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Viteri-Noël A, González-García A, Patier JL, Fabregate M, Bara-Ledesma N, López-Rodríguez M, Gómez del Olmo V, Manzano L. Hereditary Hemorrhagic Telangiectasia: Genetics, Pathophysiology, Diagnosis, and Management. J Clin Med 2022; 11:jcm11175245. [PMID: 36079173 PMCID: PMC9457069 DOI: 10.3390/jcm11175245] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/30/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia is an inherited disease related to an alteration in angiogenesis, manifesting as cutaneous telangiectasias and epistaxis. As complications, it presents vascular malformations in organs such as the lung, liver, digestive tract, and brain. Currently, diagnosis can be made using the Curaçao criteria or by identifying the affected gene. In recent years, there has been an advance in the understanding of the pathophysiology of the disease, which has allowed the use of new therapeutic strategies to improve the quality of life of patients. This article reviews some of the main and most current evidence on the pathophysiology, clinical manifestations, diagnostic approach, screening for complications, and therapeutic options, both pharmacological and surgical.
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Affiliation(s)
- Adrian Viteri-Noël
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
- Faculty of Medicine and Health Sciences, Universidad de Alcalá (UAH), 28801 Alcalá de Henares, Spain
- Correspondence:
| | - Andrés González-García
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
- Faculty of Medicine and Health Sciences, Universidad de Alcalá (UAH), 28801 Alcalá de Henares, Spain
| | - José Luis Patier
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
- Faculty of Medicine and Health Sciences, Universidad de Alcalá (UAH), 28801 Alcalá de Henares, Spain
| | - Martin Fabregate
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
| | - Nuria Bara-Ledesma
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
| | - Mónica López-Rodríguez
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
- Faculty of Medicine and Health Sciences, Universidad de Alcalá (UAH), 28801 Alcalá de Henares, Spain
| | - Vicente Gómez del Olmo
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
- Faculty of Medicine and Health Sciences, Universidad de Alcalá (UAH), 28801 Alcalá de Henares, Spain
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Lageju N, Uprety P, Neupane D, Bastola S, Lama S, Panthi S, Gnawali A. Gastric antral vascular ectasia (Watermelon stomach); an unusual cause of upper gastrointestinal bleeding in elderly: A case report. Ann Med Surg (Lond) 2022; 82:104733. [PMID: 36268406 PMCID: PMC9577822 DOI: 10.1016/j.amsu.2022.104733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/11/2022] [Accepted: 09/18/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Gastric antral vascular ectasia (GAVE) is an unusual cause of upper gastrointestinal (GI) bleeding in an elderly patient. Case presentation A 73-year-old female with erosive gastritis, hypertension, and unstable angina arrived at the emergency department with shortness of breath, easy fatigability, and melaena. Physical examination indicated pallor but no signs of distress, with an unremarkable systemic examination. Routine blood testing indicated anemia. The patient underwent upper gastrointestinal endoscopy, which revealed linear red ectatic vessels radiating from the antrum towards the body. A diagnosis of GAVE was made. Blood transfusions and argon plasma coagulation were undertaken. Clinical discussion This condition is an uncommon cause of upper GI bleeding with the antrum being the most prevalent site. The pathophysiology of GAVE is yet unknown, however, many hypotheses have been postulated. GAVE is frequently misdiagnosed as gastritis. GAVE treatment comprises initial resuscitation and symptomatic treatment with intravenous fluids and blood products. Endoscopy has increasingly been the first-line therapeutic option for GAVE in recent years, including argon plasma coagulation. Conclusion The diagnosis of gastric antral vascular ectasia is frequently overlooked during upper GI endoscopy, despite the fact that it should always be explored, especially in cases of unexplained GI bleeding in the elderly. An unusual cause of upper gastrointestinal bleeding in an elderly patient. Frequently misdiagnosed as gastritis. Linear red ectatic vessels radiating from gastric antrum towards the body. Argon plasma coagulation is a good treatment modality.
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Affiliation(s)
- Nimesh Lageju
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Pratik Uprety
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Durga Neupane
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Satish Bastola
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Suhel Lama
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Sagar Panthi
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Arun Gnawali
- Department of Gastroenterology, Tribhuvan University Teaching Hospital, Maharajgunj, Nepal
- Corresponding author.
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Hirsch BS, Ribeiro IB, Funari MP, Sagae VMT, Mancini FC, Oliveira GHPD, Moura EGHD, Bernardo WM. Endoscopic treatment of gastric antral vascular ectasia. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2022; 68:125-134. [PMID: 35239866 DOI: 10.1590/1806-9282.2022d682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 08/08/2024]
Affiliation(s)
- Bruno Salomão Hirsch
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
| | - Igor Braga Ribeiro
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
| | - Mateus Pereira Funari
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
| | - Vitor Massaro Takamatsu Sagae
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
| | - Fabio Catache Mancini
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
| | | | | | - Wanderley Marques Bernardo
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
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Aryan M, Jariwala R, Alkurdi B, Peter S, Shoreibah M. Prevalence of metabolic syndrome in cirrhotics with gastric antral vascular ectasia. Diabetes Metab Syndr 2022; 16:102377. [PMID: 34974327 DOI: 10.1016/j.dsx.2021.102377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND AIMS Gastric antral vascular ectasia (GAVE) is characterized by angliodysplastic lesions that can cause upper gastrointestinal bleeding (UGIB). The mechanism behind GAVE and its association with other diseases remains unknown. We investigated the association of metabolic syndrome in cirrhotic GAVE patients when compared to esophageal variceal hemorrhage (EVH) patients. METHODS We performed a retrospective review of 941 consecutive esophagogastroduodenoscopies (EGDs) for UGIB at a medical center between 2017 and 2019. The GAVE group consisted of EGD or biopsy diagnosed cirrhotic GAVE patients, and the EVH group consisted of EVH patients with active bleeding or stigmata of recent hemorrhage on EGD. Baseline variables including co-morbidities and cirrhotic etiology were recorded. Continuous variables were compared using Wilcoxon test and categorical variables were compared using Chi-square or Fisher's exact test. Multiple logistic regression analysis evaluated the association between GAVE and covariates. RESULTS The final cohort had 96 GAVE and 104 EVH patients. Mean BMI was significantly higher in the GAVE cohort (32.6 vs 27.9, p < 0.0001) in addition to diabetes, hypertension, and hyperlipidemia (53.1% vs 37.5%; 76% vs 47.1%; 38.5% vs 14.4%; respectively, all p < 0.05). Non-alcoholic steatohepatitis (NASH) cirrhosis was more prevalent in GAVE than EVH patients (50% vs 24%, p = 0.0001). Multiple logistics regression revealed female sex, increased BMI, hypertension, and hyperlipidemia all having significantly higher risk of GAVE (all p < 0.05). CONCLUSION Our data indicates that when compared to cirrhotics patients with EVH, cirrhotics with GAVE have increased risk of metabolic syndrome. This may play a role in the underlying pathophysiology of GAVE.
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Affiliation(s)
- Mahmoud Aryan
- Tinsley Harrison Internal Medicine Residency Program, Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, BDB 327, Birmingham, AL, 35294, United States.
| | - Ravi Jariwala
- Tinsley Harrison Internal Medicine Residency Program, Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, BDB 327, Birmingham, AL, 35294, United States; Department of Gastroenterology and Hepatology, Ochsner Medical Center, 1514 Jefferson Hwy. New Orleans, LA, 70121, United States
| | - Basem Alkurdi
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 391, Birmingham, AL, 35294, United States
| | - Shajan Peter
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 391, Birmingham, AL, 35294, United States
| | - Mohamed Shoreibah
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 391, Birmingham, AL, 35294, United States
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Jariwala R, Shoreibah M. An Unexpected Association: Might GAVE Pave the Way to How the Metabolic Syndrome Behaves. Clin Liver Dis (Hoboken) 2021; 18:297-300. [PMID: 34976375 PMCID: PMC8688897 DOI: 10.1002/cld.1156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/10/2021] [Accepted: 07/21/2021] [Indexed: 02/04/2023] Open
Abstract
Content available: Audio Recording.
