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Mohee K, Aldalati O, Dworakowski R, Haboubi H. Aortic stenosis and anemia with an update on approaches to managing angiodysplasia in 2018. Cardiol J 2018; 27:72-77. [PMID: 30009379 DOI: 10.5603/cj.a2018.0068] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/11/2018] [Indexed: 11/25/2022] Open
Abstract
Angiodyplasia and aortic stenosis are both conditions that are highly prevalent in elderly people and can often co-exist. Recent studies suggest that this association is related to subtle alterations in plasma coagulation factors. The von Willebrand factor is the strongest link between aortic stenosis and bleeding associated with gastrointestinal angiodysplasia. With an ageing population, the disease burden of aortic stenosis and its association with angiodysplasia of the bowel makes this an incredibly underdiagnosed yet important condition. Clinicians should be aware of this association when dealing with elderly patients presenting either with unexplained anemia, gastrointestinal bleeding or with aortic stenosis. A high index of suspicion and appropriate diagnostic techniques followed by appropriate and prompt treatment could be life-saving. No clear guidelines exist on management but surgical aortic valve replacement is thought to offer the best hope for long-term resolution of bleeding. With a growing number of technological armamentarium in the management of such patients, especially with the advent of transcatheter aortic valve implantation, new options can be offered even to elderly patients with comorbidities for whom conventional surgery would have been impossible.
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Affiliation(s)
- Kevin Mohee
- Department of Cardiology, ABMU Health Board, Morriston Hospital, Swansea, SA6 6NL Swansea, United Kingdom
| | | | - Rafal Dworakowski
- Kings College London, London, United Kingdom. .,Department of Cardiology, Medical University of Gdansk, Poland.
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Affiliation(s)
- Joseph Loscalzo
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
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Percutaneous sclerotherapy of peripheral venous malformations in pediatric patients. Pediatr Surg Int 2011; 27:1283-7. [PMID: 21818522 DOI: 10.1007/s00383-011-2962-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2011] [Indexed: 11/27/2022]
Abstract
PURPOSE To report the efficacy of percutaneous puncture and sclerosis using polidocanol in the treatment of venous malformations (VMs) in pediatric patients. PATIENTS/METHODS Between March 2007 and February 2011, a series of 19 patients with VMs on the upper and lower extremities had undergone a total of 89 sessions of intralesional sclerotherapy using polidocanol. All the procedures were performed in an angiographic suite under general anesthesia in order to maintain sedation for facilitating the procedure. For each injection, approximately 1 ml of 2% polidocanol was injected for each centimeter of the diameter of the lesion, with a maximum of 6 ml. Injection of the sclerosant was guided by real-time sonography and fluoroscopy. RESULTS After the treatment, the symptoms completely resolved in four patients (21%). Clinical symptoms, such as bulging and pain were improved in 12 out of 19 patients (63%). They remained unchanged in three patients (16%). During the procedures, no major complications were encountered. The minor complications (65%) encountered were swelling and pain after treatment which were resolved by taking NSAID within a few days. CONCLUSION In pediatric patients, sonographically guided percutaneous puncture and fluoroscopically guided sclerosis using 2% polidocanol is effective, less invasive and safe for the treatment of VMs, with a high success rate and minimal complications.
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Treatment of gastrointestinal angiodysplasia and unmet needs. Dig Liver Dis 2011; 43:515-22. [PMID: 21239239 DOI: 10.1016/j.dld.2010.12.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Revised: 11/23/2010] [Accepted: 12/08/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastrointestinal angiodysplasia (GIAD) may either be asymptomatic or induce overt or obscure bleeding with a high risk of recurrence. Numerous therapeutic options are available but evidence bases are lacking. AIM We conducted a comprehensive review of pharmacological and endoscopic treatments for previous or active bleeding GIAD and established the unmet needs of the clinicians. METHODS Clinical trials, series, and reports, having been selected through PubMed inquiry, manual searching, and reference list reviewing, were classified by levels of evidence. RESULTS Controlled studies focusing on GIAD treatment, excluding other GI vascular malformations, are rare. Endoscopic destruction, preferably using non-contact endoscopic techniques, is most often proposed as a first-line treatment for GIAD (expert level). In addition, APC is preferred over Nd:Yag laser due to the lower risk of perforation (expert level). Pharmacological treatments for GIAD are considered either when endoscopy fails to access the AD or in order to prevent rebleeding for "chronic bleeding patients." Octreotide and oestroprogestative treatments are the best evaluated drugs; however, no appropriate comparison on cost-effectiveness and tolerance has been performed. CONCLUSIONS The most effective therapeutic strategy for bleeding GIAD is currently inconclusive, and new trials should be performed to address unmet needs.
