.2 years. Most patients had nonpulsatile LVADs (1316, 85.3%). Three hundred and seventeen patients (20.5%) developed GI bleeding; this occurred more frequently in patients with nonpulsatile LVADs. Multiple procedures were performed without complications but often did not identify a definite bleeding site. Suspect lesions occurred throughout the GI tract but were more frequent in the upper GI tract. Many patients had arteriovenous malformations. All patients received medical therapy. None of the patients had their LVAD replaced. The use of anticoagulation did not appear to predispose these patients to more GI bleeding episodes.

CONCLUSIONS

Patients with LVADs have frequent GI bleeds, especially from arteriovenous malformations, which can occur throughout the GI tract. Most diagnostic and therapeutic interventions can be used safely in these patients. The pathogenesis of the GI bleeding in these patients may involve the use of anticoagulant medications, the formation of arteriovenous malformations, loss of von Willebrand factor activity, and mucosal ischemia.

Risk of recurrent gastrointestinal bleeding after aortic valve replacement in patients with Heyde syndrome

OBJECTIVE

We sought to evaluate the effectiveness of aortic valve replacement for reducing gastrointestinal bleeding in patients with Heyde syndrome, in whom gastrointestinal bleeding is associated with intestinal angiodysplasia and aortic valve stenosis.

METHODS

We conducted a retrospective review of patients treated at the Mayo Clinic between 1971 and 2007 for gastrointestinal bleeding and intestinal angiodysplasia who later underwent aortic valve replacement for severe aortic valve stenosis. We analyzed early and late outcomes, including recurrent gastrointestinal hemorrhage.

RESULTS

Fifty-seven patients (39 men and 18 women) were identified. At operation, the median age of patients was 75 years. Intestinal angiodysplasia occurred most commonly in the duodenum and right side of the colon. Before aortic valve replacement, the mean number of bleeding episodes was 12 per patient-year; 48 patients (84%) required blood transfusions. Bioprosthetic valves were used in 47 patients. During follow-up extending to 15 years, 45 patients (79%) had no recurrence of bleeding. In patients who experienced recurrent bleeding, the episodes were reduced from a mean ± standard deviation of 4.7 ± 7 episodes per patient-year to 1.9 ± 2 per patient-year. Recurrent bleeding occurred only in patients with lesions of the duodenum or right colon. Among patients who received bioprostheses, the overall risk of recurrent bleeding was 15%, lower than the 50% risk of subsequent gastrointestinal bleeding with mechanical prostheses.

CONCLUSIONS

Aortic valve replacement seems to decrease the risk of gastrointestinal bleeding in patients with Heyde syndrome and is curative in approximately 80%. Although rates of recurrent bleeding were not significantly different between the 2 prosthetic valve types, the higher risk of bleeding in patients receiving warfarin makes bioprosthetic valves the valve of choice for most patients.

Improved survival and decreasing incidence of adverse events with the HeartMate II left ventricular assist device as bridge-to-transplant therapy

BACKGROUND

Pulsatile left ventricular assist devices (LVADs) are effective as bridge-to-transplant therapy, but they are limited by their large size and lack of durability. Smaller, more durable, continuous flow devices such as the HeartMate II LVAD are increasingly being used. The aim of this study is to report our single-center experience with this device as bridge-to-transplant therapy.

METHODS

Overall, 47 patients received HeartMate II LVADs at our center from June 2005 to July 2007; 32 as bridge to transplant, 7 as destination therapy, and 8 as exchange therapy for a failed HeartMate XVE. We reviewed our experience with the device as bridge-to-transplant therapy and report on patient survival and adverse events.

RESULTS

The mean age of the bridge-to-transplant patients was 50.75 +/- 13.78 years; 10 (31.3%) were female. The cause of the underlying disease was ischemic in 18 patients (56.3%), idiopathic in 11 (34.4%), myocarditis in 1 (3.1%), postpartum cardiomyopathy in 1 (3.1%), and congenital heart disease in 1 (3.1%). The mean duration of HeartMate II support was 193.2 +/- 139.9 days. At 30 days after HeartMate II placement, the patient survival was 96.9% by Kaplan-Meier analysis; at 6 months (alive or transplanted), 86.9%. Major adverse events included bleeding requiring reexploration in 5 patients (15.6%), right ventricular failure requiring right ventricular assist device support in 2 (6.3%), LVAD-related infections in 4 (12.5%), neurologic or thromboembolic events in 2 (6.3%), and gastrointestinal bleeding in 5 (15.6%). We noted one serious device malfunction (3.1%) resulting in the patient's death; in addition, 2 patients experienced pump thrombosis (6.3%).