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Affiliation(s)
- Ravi Jariwala
- Internal Medicine Residency Training ProgramUniversity of Alabama at BirminghamBirminghamAL
| | - Mohamed Shoreibah
- Division of Gastroenterology & HepatologyUniversity of Alabama at BirminghamBirminghamAL
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Tenev R, Gulubova M, Ananiev J, Mumdzhiev N, Vasileva Z, Ivanova K. Gastric Antral Vascular Ectasia and Vitamin D Deficiency: New Associated Disease and Proposed Pathogenetic Mechanisms. Dig Dis Sci 2021; 66:3630-3634. [PMID: 33106980 DOI: 10.1007/s10620-020-06666-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/07/2020] [Indexed: 12/09/2022]
Affiliation(s)
- Rumen Tenev
- Department of Gastroenterology, University Hospital UMHAT Prof. Stojan Kirkovitch, Stara Zagora, Bulgaria.
| | - Maya Gulubova
- Department of General and Clinical Pathology, Medical Faculty, Trakia University, Stara Zagora, Bulgaria
| | - Julian Ananiev
- Department of General and Clinical Pathology, Medical Faculty, Trakia University, Stara Zagora, Bulgaria
| | - Nikola Mumdzhiev
- Department of Gastroenterology, University Hospital UMHAT Prof. Stojan Kirkovitch, Stara Zagora, Bulgaria
| | - Zlatina Vasileva
- Department of Gastroenterology, University Hospital UMHAT Prof. Stojan Kirkovitch, Stara Zagora, Bulgaria
| | - Koni Ivanova
- Department of General and Clinical Pathology, Medical Faculty, Trakia University, Stara Zagora, Bulgaria
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Hirsch BS, Ribeiro IB, Funari MP, de Moura DTH, Matuguma SE, Sánchez-Luna SA, Mancini FC, de Oliveira GHP, Bernardo WM, de Moura EGH. Endoscopic Band Ligation Versus Argon Plasma Coagulation in the Treatment of Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Endosc 2021; 54:669-677. [PMID: 34053215 PMCID: PMC8505186 DOI: 10.5946/ce.2021.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/28/2021] [Indexed: 11/22/2022] Open
Abstract
Background/Aims Argon plasma coagulation (APC) is the most commonly used endoscopic treatment for gastric antral vascular ectasia (GAVE). Endoscopic band ligation (EBL) has emerged as an alternative therapy. Our goal was to evaluate the feasibility, efficacy, and safety of APC and EBL for the treatment of GAVE. This is the first systematic review that included only randomized controlled trials (RCTs) on this topic.
Methods A comprehensive search was performed using electronic databases to identify RCTs comparing APC and EBL for the treatment of GAVE following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.
Results Four RCTs were included, with a total of 204 patients. EBL was related to higher endoscopic eradication rates risk difference [RD], 0.29; 95% confidence interval [CI] [0.14, 0.44]; I2=0%) and less bleeding recurrence than APC (RD, 0.29; 95% CI [0.15, 0.44]; I2=0%). Patients treated with EBL required fewer blood transfusions (mean difference [MD], 1.49; 95% CI [0.28, 2.71]; I2=96%) and hospitalizations (MD, 0.29; 95% CI [0.19, 0.39]; I2=0%). The number of sessions required for the obliteration of lesions was higher with APC. There was no difference in the incidence of adverse events.
Conclusions EBL is superior to APC in the treatment of GAVE in terms of endoscopic eradication rates, recurrence of bleeding, and transfusion requirements.
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Affiliation(s)
- Bruno Salomão Hirsch
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | | | - Sergio Eiji Matuguma
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Sergio A Sánchez-Luna
- Center for Advanced Endoscopy, Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.,Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Department of Internal Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Fabio Catache Mancini
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | | | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
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Kichloo A, Solanki D, Singh J, Dahiya DS, Lal D, Haq KF, Aljadah M, Gandhi D, Solanki S, Khan HMA. Gastric Antral Vascular Ectasia: Trends of Hospitalizations, Biodemographic Characteristics, and Outcomes With Watermelon Stomach. Gastroenterology Res 2021; 14:104-111. [PMID: 34007352 PMCID: PMC8110233 DOI: 10.14740/gr1380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/08/2021] [Indexed: 01/10/2023] Open
Abstract
Background Gastric antral vascular ectasia (GAVE) syndrome is a rare but significant cause of acute or chronic gastrointestinal (GI) bleeding, particularly in the elderly. The primary objective of this study was to determine the biodemographic characteristics, adverse outcomes, and the impact of GAVE hospitalizations on the US healthcare system. Methods This retrospective database cross-sectional study used the National Inpatient Sample (NIS) from 2001 to 2011 to identify all adult hospitalizations with a primary discharge diagnosis of GAVE, with and without hemorrhage, using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Individuals less than 17 years of age were excluded from the study. The outcomes included biodemographic characteristics, comorbidity measures, and inpatient mortality and the burden of the disease on the US healthcare system in terms of healthcare cost and utilization. Results We noted an increase in the total hospitalizations for GAVE from 25,423 in 2001 to 44,787 in 2011. Furthermore, GAVE hospitalizations with hemorrhage rose from 19,168 in 2001 to 27,679 in 2011 while GAVE hospitalization without hemorrhage increased from 6,255 in 2001 to 17,108 in 2011. We also noted a female predominance, the proportional trend of which did not show significant difference from 2001 to 2011. For GAVE hospitalizations, the inpatient mortality decreased from 2.20% in 2001 to 1.73% in 2011. However, the cost of hospitalization increased from $11,590 in 2001 to $12,930 in 2011. After adjusting for possible confounders, we observed that the presence of hemorrhage in GAVE hospitalizations was associated with an increased risk of mortality (odds ratio (OR): 1.27; 95% confidence interval (CI): 1.1 - 1.46; P = 0.001). Conclusions For the study period, the total number of GAVE hospitalizations increased with an increase noted in the proportion of GAVE hospitalizations without bleeding, reflecting an improvement in diagnostic and therapeutic techniques. Although inpatient mortality for GAVE slightly decreased, we noted a significant increase in the cost of care likely secondary to increased use of advanced and expensive interventions.
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Affiliation(s)
- Asim Kichloo
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Dhanshree Solanki
- Department of Internal Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Jagmeet Singh
- Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Darshan Lal
- Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Khwaja Fahad Haq
- Division of Gastroenterology, Henry Ford Hospital, Detroit, MI, USA
| | - Michael Aljadah
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Darshan Gandhi
- Department of Radiology, Hartford Healthcare, Hartford, CT, USA
| | - Shantanu Solanki
- Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
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Yang JK, Hyun JJ, Lee TH, Choi JH, Lee YN, Choe JW, Park JS, Kwon CI, Jeong S, Kim HJ, Moon JH, Park SH. Can prophylactic argon plasma coagulation reduce delayed post-papillectomy bleeding? A prospective multicenter trial. J Gastroenterol Hepatol 2021; 36:467-473. [PMID: 32677716 DOI: 10.1111/jgh.15186] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/03/2020] [Accepted: 07/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Endoscopic post-papillectomy bleeding occurs in 3% to 20% of the cases, and delayed bleeding is also problematic. However, there is no consensus on how to reduce delayed post-papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed bleeding and reduce the persistence of residual tumors after endoscopic papillectomy. METHODS In a prospective pilot study of patients with benign ampullary tumors, the prophylactic APC group underwent APC at the resection margin following a conventional snaring papillectomy. Then, 24 h later after the papillectomy, all patients underwent a follow-up duodenoscopy to identify post-papillectomy bleeding and were followed up until 12 months. The main outcomes were the delayed (≥24 h) post-papillectomy bleeding rate and the tumor persistence rate. RESULTS The delayed post-papillectomy bleeding rate was 30.8% (8/26) in the prophylactic APC group and 21.4% (6/28) in the non-APC group (P = 0.434). The post-procedure pancreatitis rates were 23.1% (6/26) and 35.7% (10/28), respectively (P = 0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, P = 0.656), 3 months (4.2% vs 3.7%, P = 1.00), 6 months (8.3% vs 3.7%, P = 0.595), and 12 months (0% vs 3.7%, P = 1.00). There were no procedure-related mortalities or serious complications. CONCLUSION Prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding or remnant tumor ablation immediately after conventional papillectomy (Clinical trial registration-cris.nih.go.kr; KCT0001955).
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Affiliation(s)
- Jae Kook Yang
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jong Jin Hyun
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jun-Ho Choi
- Department of Internal Medicine, College of Medicine, Dankook University, Cheonan, Republic of Korea
| | - Yun Nah Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jung Wan Choe
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Jin-Seok Park
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Chang-Il Kwon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Hong Ja Kim
- Department of Internal Medicine, College of Medicine, Dankook University, Cheonan, Republic of Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
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Ali SE, Benrajab KM, Cruz ACD. Outcome of gastric antral vascular ectasia and related anemia after orthotopic liver transplantation. World J Hepatol 2020; 12:1067-1075. [PMID: 33312430 PMCID: PMC7701976 DOI: 10.4254/wjh.v12.i11.1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/04/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is a significant complication of cirrhosis. Numerous medical, surgical, and endoscopic treatment modalities have been proposed with varied satisfactory results. In a few small studies, GAVE and associated anemia have resolved after orthotopic liver transplantation (OLT).
AIM To assess the impact of OLT on the resolution of GAVE and related anemia.
METHODS We retrospectively reviewed clinical records of adult patients with GAVE who underwent OLT between September 2012 and September 2019. Demographics and other relevant clinical findings were collected, including hemoglobin levels and upper endoscopy findings before and after OLT. The primary outcome was the resolution of GAVE and its related anemia after OLT.