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Abstract
Obscure gastrointestinal bleeding (OGIB) is defined as an intermittent or continuous loss of blood in which the source has not been identified after upper endoscopy and colonoscopy. It constitutes a diagnostic and therapeutic challenge for the general internist and the gastroenterologist. This article provides an overview of the etiology, clinical presentation, and diagnostic modalities of OGIB including push enteroscopy, double balloon enteroscopy, wireless capsule endoscopy, enteroclysis, angiography, bleeding scanning with labeled red blood cells, and surgery with intraoperative enteroscopy. Therapeutic modalities including iron replacement, combined hormones, octreotide acetate, therapeutic endoscopy, and surgery are also discussed. In addition, a rational approach to patients with OGIB according to the clinical presentation is presented herein.
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Affiliation(s)
- Ronald Concha
- Division of Gastroenterology, University of Miami, Miller School of Medicine/Mt. Sinai Medical Center, Miami Beach, FL 33140, USA
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Junquera F, Brullet E, Campo R, Calvet X, Puig-Diví V, Vergara M. Usefulness of endoscopic band ligation for bleeding small bowel vascular lesions. Gastrointest Endosc 2003; 58:274-9. [PMID: 12872104 DOI: 10.1067/mge.2003.357] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal therapy for bleeding small bowel vascular lesions is controversial. This study investigated the efficacy and safety of endoscopic band ligation in this clinical condition. METHODS Fourteen patients bleeding from angiodysplasia and 4 bleeding from Dieulafoy's lesions located in the small bowel were included in this pilot study. Endoscopic band ligation was performed by using less than 200 mBar negative pressure in suctioning the target lesion into the ligation cap just before band release. Mean follow-up was 18 months (range 6-31 months). OBSERVATIONS Endoscopic band ligation achieved hemostasis in a single session in all patients. No adverse events occurred except for mild abdominal pain in two patients. Mortality was null, and no patient required further blood transfusion during the 40 days after endoscopic band ligation. No patient with Dieulafoy's lesion had further bleeding, whereas bleeding recurred in 6 of 14 (43%) patients with angiodysplasia during long-term follow-up. CONCLUSIONS Endoscopic band ligation is safe and effective for treatment of acutely bleeding small bowel vascular lesions. Although endoscopic band ligation is definitive therapy for Dieulafoy's lesion, long-term efficacy in the treatment of GI bleeding from angiodysplasia is limited.
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Affiliation(s)
- Félix Junquera
- Endoscopy Unit, UDIAT-CD, Corporació Parc Taulí, Sabadell, Spain
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Jain R, Bandhu S, Sawhney S, Mittal R. Sonographically guided percutaneous sclerosis using 1% polidocanol in the treatment of vascular malformations. JOURNAL OF CLINICAL ULTRASOUND : JCU 2002; 30:416-423. [PMID: 12210459 DOI: 10.1002/jcu.10091] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
PURPOSE The aim of this prospective study was to assess the safety and efficacy of sonographically guided percutaneous injection of 1% polidocanol for sclerosis of peripheral vascular malformations. METHODS Patients with vascular malformations of soft tissues were invited to enroll in the study. Gray-scale and color Doppler sonography were performed to determine the texture, margins, and size of the lesions and to determine whether high-velocity blood flow was present. Using real-time sonographic guidance, lesions were punctured with a 20/21-gauge spinal needle. When possible, venous return was occluded before injection. For each injection, 1-6 ml of 1% polidocanol was injected into 1 or more sites within the lesion. The sclerosing agent was not aspirated after injection. Repeat radiography was performed 1 month after each injection session. The procedure was repeated if the patient did not have a complete response, defined as an 80% or greater decrease in the volume of the lesion or resolution of the presenting symptoms. RESULTS Of the 15 patients enrolled, 9 had venous malformations, 3 had lymphangiomas, 1 had a recurrent aneurysmal bone cyst, 1 had a venous pseudoaneurysm, and 1 had an arteriovenous malformation of the pinna. Each patient received 1-20 injections of 1% polidocanol (mean +/- standard deviation, 3.3 +/- 4.8 injections). This treatment resulted in a complete response of 7 venous malformations, 3 lymphangiomas, and the arteriovenous malformation and partial response of 2 venous malformations, the recurrent aneurysmal bone cyst, and the venous pseudoaneurysm. Only minor complications occurred. CONCLUSIONS Sonographically guided percutaneous injection of 1% polidocanol for sclerosis of peripheral vascular lesions is simple, effective, and safe. This technique is especially effective in cases of soft tissue venous malformation and lymphangioma.