CONCLUSIONS

Despite morbidity, use of the HeartMate II LVAD as bridge-to-transplant therapy is associated with excellent survival and low mortality rates. We found a marked decrease in morbidity related to right ventricular failure, to device-related infections, and to thromboembolic events. However, the requirements for anticoagulation therapy may be associated with increased mediastinal and gastrointestinal bleeding. Strategies to optimize anticoagulation therapy may further improve results for these critically ill patients.

Gastrointestinal bleeding, angiodysplasia, cardiovascular disease, and acquired von Willebrand syndrome

Recent evidence points to isolated deficiency of the largest multimers of von Willebrand factor (VWF)-known as von Willebrand syndrome type 2A (VWS-2A)-as a risk factor for bleeding from gastrointestinal (GI) angiodysplasia. This disorder is not widely recognized, perhaps because most patients do not exhibit generalized hemostatic impairment (bleeding is generally restricted to GI angiodysplasia) and because all but the largest multimers of VWF remain detectable in the plasma (thus, routine screening tests for VWS-2A are usually normal). The "Rosetta stone" for elucidating this syndrome was the enigma of Heyde's syndrome (aortic stenosis plus bleeding GI angiodysplasia), particularly the striking observation that aortic valve replacement generally cures GI bleeding and that preoperative deficiency of the largest VWF multimers undergoes long-term normalization after valve replacement. We critically review the evidence implicating VWS-2A as a risk factor for bleeding GI angiodysplasia. We hypothesize that VWS-2A secondary to cardiovascular disease other than severe aortic stenosis, such as peripheral arterial occlusive disease, could explain why elderly patients often develop recurrent GI bleeding or iron deficiency anemia from GI angiodysplasia.

A prospective controlled evaluation of endoscopic detection of angiodysplasia and its association with aortic valve disease

BACKGROUND

In view of controversy about the association of aortic stenosis and angiodysplasia of the gut, we performed a prospective, controlled study to evaluate the relationship between aortic valve disease and gastrointestinal angiodysplasia.

METHODS

Forty patients who had endoscopy for clinical indications such as gastrointestinal bleeding, anemia, polyps, colon cancer, and dyspepsia, and who were found to have angiodysplasia of the gastrointestinal tract, underwent two-dimensional and Doppler echocardiography. Thirty-seven controls matched for age, sex, indication, and nature of endoscopic examination, but without angiodysplasia, underwent similar echocardiographic examination.

RESULTS

None of the patients in either group had aortic stenosis. The prevalence of aortic sclerosis, aortic insufficiency, and low left ventricular ejection fraction was similar in patients with and without angiodysplasia.

CONCLUSIONS

This study does not support the role of aortic valve disease as the cause of angiodysplasia of the gastrointestinal tract. A subgroup of patients with angiodysplasia with aortic sclerosis, with or without other valvular disease (but none with aortic stenosis), had increased prevalence of gastrointestinal bleeding when compared with controls. When aortic valve disease or decreased left ventricular ejection fraction were analyzed as independent predictors, none of them in and of itself appeared to be a factor in bleeding from these gastrointestinal lesions.

Small intestinal bleeding

Bleeding from the small intestine may be difficult to diagnose, because of the organ's length and free intraperitoneal location. Although there is a variety of causes of intestinal bleeding, angiodysplasia is the most common. Several different tests can be used to identify the bleeding site preoperatively or intraoperatively, including enteroscopy.

Pathology of aortic valve stenosis and pure aortic regurgitation. A clinical morphologic assessment--Part I

This two-part article examines the histologic and morphologic basis for stenotic and purely regurgitant aortic valves. Part I discusses stenotic aortic valves and Part II will discuss causes of purely regurgitant aortic valves. In over 95% of stenotic aortic valves, the etiology is one of three types: congenital (primarily bicuspid), degenerative, or rheumatic. Other rare causes of stenotic aortic valves include active infective endocarditis, homozygous type II hyperlipoproteinemia, and systemic lupus erythematosis. The causes of pure aortic regurgitation are multiple but can be separated into diseases affecting the valve (normal aorta) (infective endocarditis, congenital bicuspid, rheumatic, floppy), diseases affecting the walls of aorta (normal valve) (syphilis, Marfan's, dissection), disease affecting both aorta and valve (abnormal aorta, abnormal valve) (ankylosing spondylitis), and diseases affecting neither aorta nor valve (normal aorta, normal valve) (ventricular septal defect, systemic hypertension). Diseases affecting the aortic valve alone are the most common subgroup of conditions producing pure aortic valve regurgitation.