RESULTS Sixteen patients were identified. Mean pre-OLT Hgb was 7.7 g/dL and mean 12 mo post-OLT Hgb was 11.9 g/dL, (P = 0.001). Anemia improved (defined as Hgb increased by 2g) in 87.5% of patients within 6 to 12 mo after OLT and resolved completely in half of the patients. Post-OLT esophagogastroduodenoscopy was performed in 10 patients, and GAVE was found to have resolved entirely in 6 of those patients (60%).
CONCLUSION Although GAVE and associated anemia completely resolved in the majority of our patients after OLT, GAVE persisted in a few patients after transplant. Further studies in a large group of patients are necessary to understand the causality of disease and to better understand the factors associated with the persistence of GAVE post-transplant.
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Affiliation(s)
- Saad Emhmed Ali
- Division of Hospital Medicine, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Karim M Benrajab
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Anna Christina Dela Cruz
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, United States
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Shukla R, Warner R, Whorwell P, Herrick AL. Upper gastrointestinal vascular ectasia: an under-recognized complication of systemic sclerosis. Scand J Rheumatol 2020; 50:325-326. [PMID: 32783483 DOI: 10.1080/03009742.2020.1794029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- R Shukla
- Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R Warner
- Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - P Whorwell
- Neurogastroenterology Unit, Wythenshawe Hospital, Centre for Gastrointestinal Sciences, University of Manchester, Manchester, UK
| | - A L Herrick
- Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, University of Manchester, Manchester, UK
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12
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Douglas AR, Holleran G, Smith SM, McNamara D. Shared changes in angiogenic factors across gastrointestinal vascular conditions: A pilot study. World J Gastrointest Pharmacol Ther 2020; 11:40-47. [PMID: 32844042 PMCID: PMC7416378 DOI: 10.4292/wjgpt.v11.i3.40] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/11/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Neovascularisation is common to a variety of gastrointestinal (GI) disorders with differing aetiologies and presentations; usually affecting adults above 60 years. Shared angiogenic factors modulated by disease specific elements could be a common denominator and represent novel diagnostic and therapeutic targets. As yet, assessment of angiogenic factors across several GI vascular disorders associated with recurrent bleeding and anaemia has not been reported.
AIM To assess serum levels of angiogenic factors in several intestinal vascular disorders.
METHODS A case control study was performed in Tallaght University Hospital in patients with endoscopically proven small bowel angiodysplasia (SBA), portal hypertensive gastropathy (PHG), gastric antral vascular ectasia (GAVE) and non-bleeding, non-anaemic controls. Using enzyme-linked immunosorbent assay, concentrations of Angiopoietin 1 (Ang-1), Ang-2 and vascular endothelial growth factor (VEGF) were measured from 2 serum tubes of blood following informed consent. The relative expression of Ang-1 and Ang-2 and Ang-1/2 ratio was calculated and compared between groups. Statistical analysis was applied using a t-test, and a P value of < 0.05 was considered significant.
RESULTS To date 44 samples were tested: 10 SBA, 11 PHG, 8 GAVE and 15 controls. Mean age 60 (range 20-85) years and 20 (45%) were males. Controls were significantly younger (49 years vs 66 years, P = 0.0005). There was no difference in VEGF levels between the groups (P = 0.6). SBA, PHG and GAVE Ang-1 levels were similar and were significantly lower than controls, (P = 0.0002, 95%CI: 241 to 701). Ang-2 levels were statistically higher in PHG and GAVE groups compared to controls (P = 0.01, 95%CI: 77.8 to 668) and as a result, also had a lower Ang-1/2 ratios compared to controls. While SBA Ang-2 levels were higher than controls, this did not reach statistical significance. Neither age nor haemoglobin level, which was similar between disease groups, could explain the difference. In addition, the median Ang-1/Ang-2 ratio for all patients was found to be significantly lower compared to controls, 8 vs 28 respectively, P = 0.001, 95%CI: -27.55 to -7.12.
CONCLUSION Our novel pilot study suggests common alterations in Ang-1 and Ang-2 levels across several GI vascular disorders. Differences in Ang-1/Ang-2 ratios among vascular disorders compared to controls suggest disease-specific modulation.
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Affiliation(s)
| | - Grainne Holleran
- TAGG Research Centre, School of Medicine, Trinity College Dublin, Dublin D24, Ireland
| | - Sinead M Smith
- TAGG Research Centre, School of Medicine, Trinity College Dublin, Dublin D24, Ireland
| | - Deirdre McNamara
- TAGG Research Centre, School of Medicine, Trinity College Dublin, Dublin D24, Ireland
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Gastric antral vascular ectasia (GAVE) and hereditary hemorrhagic telangiectasia (HHT): two different conditions, one treatment. Ann Hematol 2019; 99:367-369. [DOI: 10.1007/s00277-019-03845-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
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Comparison of Argon Plasma Coagulation and Injection Therapy with Adrenalin and Polidocanol in the Management of Bleeding Angiodysplasia in Upper Gastrointestinal Tract. ACTA ACUST UNITED AC 2019; 39:63-68. [PMID: 30864370 DOI: 10.2478/prilozi-2018-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The term angiodysplasia (AD) refers to acquired malformation of the blood vessels (communications between veins and capillaries), frequently found within the gastrointestinal mucosa and submucosa. AD of stomach and duodenum are cause of upper gastrointestinal bleeding in 4%-7% of patients. The means of treatment are usually endoscopic, including argon plasma coagulation (APC), electrocoagulation, mechanical hemostasis by clippsing, laser photo-coagulation and injection therapy. AIM To compare the success rate, and adverse events (ulcer lesions, perforations) of APC and injection therapy in the treatment of bleeding angiodysplasia in the upper gastrointestinal tract (GIT). MATERIAL AND METHODS In a prospective study including 50 patients with bleeding angiodysplasia of the upper GIT, 35 patients were treated with APC, and remaining 15 with injection therapy using adrenaline and 1.5% solution of polidocanol. Follow-up period was 6 months. RESULTS A total of 50 patients aged 18 to 64 years, 64% male and 36% female, have been treated during 2 years period. The rate of recurrent bleeding and side effects was significantly higher in the adrenaline group (p <0.01). Blood transfusion was required in 68% during the first hospital admission. Angiodysplasia of the stomach was present in 66%, versus 34% in duodenum. CONCLUSION Endoscopy is "gold standard" for diagnosis and treatment of AD in the gastrointestinal tract. The study unveiled APC as more effective treatment option with lower degree of complications and adverse events in comparison to injection therapy in patients with bleeding AD.
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Abstract
Gastrointestinal angiodysplasias (GIADs) have a wide variety of presentations, which can be significant and debilitating in a subset of patients. Endoscopic ablation is currently the most effective treatment for GIADs, however re-bleeding rates are high. Several medical have been used for GIADs and reported in the literature, however these medications have significant side effect profiles and randomized controlled trials are lacking. A relatively poor understanding of the pathophysiology of GIAD formation has limited the development of more effective treatments and improved diagnostic and prognostic markers for GIAD. However, recent advances in research in the area of angiogenesis have identified a potential role for certain angiogenic factors including Angiopoeitin 1 and 2, in the pathophysiology of GIAD. Areas covered: We performed an extensive pubmed search of all articles mentioning GIAD and summarized our findings focussing on patient management and prospects. We summarize the available literature regarding the medical, endoscopic, and radiological management of GIAD and the value of clinical prognostic factors. Expert commentary: Although the area of angiogenesis is a novel area of research in GIAD, it represents an exciting avenue for development with the potential to improve diagnostic and prognostic tools to improve patient outcome.
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Affiliation(s)
- Grainne Holleran
- a Department of Gastroenterology and Clinical Medicine , Trinity Centre for Health Sciences' Tallaght Hospital , Dublin , Ireland
| | - Deirdre McNamara
- a Department of Gastroenterology and Clinical Medicine , Trinity Centre for Health Sciences' Tallaght Hospital , Dublin , Ireland
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Almadi MA, Barkun AN. Patient Presentation, Risk Stratification, and Initial Management in Acute Lower Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2018; 28:363-377. [PMID: 29933781 DOI: 10.1016/j.giec.2018.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The approach to lower gastrointestinal bleeding (LGIB) has evolved over the last few years to incorporate a multidisciplinary management strategy. Although the causes of LGIB vary depending on the age and comorbid conditions of patients, the initial resuscitation and principles of optimizing patients' condition before endoscopic evaluation, when appropriate, are the cornerstones to clinical care. The role of risk stratification is to triage patients as well as to mobilize health care resources based on predicted outcomes. Individualized management according to patients' comorbid conditions has been a focus in most recent guidelines.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada; Division of Clinical Epidemiology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada.