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Affiliation(s)
- Rajeev Jain
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110-029, India
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Adler DG, Baron TH. Endoscopic palliation of malignant gastric outlet obstruction using self-expanding metal stents: experience in 36 patients. Am J Gastroenterol 2002; 97:72-8. [PMID: 11808972 DOI: 10.1111/j.1572-0241.2002.05423.x] [Citation(s) in RCA: 366] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Malignant gastric outlet obstruction is seen in the setting of a variety of cancers, most commonly pancreatic. Self-expanding metal stents can be used to palliate these patients and restore the ability to eat. METHODS We reviewed the Mayo Clinic experience in the endoscopic treatment of malignant gastric outlet obstruction. Thirty-six patients (26 male, 10 female) were treated between October, 1998 and January, 2001. Data were collected from charts, endoscopy reports, x-rays, and telephone calls. A scoring system was created to grade the ability to eat. RESULTS All procedures were successful. Thirty-one of 36 patients (86%) required one stent at initial endoscopy, and 5/36 patients (14%) required two or more stents. Pretreatment, 19/36 patients (53%) were nil per os, 15/36 (42%) drank liquids, and 2/36 were able to eat soft solids. After stent placement, only 1/36 (3%) was still nil per os, 13/36 (36%) drank liquids, 13/36 (36%) ate soft solids, and 9/36 (25%) ate a full diet. The improvement in ability to eat using the scoring system was statistically significant (p < 0.0001). Nine of 36 patients (25%) required reintervention for recurrent symptoms. Sixteen of 36 patients (44%) had concomitant or subsequent development of biliary obstruction, of which 15 were successfully decompressed. CONCLUSIONS Self-expanding metal stents are a safe and efficacious method for palliating malignant gastric outlet obstruction. The majority of patients do not require reintervention, and those that do can usually be managed nonoperatively.
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Affiliation(s)
- Douglas G Adler
- Department of Medicine, Mayo Medical Center, Rochester, Minnesota, USA
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Mauro MA, Koehler RE, Baron TH. Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents. Radiology 2000; 215:659-69. [PMID: 10831681 DOI: 10.1148/radiology.215.3.r00jn30659] [Citation(s) in RCA: 164] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Metallic stents are currently an established component of the endoluminal treatment of stenoses within the blood vessels, bile ducts, esophagus, trachea, and bronchi. With the development of newer stent designs and delivery systems and the general momentum toward minimally invasive therapies, metallic stent placement has expanded into the nonsurgical therapy for gastroduodenal and colorectal obstructions. The use of metallic stents within the stomach, duodenum, or colon is intended not to be curative but to provide nonsurgical palliation for the symptoms of gastric or colonic obstruction. This palliation may be intended for the life of the patient in the case of unresectable disease or as a temporizing procedure prior to a definitive surgical procedure. In the latter clinical scenario, the benefits of a minimally invasive intestinal decompression procedure include (a) quick and noninvasive relief of the intestinal obstruction in an acutely ill patient that obviates a more extensive procedure; (b) allowance of time to improve a patient's overall medical condition and thus to allow a patient to better tolerate the definitive surgical procedure; and (c) reduction of the complexity of the definitive procedure by eliminating the need for staged procedures and allowing the definitive procedure to be performed at one setting.