Aortic stenosis, idiopathic gastrointestinal bleeding, and angiodysplasia: is there an association? A methodologic critique of the literature

To assess the reported association between colonic angiodysplasia and aortic stenosis, we performed a quantitative and methodologic analysis of the literature. In four controlled studies that support an association between aortic stenosis and idiopathic gastrointestinal bleeding there are major methodologic deficiencies including the following: nonblinded data collection, noncomparable diagnostic examination, nonblinded ascertainment of exposure, and noncomparable demographic susceptibility. None of the studies directly assesses angiodysplasia. Additional case reports about aortic valve replacement used to treat bleeding from angiodysplasia are limited in number and in duration of follow-up. We conclude that the existing literature does not demonstrate an association between aortic stenosis and angiodysplasia. Further controlled evaluation of this topic would be useful.

The association of unexplained gastrointestinal bleeding with calcific aortic stenosis

The association of chronic gastrointestinal bleeding and aortic stenosis remains problematical. The cases of 91 patients (age 38 to 80 years) with these disorders who were examined between 1955 and 1975 were reviewed to address this controversy. All patients underwent upper and lower gastrointestinal radiography, small bowel series, and proctoscopy. Other studies were endoscopy in 84 patients, colonoscopy in 61, and visceral angiography in 16. Of the 37 patients who underwent abdominal exploration, 35 (95%) continued to bleed postoperatively, including 8 of 10 patients who had bowel resection for angiodysplasia. Forty patients did not have an abdominal operation, and all have continued to bleed. Sixteen patients (2 of whom had had an abdominal procedure) underwent aortic valve replacement for aortic stenosis. There were 2 intraoperative deaths among these 16 patients. At follow-up, which ranged from 8 to 12 years, only 1 patient who underwent aortic valve replacement had recurrent bleeding secondary to excessive anticoagulation. Thus, overall, gastrointestinal operation was successful in only 5% of patients, but aortic valve replacement was effective in 93%. For unexplained gastrointestinal bleeding associated with aortic stenosis, aortic valve replacement should be considered because of the likelihood of cure.

Upper gastrointestinal endoscopic ultrasonography in gastroenterology

Endoscopic ultrasound is a new technique in which high-frequency, high-resolution real-time ultrasound images are obtained from within the gastrointestinal tract by use of an ultrasound probe incorporated into the tip of a fibreoptic endoscope. Forty patients were scanned for gastrointestinal indications. In six patients the scans were technically unsuccessful, in three of these because of difficulties with the prototype instrument. New information was obtained in 20 patients, later confirmed by other means in 12. Endoscopic ultrasound did not provide any new information in 14 patients. The technique shows considerable promise in patients with pancreatic disorders and gut-wall malignancies. It has the ability to provide images with a spatial resolution unobtainable by other imaging methods.

Resolution of Heyde's syndrome of aortic stenosis and gastrointestinal bleeding after aortic valve replacement

The observation by Heyde that unexplained gastrointestinal bleeding may be associated with aortic stenosis has been confirmed by many others. It has been suggested that the combination of gastrointestinal bleeding and aortic stenosis be termed Heyde's syndrome. Gastrointestinal bleeding in this syndrome has been attributed to angiodysplasia. Segmental resection of those portions of the gastrointestinal tract containing the angiodysplastic lesions has been considered the definitive treatment for patients with Heyde's syndrome who are symptomatic because of chronic blood loss. However, recent observations suggest that aortic valve replacement with a bioprosthesis is a better therapeutic approach for those patients with severe aortic stenosis. This treatment has been shown to alleviate the symptomatology of both the stenosed aortic valve and the chronically bleeding bowel.

Utility of specimen angiography in angiodysplasia of the colon

This study reviews the utility of specimen angiography in identifying colonic lesions clinically thought to represent angiodysplasia. Four elderly patients presented with acute rectal bleeding. The diagnosis of angiodysplasia was made preoperatively in 3 patients by colonoscopy or angiography, or both. These specimens were injected with silicon rubber compound, xerographed, cleared with methyl salicylate, and examined with transillumination before histologic sampling. Although this technique was not used in the fourth case, fortuitous random sampling of the ascending colon revealed vascular changes indicative of angiodysplasia that correlated with a preoperative bleeding scan. Associated lesions in 1 patient were carcinoma of the colon and primary amyloidosis, the concurrence of which has not been described previously. With the injection technique the lesions of angiodysplasia appear grossly as spiderlike, dilated blood vessels. Microscopically, dilated veins, venules, and capillaries are found in the submucosa only or in the mucosa and submucosa. The importance of the postoperative injection is that it prevents the collapse of the blood vessels and enables the pathologist to identify the lesions grossly. As these lesions are usually small, this is important for proper sampling and histologic documentation.