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Gupta S, Greenwald DA. Prevention of Recurrent Lower Gastrointestinal Hemorrhage. Gastrointest Endosc Clin N Am 2018; 28:409-424. [PMID: 29933784 DOI: 10.1016/j.giec.2018.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This article summarizes current knowledge regarding the incidence of and risk factors associated with recurrent lower gastrointestinal hemorrhage. The literature regarding medical, endoscopic, and surgical methods to prevent rebleeding from diverticulosis, angioectasia, and chronic hemorrhagic radiation proctopathy is reviewed. In addition, the evidence for endoscopic clipping as primary prophylaxis against postpolypectomy bleeding is explored.
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Affiliation(s)
- Shivani Gupta
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1069, New York, NY 10029-6574, USA.
| | - David A Greenwald
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1069, New York, NY 10029-6574, USA
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Abstract
PURPOSE OF REVIEW The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial. RECENT FINDINGS Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias. SUMMARY SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.
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St Romain P, Boyd A, Zheng J, Chow SC, Burbridge R, Wild D. Radiofrequency ablation (RFA) vs. argon plasma coagulation (APC) for the management of gastric antral vascular ectasia (GAVE) in patients with and without cirrhosis: results from a retrospective analysis of a large cohort of patients treated at a single center. Endosc Int Open 2018; 6:E266-E270. [PMID: 29497685 PMCID: PMC5829995 DOI: 10.1055/s-0043-123187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/08/2017] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION AND STUDY AIMS Gastric antral vascular ectasia (GAVE) is a mucosal abnormality associated with multiple conditions, most notably cirrhosis and systemic sclerosis, that causes indolent gastrointestinal bleeding. It is primarily managed with endoscopic therapy. Traditionally, GAVE is endoscopically ablated using argon plasma coagulation (APC) but radiofrequency ablation (RFA) is emerging as an alternative modality. No prior comparison of the 2 modalities has been published. PATIENTS AND METHODS After receiving IRB approval, we reviewed our electronic health records to identify all patients who underwent endoscopic evaluation for GAVE between January, 2011 and October, 2016. We compared important variables between APC and RFA, as well as between cirrhosis and non-cirrhosis, using the Chi-square test and the Wilcoxon two-sample test as appropriate. RESULTS During our study period, 81 patients were endoscopically evaluated for GAVE. 24 patients were treated with APC alone, 28 with RFA alone and 25 patients received both treatment modalities. CONCLUSIONS RFA and APC were both effective in treating bleeding from GAVE. Though we found subtle differences, patients underwent a similar number of treatment sessions and had similar procedure times and a similar time between sessions no matter the treatment modality used.
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Affiliation(s)
- Paul St Romain
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina, United States,Corresponding author Paul St. Romain Duke University Medical CenterDepartment of Medicine, Division of Gastroenterology03142 Orange ZoneDurham, NC 27710+1-919-684-8857
| | - Amanda Boyd
- Division of Internal Medicine, Duke University Medical Center, Durham, North Carolina, United States
| | - Jiayin Zheng
- Division of Biostatistics, Duke University Medical Center, Durham, North Carolina, United States
| | - Shein-Chung Chow
- Division of Biostatistics, Duke University Medical Center, Durham, North Carolina, United States
| | - Rebecca Burbridge
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina, United States
| | - Daniel Wild
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina, United States
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Benamouzig R, Benallaoua M, Saurin JC, Boubaya M, Cellier C, Laugier R, Vincent M, Boustière C, Gincul R, Samaha E, Grandval P, Aparicio T, Airinei G, Bejou B, Bon C, Raynaud JJ, Levy V, Sautereau D. 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. Therap Adv Gastroenterol 2018; 11:1756283X18756260. [PMID: 29479375 PMCID: PMC5818089 DOI: 10.1177/1756283x18756260] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 10/31/2017] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - René Laugier
- Gastroenterology Unit, Timone Hospital, Marseille, France
| | | | | | - Rodica Gincul
- Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
| | - Elia Samaha
- Gastroenterology Unit, Georges-Pompidou Hospital, Paris, France
| | | | | | | | - Bakhtiar Bejou
- Gastroenterology Unit, Avicenne Hospital, Bobigny, France
| | - Cyriaque Bon
- Gastroenterology Unit, Avicenne Hospital, Bobigny, France
| | | | - Vincent Levy
- Clinical Research Unit, Avicenne Hospital, Bobigny, France
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Role of Octreotide in Pediatric Gastrointestinal Bleeding Secondary to Angiodysplasia in Children With Right Heart Failure. J Pediatr Gastroenterol Nutr 2018; 66:e41-e44. [PMID: 28614113 DOI: 10.1097/mpg.0000000000001659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Angiodysplasia (AD) is a relatively uncommon cause of gastrointestinal bleeding in children and may be seen in right heart failure. Octreotide has been used successfully in adult patients with gastrointestinal bleeding due to ADs. METHODS We describe 2 patients who had congenital heart disease with right heart failure and gastrointestinal bleeding from AD. RESULTS AD lesions were documented on traditional endoscopy and capsule endoscopy. Bleeding resolved after initiation of IV octreotide and did not recur on subcutaneous octreotide during the 2-year follow-up period. CONCLUSIONS Based on the successful outcomes in the 2 patients, a trial of octreotide may be considered in pediatric patients who present with gastrointestinal bleeding secondary to AD.
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Chetcuti Zammit S, Koulaouzidis A, Sanders DS, McAlindon ME, Rondonotti E, Yung DE, Sidhu R. Overview of small bowel angioectasias: clinical presentation and treatment options. Expert Rev Gastroenterol Hepatol 2018; 12:125-139. [PMID: 28994309 DOI: 10.1080/17474124.2018.1390429] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging.
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Affiliation(s)
| | | | - David S Sanders
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
| | - Mark E McAlindon
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
| | | | - Diana E Yung
- b Endoscopy Unit , the Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Reena Sidhu
- a Gastroenterology Department , Royal Hallamshire Hospital , Sheffield , UK
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Grooteman KV, van Geenen EJM, Drenth JPH. Tranexamic acid in treatment-resistant chronic transfusion-dependent gastrointestinal angiodysplasia bleeding. BMJ Case Rep 2017; 2017:bcr-2017-221832. [PMID: 29092972 DOI: 10.1136/bcr-2017-221832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
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 endoscopic argon plasma coagulation is ineffective, the angiogenesis inhibitors thalidomide and octreotide can be considered. We describe a 77-year-old woman who had side effects of these angiogenesis inhibitors, which caused her to have continued bleeding. She was successfully treated with tranexamic acid with a substantial decrease in need for red blood cell transfusions.
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Affiliation(s)
| | | | - Joost P H Drenth
- Gastroenterology and Hepatology, Radboudumc, Nijmegen, Netherlands
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Chetcuti Zammit S, Sanders DS, Sidhu R. Lanreotide in the management of small bowel angioectasias: seven-year data from a tertiary centre. Scand J Gastroenterol 2017; 52:962-968. [PMID: 28506132 DOI: 10.1080/00365521.2017.1325929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Haemorrhage from small bowel angioectasias (SBAs) can be debilitating to patients who are very often elderly and have multiple comorbidities. Our aim was to assess the use of lanreotide in addition to endotherapy in patients with SBAs. METHOD Patients with SBAs on capsule endoscopy (CE) who received lanreotide injections from January 2010 to till the present day at the Royal Hallamshire Hospital in Sheffield were included. Baseline demographics were recorded. Efficacy was evaluated in terms of improvement in mean haemoglobin, transfusion requirements and bleeding episodes. RESULTS Twelve patients (67% males, mean age 74 SD ± 15.5 years) were included. All patients had multiple comorbidities. Lanreotide was given at a dosage of 60 mg (42%), 90 mg (33%) or 120 mg (25%). It was given at a four-week interval in 75% of patients and at a six-week interval in 17% of patients. One patient (8%) received a single dose. The mean duration of treatment was 19 months SD ± 14.5. Only 17% of patients had their lanreotide stopped due to cholelithiasis. There was a significant improvement in mean haemoglobin: 86.8 versus 98.0 (131-166 g/L, p = .012). The mean number of bleeding episodes (4.18 versus 1.09, p = .010) and packed red cells (323 versus 152, p = .006) received improved. Patients required less DBEs ± APCs after starting lanreotide (19 versus 11 p = .048). CONCLUSION Lanreotide is a useful adjuvant treatment to therapeutic enteroscopy in patients with refractory obscure gastrointestinal bleeding due to SBAs. It improves haemoglobin levels, reduces transfusion requirements, bleeding episodes and number of DBEs. Overall, it has a good safety profile.
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Affiliation(s)
- S Chetcuti Zammit
- a Department of Gastroenterology , Royal Hallamshire Hospital , Sheffield, UK
| | - D S Sanders
- a Department of Gastroenterology , Royal Hallamshire Hospital , Sheffield, UK
| | - R Sidhu
- a Department of Gastroenterology , Royal Hallamshire Hospital , Sheffield, UK
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Allamneni C, Alkurdi B, Naseemuddin R, McGuire BM, Shoreibah MG, Eckhoff DE, Peter S. Orthotopic liver transplantation changes the course of gastric antral vascular ectasia: a case series from a transplant center. Eur J Gastroenterol Hepatol 2017; 29:973-976. [PMID: 28520574 DOI: 10.1097/meg.0000000000000908] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIM Gastric antral vascular ectasia (GAVE) is an important cause of upper gastrointestinal bleeding and anemia in patients with cirrhosis. The aim of our study was to evaluate the effect of orthotopic liver transplantation (OLT) on GAVE and associated anemia. PATIENTS AND METHODS We performed a chart review and identified all cirrhotic patients with GAVE who underwent OLT at the University Of Alabama at Birmingham between 2005 and 2013. Population's demographics, etiology of cirrhosis, comorbidities, presentation and treatment modalities of GAVE, endoscopic and histopathologic reports, hemoglobin values before and after transplant, and immunosuppressive regimens were collected. RESULTS Twelve patients were identified, mean age 52.4±4.4 years; seven were men (58.3%); 11 (91.7%) were White; and 6 of 12 patients had biopsy-proven GAVE. The most common etiology of cirrhosis in the cohort was chronic hepatitis C and obesity was the most common chronic condition in 50 and 83.3%, respectively. Anemia resolution was observed in 9/12 (75%) patients who underwent OLT with an increase in hemoglobin from 8.1±2.4 (5.7-13.1) before transplant to 12.0±1.4 (10-15) after transplant (P<0.0001). Esophagogastroduodenoscopy after transplant was performed in all 12 (100%) patients. The mean time between transplant and post-OLT esophagogastroduodenoscopy was 13.8±18.28 (2-57) months; complete resolution of GAVE was observed in 10 (83.3%) patients, with resolving GAVE in one (8.3%) patient. CONCLUSION GAVE is an important cause of anemia and upper gastrointestinal bleeding in patients with liver cirrhosis. Our findings show that liver transplantation can resolve GAVE and related anemia.
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Affiliation(s)
- Chaitanya Allamneni
- aDepartment of Medicine, Division of Gastroenterology and Hepatology bDepartment of Surgery, Division of Transplant Surgery cDepartment of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Garg S, Aslam B, Nickl N. Endoscopic resolution and recurrence of gastric antral vascular ectasia after serial treatment with argon plasma coagulation. World J Gastrointest Endosc 2017; 9:263-266. [PMID: 28690769 PMCID: PMC5483418 DOI: 10.4253/wjge.v9.i6.263] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/11/2017] [Accepted: 04/24/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To evaluate long-term endoscopic resolution and recurrence rate of gastric antral vascular ectasia (GAVE) after argon plasma coagulation (APC) treatment.
METHODS This was an IRB-approved retrospective single center study that included patients endoscopically treated for GAVE between 1/1/2008 to 12/31/2014. The primary and secondary end points of the study were rate of endoscopic resolution of GAVE after APC treatment and recurrence rate of GAVE after endoscopic resolution, respectively. Endoscopic resolution of GAVE was defined as no endoscopic evidence of GAVE after treatment with APC. Recurrence of GAVE was defined as endoscopic reappearance of GAVE after prior resolution.
RESULTS Twenty patients met the study criteria. Median age (range) of the patients was 59.5 years (42-74 years). GAVE was associated with underlying cirrhosis in 16 (80%) patients. Indications for initial esophagogastroduodenoscopy (EGD) included hematemesis and/or melena (9/20, 45%), iron deficiency anemia (6/20, 30%), screening or surveillance of varices (4/20, 20%), and occult gastrointestinal bleeding (1/20, 5%). The patients were treated with a total of 55 APC sessions (range 1-7 sessions). Successful endoscopic resolution of GAVE was achieved in 8 out of 20 patients (40%). There was no correlation between number of treatment sessions and GAVE treatment success (P = NS). Recurrence of GAVE was noted on a subsequent EGD in 2 out of 8 patients (25%) with prior endoscopic resolution of GAVE. Median follow-up period for the study population was 627 d (range 63-1953 d).
CONCLUSION Endoscopic resolution rate of GAVE was low (40%) with a 25% recurrence rate after treatment with APC. These rates suggest that APC treatment of GAVE may not be optimal in many circumstances.
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Duarte BKL, de Souza SM, Costa-Lima C, Medina SS, Ozelo MC. Thalidomide for the Treatment of Gastrointestinal Bleeding Due to Angiodysplasia in a Patient with Glanzmann's Thrombasthenia. Hematol Rep 2017; 9:6961. [PMID: 28670433 PMCID: PMC5477473 DOI: 10.4081/hr.2017.6961] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 03/21/2017] [Indexed: 01/06/2023] Open
Abstract
Angiodysplasia is a frequent cause of persistent gastrointestinal (GI) hemorrhage in elderly patients. Although GI bleeding isn't the most common manifestation in patients with bleeding disorders, when present, it represents a challenging complication. We describe a 62-year-old patient with Glanzmann's thrombasthenia, who used thalidomide for severe and recurrent GI bleeding. For 6 months, the patient experienced temporary control of GI bleeding with thalidomide in a daily oral dose of 100 mg. The anti-angiogenic effects of thalidomide have recently been explored by several groups, particularly in the management of bleeding from angiodysplasia, including cases with von Willebrand disease. Here, we review the relevant descriptions of the use of thalidomide in this situation, and also discuss potential reasons why we observed only a temporary control of the GI bleeding in our patient, such as the use of low-dose regimen due to limitations posed by thalidomide side effects.
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Affiliation(s)
- Bruno K L Duarte
- Instituto Nacional de Ciência e Tecnologia do Sangue, Hemocentro Unicamp, Campinas, SP, Brazil
| | - Sílvia M de Souza
- Instituto Nacional de Ciência e Tecnologia do Sangue, Hemocentro Unicamp, Campinas, SP, Brazil
| | - Carolina Costa-Lima
- Instituto Nacional de Ciência e Tecnologia do Sangue, Hemocentro Unicamp, Campinas, SP, Brazil
| | - Samuel S Medina
- Instituto Nacional de Ciência e Tecnologia do Sangue, Hemocentro Unicamp, Campinas, SP, Brazil
| | - Margareth C Ozelo
- Instituto Nacional de Ciência e Tecnologia do Sangue, Hemocentro Unicamp, Campinas, SP, Brazil.,Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
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Bosch X, Montori E, Guerra-García M, Costa-Rodríguez J, Quintanilla MH, Tolosa-Chapasian PE, Moreno P, Guasch N, López-Soto A. A comprehensive evaluation of the gastrointestinal tract in iron-deficiency anemia with predefined hemoglobin below 9mg/dL: A prospective cohort study. Dig Liver Dis 2017; 49:417-426. [PMID: 28065528 DOI: 10.1016/j.dld.2016.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 12/06/2016] [Accepted: 12/09/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anemia is defined as hemoglobin below the cutoff of normal in studies examining the gastrointestinal (GI) tract in iron-deficiency anemia (IDA). Although the risk of GI cancer (GIC) increases as hemoglobin decreases, guidelines do not usually recommend hemoglobin thresholds for IDA investigation. METHODS To elucidate whether underlying GI disorders explain the different hemoglobin values and clinical outcomes observed initially in IDA patients referred for GI workup, we prospectively investigated the diagnostic yield of a thorough GI examination in consecutive IDA adults with predefined hemoglobin <9g/dL and no extraintestinal bleeding. RESULTS 4552 patients were enrolled over 10 years. 96% of 4038 GI lesions were consistent with occult bleeding disorders and 4% with non-bleeding disorders. Predominant bleeding disorders included upper GI ulcerative/erosive lesions (51%), GIC (15%), and angiodysplasias (12%). Diffuse angiodysplasias (45% of angiodysplasias) and GIC showed the lowest hemoglobin values (6.3 [1.5] and 6.4 [1.3]g/dL, respectively). While the spread (diffuse vs. localized) and number (<3 vs. ≥3) of angiodysplasias correlated with the degree of anemia, hemoglobin values were lower in GIC with vs. without ulcerated/friable lesions (6.0 [1.1] vs. 7.0 [1.2]g/dL, P<0.001). CONCLUSION Not only GIC but also diffuse angiodysplasias caused the most severe anemia in IDA with predefined hemoglobin values <9g/dL.