Colonic vascular ectasias and aortic stenosis: coincidence or causal relationship?

Eleven patients with vascular ectasias of the colon and associated gastrointestinal hemorrhage were evaluated. All had the clinical features associated with aortic stenosis. In two patients, the configuration of the pulse wave in the mesenteric vessel was studied. In both, the abnormal peripheral pulse wave pattern associated with aortic stenosis was also transmitted to the ileocolic artery, where it differed quite clearly from the pattern in control patients. In a parallel study, the computer records of 3,623 patients with aortic or mitral stenosis admitted to the Mount Sinai Hospital over a 10 year period were reviewed for the presence of cryptogenic gastrointestinal hemorrhage. Twenty-one of 1,811 patients with aortic stenosis but only 1 of 1,812 patients with mitral stenosis had concomitant gastrointestinal hemorrhage (chi-square = 18, p less than 0.001). These data suggest that the cause of colonic vascular ectasias should be attributed to pathologic abnormalities of the arterial inflow pulse wave, rather than to chronic intermittent submucosal venous outflow obstruction.

The aortic valve. Colonic axis

In the past few years, a correlation has been recognized between calcific aortic stenosis and lower gastrointestinal bleeding in elderly patients. It has been suggested by several authors that mucosal arteriovenous malformations, usually in the right colon, are the cause of bleeding in those patients. Although attention is usually focused on doing a partial colectomy (usually right hemicolectomy) for treating colonic arteriovenous malformation bleeding, several patients with calcific aortic stenosis and gastrointestinal bleeding have been reported in whom bleeding stopped after aortic valve replacement alone. The purpose of this paper is to review the possible mechanisms of lower intestinal bleeding in patients with calcific aortic stenosis, delineate the methods of diagnosis, and finally, to outline the appropriate surgical management.

Aortic stenosis associated with gastrointestinal bleeding. A survey of 612 patients

A retrospective study was done in order to examine the association between aortic stenosis (AS) and gastrointestinal tract (GIT) bleeding. Four groups of patients included a group of 152 patients with AS, a control group of 152 patients with MS, and another two groups of 154 patients each with and without GIT bleeding. GIT bleeding of known and of idiopathic sources was significantly more prevalent among patients with AS (three and four patients, respectively) than among those with MS (none). Moreover, AS was significantly more prevalent in association with idiopathic GIT bleeding (seven out of 24, 29.1%), in comparison to its association with bleeding from a known source (two out of 130, 1.5%), and its incidence in routinely admitted patients without GIT bleeding (three out of 154, 1.9%). This study supports the assumption that GIT bleeding may be associated with AS.

Twelve-year history of gastrointestinal bleeding in a patient with calcific aortic stenosis and hemorrhagic telangiectasia

A case has been presented of a patient with a 12-year history of unexplained gastrointestinal bleeding who developed severe aortic stenosis. Small telangiectasia were finally noted on his lip and gastroscopy revealed gastric and duodenal telangiectasia though he had no history of epistaxis and an unremarkable family history. Patients with aortic stenosis and unexplained gastrointestinal bleeding should be carefully evaluated for hemorrhagic telangiectasia in spite of a negative family history and no visible evidence of telangiectasia.

Differential diagnosis of early opacification of the portal vein and its tributaries during arteriography

Twenty-two cases with communication of an artery and the portal vein or one of its tributaries are discussed. Four conditions in which relatively significant arterio-portal shunts may exist can be differentiated: (1) angiodysplasias or arteriovenous malformations, (2) cirrhosis of the liver and inflammatory lesions, (3) traumatic and postoperative lesions, and (4) benign and malignant tumors. The significance of the portal vein's early opacification during arteriographic examinations of the abdominal organs is discussed, and the findings are compared to those reported in the literature.

Angiodysplasia of the colon: a cause of rectal bleeding

Colonic angiodysplasia is a vascular lesion of the colon that may become the source of low grade chronic or intermittently massive rectal bleeding. It is a lesion of the elderly, almost always found in the cecum and the ascending colon. Etiology and pathogenesis are unknown. The diagnosis can be made with angiography based on the demonstration of a vascular tuft and early opacification of draining veins. Right hemicolectomy is the mode of therapy. The lesions are minute, and in resected specimens they can be found only with special vessel injection techniques. Histologically, the lesions represent clusters of dilated vessels, mostly veins, in the mucosa and submucosa of the cecum and ascending colon.