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Affiliation(s)
- Xavier Bosch
- Quick Diagnosis Unit, Adult Day Care Center, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Department of Internal Medicine, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Elisabet Montori
- Quick Diagnosis Unit, Department of Internal Medicine, Hospital Plató, Barcelona, Spain
| | - Mar Guerra-García
- Quick Diagnosis Unit, Adult Day Care Center, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | | | | | | | - Pedro Moreno
- Department of Internal Medicine, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Neus Guasch
- Quick Diagnosis Unit, Adult Day Care Center, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Alfons López-Soto
- Department of Internal Medicine, Clinical Institute of Medicine and Dermatology (ICMiD), Hospital Clínic, Institutd'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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El-Gendy H, Shohdy KS, Maghraby GG, Abadeer K, Mahmoud M. Gastric antral vascular ectasia in systemic sclerosis: Where do we stand? Int J Rheum Dis 2017; 20:2133-2139. [PMID: 28217887 DOI: 10.1111/1756-185x.13047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Gastric antral vascular ectasia (GAVE) continues to be a challenge in both diagnosis and treatment. GAVE has a diverse group of associations and presumed causes, including cirrhosis, chronic renal failure and autoimmune connective tissue diseases. However, in most occasions, the management plan of GAVE itself is the same whatever the underlying disease by using Argon plasma coagulation (APC). Herein, we will discuss three cases of systemic sclerosis-associated GAVE presenting with either acute or chronic gastrointestinal bleeding showing variable responses to APC. Anemia and telangiectasia may be the first striking presentation of systemic sclerosis (SSc). Renal artery stenosis, aortic stenosis, widespread cutaneous and mucosal telangiectasia and hypertension seem to be associated with poor prognosis and should prompt rapid intervention and careful follow-up. Moreover, the hunt for molecular underpinnings of the broad array of vascular lesions in SSc has to include von Willebrand factor and endoglin. Eventually, we will review the recent alternatives that can be effective in SSc-GAVE, such as band ligation, hematopoietic stem cells transplantation and immunotherapy.
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Affiliation(s)
- Hala El-Gendy
- Rheumatology & Clinical Immunology Unit, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Kyrillus S Shohdy
- Rheumatology & Clinical Immunology Unit, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Gehad G Maghraby
- Rheumatology & Clinical Immunology Unit, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Moustafa Mahmoud
- Rheumatology & Clinical Immunology Unit, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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30
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Martins NB, Chaput KJ, Stawicki SP, Modi R. Octreotide as an adjunct in the management of arterial gastrointestinal bleeding: Should it be considered in refractory cases of obscure origin? Int J Crit Illn Inj Sci 2017; 7:8-11. [PMID: 28382252 PMCID: PMC5364774 DOI: 10.4103/ijciis.ijciis_14_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Noel B Martins
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Kimberly J Chaput
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Stanislaw P Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Ronak Modi
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
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31
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Zepeda-Gómez S. Endoscopic Treatment for Gastric Antral Vascular Ectasia: Current Options. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 24:176-182. [PMID: 29255747 DOI: 10.1159/000453271] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/04/2016] [Indexed: 01/10/2023]
Abstract
Gastric antral vascular ectasia (GAVE) is a capillary-type vascular malformation located primarily in the gastric antrum. Patients can present with iron-deficiency anemia, overt gastrointestinal bleeding, or both. Diagnosis and characterization is made at endoscopic examination, and the preferred management of patients with GAVE is endoscopic therapy. Herein, we present a review of the evidence about the efficacy, complications, and outcomes of the most frequently used endoscopic therapies for GAVE.
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Abstract
OBJECTIVE 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. METHODS We administered a 19-item web-based survey to gastroenterologists in the Netherlands between February and April of 2015. RESULTS 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. CONCLUSION 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.
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Iannone A, Principi M, Barone M, Losurdo G, Ierardi E, Di Leo A. Gastrointestinal bleeding from vascular malformations: Is octreotide effective to rescue difficult-to-treat patients? Clin Res Hepatol Gastroenterol 2016; 40:373-7. [PMID: 27595456 DOI: 10.1016/j.clinre.2016.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 01/15/2016] [Accepted: 02/09/2016] [Indexed: 02/07/2023]
Abstract
Gastrointestinal vascular malformations are responsible for 2-8% of all cases of bleeding and 30-40% of all obscure hemorrhages, being the most frequent cause of occult bleeding in older people. The aim of this review was to provide an up-to-date report about the use of octreotide in bleeding from both hereditary and acquired vascular malformations of the gastrointestinal tract. A systematic literature search was performed, using the keywords "gastrointestinal vascular malformation", "octreotide", "angiodysplasia", "portal hypertensive gastropathy", "gastric antral vascular ectasia", and "hereditary vascular malformations". The first line therapy of acute/chronic bleeding from digestive vascular malformations is endoscopy, followed by angiographic embolization and surgical resection when this is unsuccessful. In the setting of difficult-to-treat patients, octreotide has been proposed as an alternative therapeutic strategy. Studies reported in the literature show a high efficacy and safety of octreotide, but described only a small number of enrolled patients, heterogeneous therapeutic schedules and short-term follow-up, with the exception of acute bleeding from esophageal varices. As a consequence, the use of octreotide is not approved in this setting and it is currently still prescribed as an off-label drug. Studies in larger populations are needed to confirm the promising results observed in the small case series reports, so as to provide physicians with a treatment option for patients without available alternatives. Octreotide could also determine a strong decrease in the management costs of these clinical conditions, and especially, could dramatically reduce hospital admission costs.
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Affiliation(s)
- Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Mariabeatrice Principi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Michele Barone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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Emmanuel A. Current management of the gastrointestinal complications of systemic sclerosis. Nat Rev Gastroenterol Hepatol 2016; 13:461-72. [PMID: 27381075 DOI: 10.1038/nrgastro.2016.99] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic sclerosis is a multisystem autoimmune disorder that involves the gastrointestinal tract in more than 90% of patients. This involvement can extend from the mouth to the anus, with the oesophagus and anorectum most frequently affected. Gut complications result in a plethora of presentations that impair oral intake and faecal continence and, consequently, have an adverse effect on patient quality of life, resulting in referral to gastroenterologists. The cornerstones of gastrointestinal symptom management are to optimize symptom relief and monitor for complications, in particular anaemia and malabsorption. Early intervention in patients who develop these complications is critical to minimize disease progression and improve prognosis. In the future, enhanced therapeutic strategies should be developed, based on an ever-improving understanding of the intestinal pathophysiology of systemic sclerosis. This Review describes the most commonly occurring clinical scenarios of gastrointestinal involvement in patients with systemic sclerosis as they present to the gastroenterologist, with recommendations for the suggested assessment protocol and therapy in each situation.
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Affiliation(s)
- Anton Emmanuel
- Gastrointestinal Physiology Unit, University College Hospital, 235 Euston Road, London NW1 2BU, UK
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35
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Small Intestinal Angioectasias Are Not Randomly Distributed in the Small Bowel and Most May Be Reached by Push Enteroscopy. J Clin Gastroenterol 2016; 50:561-5. [PMID: 26485105 DOI: 10.1097/mcg.0000000000000425] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
GOALS The goal was to describe the location of angioectasias within small bowel on capsule endoscopy and the utility of push enteroscopy versus deep enteroscopy in treatment of overt bleeding from these. BACKGROUND Overt bleeding from small bowel angioectasias is a clinical challenge. Thalidomide and octreotide can be difficult to prescribe and may not be effective. Endoscopy remains a mainstay of treatment for overt bleeding from angioectasias but data regarding the long-term efficacy of endoscopic therapy are limited. We sought to define the location of small bowel angioectasias using capsule endoscopy and review our outcomes for push and double-balloon enteroscopy. METHODS We retrospectively reviewed all 428 capsule endoscopy studies from the Veterans Administration Hospital in West Haven, CT from 2005 to 2012. Location of angioectasias was evaluated using lead mapping and small bowel transit time. RESULTS We identified 69 patients with small bowel angioectasia. At least 66.8% of lesions were in duodenum or ligament of Treitz, with 78.3% within the first 25% of small bowel transit. Twenty-four patients underwent endoscopic treatment of overt bleeding from small bowel angioectasias. Thirty-three percent rebled requiring multiple procedures. Eight patients had 10 anterograde double-balloon examinations. Only 2 patients had both cessation of bleeding with double balloon and lesions outside the reach of push enteroscopy. CONCLUSIONS Push enteroscopy for bleeding angioectasias is effective in many patients. Deep enteroscopy may not benefit most patients as most angioectasias are proximal. Patients with deeper lesions tended to have multiple lesions and rebleeding despite deep enteroscopy.
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Evaluation of Superselective Transcatheter Arterial Embolization with n-Butyl Cyanoacrylate in Treating Lower Gastrointestinal Bleeding: A Retrospective Study on Seven Cases. Gastroenterol Res Pract 2016; 2016:8384349. [PMID: 27528867 PMCID: PMC4978829 DOI: 10.1155/2016/8384349] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 06/19/2016] [Indexed: 12/20/2022] Open
Abstract
Background. To investigate the safety and efficacy of superselective transcatheter arterial embolization (TAE) with n-butyl cyanoacrylate (NBCA) in treating lower gastrointestinal bleeding caused by angiodysplasia. Methods. A retrospective study was performed to evaluate the clinical data of the patients with lower gastrointestinal bleeding caused by angiodysplasia. The patients were treated with superselective TAE with NBCA between September 2013 and March 2015. Angiography was performed after the embolization. The clinical signs including melena, anemia, and blood transfusion treatment were evaluated. The complications including abdominal pain and intestinal ischemia necrosis were recorded. The patients were followed up to evaluate the efficacy in the long run. Results. Seven cases (2 males, 5 females; age of 69.55 ± 2.25) were evaluated in the study. The embolization was successfully performed in all cases. About 0.2-0.8 mL (mean 0.48 ± 0.19 mL) NCBA was used. Immediate angiography after the embolization operation showed that the abnormal symptoms disappeared. The patients were followed up for a range of 2-19 months and six patients did not reoccur. No serious complications, such as femoral artery puncture point anomaly, vascular injury, and intestinal necrosis perforation were observed. Conclusion. For the patients with refractory and repeated lower gastrointestinal hemorrhage due to angiodysplasia, superselective TAE with NBCA seem to be a safe and effective alternative therapy when endoscopy examination and treatment do not work.
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Papachristos DA, Nikpour M, Hair C, Stevens WM. Intravenous cyclophosphamide as a therapeutic option for severe refractory gastric antral vascular ectasia in systemic sclerosis. Intern Med J 2016; 45:1077-81. [PMID: 26429218 DOI: 10.1111/imj.12883] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 04/07/2015] [Indexed: 12/17/2022]
Abstract
Gastric antral vascular ectasia (GAVE) is a rare but important cause of upper gastrointestinal bleeding. It is commonly associated with autoimmune conditions such as systemic sclerosis, and standard treatment involves both supportive measures, as well as endoscopic interventional therapies. While the current therapies are effective for most patients, a few patients develop severe and refractory bleeding. Herein we report two cases of refractory GAVE in patients with diffuse scleroderma, which improved significantly after the administration of intravenous cyclophosphamide. One of these cases is, to our knowledge, the first reported case of cyclophosphamide being used specifically for the treatment of refractory GAVE.
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Affiliation(s)
- D A Papachristos
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - M Nikpour
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - C Hair
- Department of Gastroenterology, Barwon Health, Geelong, Victoria, Australia.,Department of Medicine, Deakin University, Geelong, Victoria, Australia
| | - W M Stevens
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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Barré A, Dréanic J, Flaujac C, Roussel-Robert V, Stieltjes N, Combe-Marzelle S, Coriat R, Horellou MH. Is there a role for antiangiogenic therapy, bevacizumab, in the treatment of recurrent digestive bleeding due to angiodysplasia in Glanzmann's thrombasthenia? Haemophilia 2016; 22:e347-8. [DOI: 10.1111/hae.12977] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2016] [Indexed: 11/28/2022]
Affiliation(s)
- A. Barré
- Department of Gastroenterology; Hôpital Cochin; Assistance Publique Hôpitaux de Paris (AP-HP); Paris France
| | - J. Dréanic
- Department of Gastroenterology; Hôpital Cochin; Assistance Publique Hôpitaux de Paris (AP-HP); Paris France
- Department of Haematology and Regional Centre of Haemophilia Treatment; Hôpital Cochin; Assistance Publique Hôpitaux de Paris (AP-HP); Sorbonne Paris Cité; Université Paris Descartes; Paris France
| | - C. Flaujac
- Department of Haematology and Regional Centre of Haemophilia Treatment; Hôpital Cochin; Assistance Publique Hôpitaux de Paris (AP-HP); Sorbonne Paris Cité; Université Paris Descartes; Paris France
| | - V. Roussel-Robert
- Department of Haematology and Regional Centre of Haemophilia Treatment; Hôpital Cochin; Assistance Publique Hôpitaux de Paris (AP-HP); Sorbonne Paris Cité; Université Paris Descartes; Paris France
| | - N. Stieltjes
- Department of Haematology and Regional Centre of Haemophilia Treatment; Hôpital Cochin; Assistance Publique Hôpitaux de Paris (AP-HP); Sorbonne Paris Cité; Université Paris Descartes; Paris France
| | - S. Combe-Marzelle
- Department of Haematology and Regional Centre of Haemophilia Treatment; Hôpital Cochin; Assistance Publique Hôpitaux de Paris (AP-HP); Sorbonne Paris Cité; Université Paris Descartes; Paris France
| | - R. Coriat
- Department of Gastroenterology; Hôpital Cochin; Assistance Publique Hôpitaux de Paris (AP-HP); Paris France
- Faculté de médecine Paris Descartes; Sorbonne Paris Cité; Paris France
| | - MH. Horellou
- Department of Haematology and Regional Centre of Haemophilia Treatment; Hôpital Cochin; Assistance Publique Hôpitaux de Paris (AP-HP); Sorbonne Paris Cité; Université Paris Descartes; Paris France
- Faculté de médecine Paris Descartes; Sorbonne Paris Cité; Paris France
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Upper gastrointestinal bleeding (watermelon stomach) in a patient with limited scleroderma (CREST syndrome). ACTA ACUST UNITED AC 2016; 13:361-362. [PMID: 27353193 DOI: 10.1016/j.reuma.2016.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 05/20/2016] [Accepted: 05/26/2016] [Indexed: 01/19/2023]
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40
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ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol 2016; 111:459-74. [PMID: 26925883 PMCID: PMC5099081 DOI: 10.1038/ajg.2016.41] [Citation(s) in RCA: 276] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 01/02/2016] [Indexed: 12/11/2022]
Abstract
This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.
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Dias de Castro F, Boal Carvalho P, Cúrdia Gonçalves T, Magalhães J, Moreira MJ, Marinho C, Cotter J. Treating Gastric Antral Vascular Ectasia - When Argon Therapy Is Not Enough. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:249-253. [PMID: 28868470 PMCID: PMC5579983 DOI: 10.1016/j.jpge.2016.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 01/03/2016] [Indexed: 02/07/2023]
Abstract
Gastric antral vascular ectasia (GAVE) is a capillary-type vascular malformation of the gastric antrum and an infrequent cause of chronic gastrointestinal blood loss and iron deficiency anemia. The authors describe a case report of GAVE in a female cirrhotic patient presenting with severe symptomatic iron deficiency anemia. After failure of argon plasma coagulation (APC), the patient was treated with endoscopic band ligation (EBL) with resolution of anemia, without new episodes of rebleeding and no need for further hospitalizations or transfusion requirements. Even though APC is the current treatment of choice for GAVE recurrence-free survival at one year is achieved in less than 50% of the patients and failed therapy has been described in up to 14% of the patients. EBL has been reported to be a relatively easy technique for GAVE therapy and has been shown to be safe and effective with lower complication rates in comparison with APC. This technique may in the future be used as the initial endoscopic treatment to eradicate GAVE.
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Affiliation(s)
- Francisca Dias de Castro
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Pedro Boal Carvalho
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Joana Magalhães
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Maria João Moreira
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Carla Marinho
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Guimarães, Portugal
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Salzano A, Rocca A, Arcopinto M, Amato B, Marra AM, Simonelli V, Mozzillo P, Giuliani A, Tafuri D, Cinelli M. Bowel Angiodysplasia and Myocardial Infarction secondary to an ischaemic imbalance: a case report. Open Med (Wars) 2015; 10:543-548. [PMID: 28352752 PMCID: PMC5368879 DOI: 10.1515/med-2015-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 11/05/2015] [Indexed: 11/24/2022] Open
Abstract
Angiodysplasia, defined as a vascular ectasia or arteriovenous malformation, is the most frequent cause of occult bleeding in patients older than 60 years and a significant association with several cardiac condition is described. Patients with anemia and negative findings on upper endoscopy and colonoscopy should be referred for further investigation of the small bowel. The investigation of choice, when available, is wireless capsule endoscopy. Several therapeutic options are available in this cases, as we reviewed in this report. We report a case of 78-year old man admitted to our Intensive Coronary Unit for dyspnea and chest pain. A diagnosis of non-ST-segment elevation acute coronary syndrome was made and a concomintant, significant anemia was found (hemoglobin 8.2 g/dl). No cororary disease was found by an angiography though the past medical history revealed systemic hypertension, chronic kidney disease (KDOQY stage III), and diabetes mellitus type II on insuline therapy. A Wireless Video capsule examination was positive for jejunum angiodysplasia and an argon plasma coagulation was chosen as terapeutic option. No subsequent supportive therapy and interventions were required in subsequent one year of follow-up.
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Affiliation(s)
- Andrea Salzano
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - Aldo Rocca
- Department of Clinical Medicine and Surgery, University of Naples "Federico II" Naples, Italy, Via Sergio Pansini, 80131 Naples, Italy
| | - Michele Arcopinto
- Department of Cardiac Surgery, IRCCS Policlinico San Donato Milanese, Milan, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Alberto Maria Marra
- Pulmonary Hypertension Center, Thoraxclinic at the University of Heidelberg, Heidelberg, Germany
| | | | - Pasquale Mozzillo
- Centre Hospitalier intercommunal de Poissy, Saint-Germain-en-Laye, France
| | - Antonio Giuliani
- Unit of Hepatobiliary Surgery and Liver Transplant Center, Department of Gastroenterology and Transplantation, "A. Cardarelli" Hospital, Naples, Italy
| | - Domenico Tafuri
- Department of Sport Sciences and Wellness, University of Naples "Parthenope", Naples, Italy
| | - Mariapia Cinelli
- Department of Public Health, University of Naples "Federico II", Naples, Italy
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Abstract
Systemic sclerosis (SSc) is a rare autoimmune disease characterized by autoantibody production, small-vessel vasculopathy, and skin and other organ fibrosis. The disease is clinically heterogeneous with most patients having some degree of skin sclerosis with varying organ system involvement. Early disease can be difficult to diagnose, especially with minimal skin sclerosis and absence of anti-nuclear antibody (ANA) positivity; however, studies have demonstrated early diagnosis is important as early treatment could potentially lead to better outcomes. New classification criteria have recently been published that have higher sensitivity for detecting early disease thus allowing for a broader spectrum of patients to be represented in clinical trials. Treatment guidelines have been published based on a limited number of randomized-controlled clinical trials; however, there are ongoing phase II and III clinical trials with novel agents that are promising and will change the treatment landscape over the next decade.
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Affiliation(s)
- Courtney J McCray
- Division of Rheumatology and Clinical Immunogenetics, Department of Internal Medicine, University of Texas Health Science Center-Houston (UTHSC-H), 6431 Fannin St. MSB 5.278, Houston, TX, 77030, USA
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44
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Parikh K, Ali MA, Wong RCK. Unusual Causes of Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:583-605. [PMID: 26142040 DOI: 10.1016/j.giec.2015.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Upper gastrointestinal (GI) bleeding is an important clinical condition managed routinely by endoscopists. Diagnostic and therapeutic options vary immensely based on the source of bleeding and it is important for the gastroenterologist to be cognizant of both common and uncommon etiologies. The focus of this article is to highlight and discuss unusual sources of upper GI bleeding, with a particular emphasis on both the clinical and endoscopic features to help diagnose and treat these atypical causes of bleeding.
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Affiliation(s)
- Keyur Parikh
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA
| | - Meer Akbar Ali
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA
| | - Richard C K Wong
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA.
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45
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Abstract
PURPOSE OF REVIEW The gastrointestinal tract is the most common extra-cutaneous organ system involved with systemic sclerosis (SSc) affecting approximately 90% of patients. This review summarizes the recent advances in the evaluation and management of gastrointestinal manifestations of SSc. RECENT FINDINGS There is a growing body of evidence that uncontrolled GERD can play a significant role in the pathogenesis of SSc-associated interstitial lung disease. Newer forms of management of Barrett esophagus are showing significant promise as potentially curative therapy. Gastric antral vascular ectasias have strongly been associated with the presence of RNA polymerase III antibody. Newer technologies have advanced the assessment of gastrointestinal dysmotility in SSc. Evidence of probiotic use for the treatment of gastrointestinal complications is emerging. The UCLA SCTC GIT 2.0 questionnaire is being increasingly accepted by the SSc experts as a validated instrument for evaluation of patient-reported outcomes involving the gastrointestinal tract. SUMMARY Our knowledge of the complex pathogenesis of gastrointestinal manifestations of SSc has expanded substantially in the last few decades. There has also been considerable technological progress in the evaluation of these manifestations. Patient care is being optimized by close collaboration of rheumatologists and gastroenterologists, leading to a more coordinated approach in the management of these complications.
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46
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Peter S, Wilcox CM. Radiofrequency ablation therapy - the grave for GAVE (gastric antral vascular ectasia)? Endosc Int Open 2015; 3:E128-9. [PMID: 26135653 PMCID: PMC4477023 DOI: 10.1055/s-0034-1391854] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 02/20/2015] [Indexed: 02/07/2023] Open
Affiliation(s)
- Shajan Peter
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, AL, USA,Corresponding author Shajan Peter, MD Department of GastroenterologyBasil Hirschowitz Endoscopic Center of Endoscopic Excellence6th Floor Jefferson Tower625 19th Street SouthBirminghamAL 35249USA+1-205-934-8493
| | - C. Mel Wilcox
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, AL, USA
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47
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Nagaraja V, McMahan ZH, Getzug T, Khanna D. Management of gastrointestinal involvement in scleroderma. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2015; 1:82-105. [PMID: 26005632 DOI: 10.1007/s40674-014-0005-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastrointestinal tract (GIT) commonly affects patients with systemic sclerosis (SSc). The GI involvement is quite heterogeneous varying from asymptomatic disease to significant dysmotility causing complications like malabsorption, weight loss and severe malnutrition. This review focuses on the management of GI involvement in SSc and has been categorized based on the segment of GIT involved. A brief discussion on the role of patient reported outcome measures in SSc-GI involvement has also been incorporated.
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Affiliation(s)
- Vivek Nagaraja
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | | | - Terri Getzug
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
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48
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Patwardhan VR, Cardenas A. Review article: the management of portal hypertensive gastropathy and gastric antral vascular ectasia in cirrhosis. Aliment Pharmacol Ther 2014; 40:354-62. [PMID: 24889902 DOI: 10.1111/apt.12824] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/12/2014] [Accepted: 05/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are important causes of both acute and chronic gastrointestinal bleeding in patients with cirrhosis. AIM To review the current management of PHG and GAVE. METHODS PubMed was searched for English language articles using the key words 'GAVE', 'gastric antral vascular ectasia', 'cirrhosis', 'gastrointestinal bleeding', 'acute', 'chronic', 'portal hypertensive gastropathy', 'watermelon stomach', 'radiofrequency ablation', 'band ligation', 'thermoablation' and 'TIPSS'. RESULTS GAVE and PHG are both encountered in patients with cirrhosis. They can be seen in asymptomatic patients and in those with either acute or chronic gastrointestinal bleeding. PHG, by definition, requires the presence of portal hypertension, with or without cirrhosis, whereas GAVE requires neither cirrhosis nor portal hypertension. They can often be diagnosed on endoscopic appearance alone, but may require biopsy in certain cases. The treatment of PHG is aimed at reducing hepatic venous pressure gradients, most often by pharmacologic means, but may require shunt procedures in severe cases. Management of GAVE on the other hand is predominantly endoscopic, focusing on various ablative techniques. CONCLUSIONS Gastric antral vascular ectasia and portal hypertensive gastropathy are distinct entities and are both encountered in cirrhotic patients. Management of portal hypertensive gastropathy is centred on reduction in portal pressures, whereas treatment of gastric antral vascular ectasia is predominantly endoscopic.
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49
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Nardone G, Compare D, Scarpignato C, Rocco A. Long acting release-octreotide as "rescue" therapy to control angiodysplasia bleeding: A retrospective study of 98 cases. Dig Liver Dis 2014; 46:688-94. [PMID: 24893688 DOI: 10.1016/j.dld.2014.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 03/25/2014] [Accepted: 04/26/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastrointestinal angiodysplasias are an important cause of difficult to manage bleeding, especially in older patients. AIM To retrospectively evaluate the long-term efficacy of long acting release-octreotide in controlling angiodysplasia bleeding. METHODS 98 patients with a history of bleeding due to gastrointestinal angiodysplasias lasting over 2 years were retrospectively selected among those treated from January 2000 to December 2008. All patients had received octreotide 0.1mg tid for 28 days and, then from day 14, long acting release-octreotide 20mg monthly, for 6 months. RESULTS The mean follow-up was 78 months. In all patients mean haemoglobin levels significantly increased and the number of bleeding episodes, hospitalizations, patients requiring blood transfusions and units of transfused red cells significantly decreased, compared to the two-year observation period before starting therapy. According to outcome patients were classified as: 40 full responders (40.8%), 32 relapsers (32.6%) and 26 poor responders (26.5%). At multivariate analysis age >65 years, male sex, chronic antiplatelet therapy, chronic obstructive pulmonary disease and chronic renal failure were the only covariates independently associated with poor response to therapy. CONCLUSION Our study suggests that long acting release-octreotide could be used as rescue therapy to control bleeding due to gastrointestinal angiodysplasias in patients not suitable for endoscopic or surgical treatments.
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Affiliation(s)
- Gerardo Nardone
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy.
| | - Debora Compare
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy
| | - Carmelo Scarpignato
- Laboratory of Clinical Pharmacology, Division of Gastroenterology, Department of Clinical Sciences, University of Parma, Parma, Italy
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy
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