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Affiliation(s)
- M A Mauro
- Department of Radiology and Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 2759, USA
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Mortensen MB. The role of gastrointestinal endosonography in diagnostic and therapeutic interventional procedures. EUROPEAN JOURNAL OF ULTRASOUND : OFFICIAL JOURNAL OF THE EUROPEAN FEDERATION OF SOCIETIES FOR ULTRASOUND IN MEDICINE AND BIOLOGY 1999; 10:93-104. [PMID: 10586014 DOI: 10.1016/s0929-8266(99)00057-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the past 15 years endoscopic ultrasonography (EUS) has become an integrated part of gastrointestinal imaging. The more recent development of echoendoscopes and needles for EUS guided fine needle aspiration has stimulated the interest in interventional EUS procedures, both for diagnostic and therapeutic purposes. This paper describes the technique and experience with some of the interventional EUS procedures based on the present literature. Many of the techniques must still be considered experimental and will need substantial clinical testing in larger series before any final conclusions can be made. However, the present level of interventional EUS seems to indicate, that some of these techniques could be cost-effective alternatives in specific clinical situations, and in some cases even the only possible theraputic action. Future research in interventional EUS should be concentrated in experienced endosonography centers under careful monitoring of complications and clinical outcome.
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Affiliation(s)
- M B Mortensen
- Center for Advanced Endoscopic and Intraoperative Ultrasonography, Department of Surgical Gastroenterology, Odense University Hospital, Sdr Boulevard 29, 5000, Odense, Denmark
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Nesje LB, Skarstein A, Matre K, Myking AO, Odegaard S. Dieulafoy's vascular malformation: role of endoscopic ultrasonography in therapeutic decision-making. Scand J Gastroenterol 1998; 33:104-8. [PMID: 9489917 DOI: 10.1080/00365529850166293] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dieulafoy's vascular malformation may cause severe, potentially life-threatening gastrointestinal bleeding. Endoscopic diagnosis may be difficult because of minute mucosal lesions, and additional intramural abnormalities are usually not encountered. Endoluminal high-frequency ultrasonography is a new modality for imaging intramural and perivisceral structures. METHODS We report two cases of recurrent severe gastric bleeding in which different endosonographic modalities were used in the diagnosis of Dieulafoy's malformation, and the impact of endosonography on therapeutic strategy is discussed. In the first case a radial-scanning 7.5/12-MHz echoendoscope and a linear 20-MHz miniature probe were applied for B-mode imaging in a stable-state patient who had undergone previous endoscopic sclerotherapy, and arterial flow signals from the small intramural lesion were recorded using a 10-MHz transendoscopic pulsed Doppler probe. In the other case urgent endosonography was performed shortly after a bleeding episode, disclosing an aberrant large-calibre artery entering the gastric wall with a long submucosal branch. RESULTS Both patients were successfully operated on with a transabdominal approach. CONCLUSION Endosonography is a quick and safe diagnostic method and should be considered when vascular malformations are suspected as the cause of gastric bleeding.
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Affiliation(s)
- L B Nesje
- Medical Dept. A, Haukeland Hospital, Deaconess Hospital, University of Bergen, Norway
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Abstract
PURPOSE AND METHODS Certain factors in a patient's history, such as prior abdominal surgery or complicated diverticular disease, have been reported to hinder cecal intubation during colonoscopy. Over a 16-month period, 1,047 consecutive colonoscopies were prospectively evaluated to determine whether these factors were indeed clinically relevant. RESULTS Of the 90 patients (9 percent) who had incomplete intubation of the colon, there were significantly more women (66 percent) than men (34 percent) (P < 0.001). Women with a history of abdominal hysterectomy had a significantly lower cecal intubation rate (P < 0.01). A history of diverticulitis did not alter the cecal intubation rate. In patients with incomplete colonic intubation, the most proximal extent of intubation was the sigmoid colon in women (31 percent) and the right colon in men (68 percent). Sixty-seven percent of patients with incomplete intubation of the colon had a prior colonoscopy completed to the cecum (67 percent women, 67 percent men), whereas 50 percent had a follow-up colonoscopy completed to the cecum (56 percent women, 40 percent men). CONCLUSIONS Women, especially those with a history of abdominal hysterectomy, had a significantly lower cecal intubation rate usually because of an impassable sigmoid colon. Prior inability to complete colonoscopy to the cecum does not necessarily forecast future failure.
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Affiliation(s)
- W C Cirocco
- Department of Colon and Rectal Surgery, Saint Vincent Health Center/Hamot Medical Center, Erie, Pennsylvania, USA
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O'Connor JJ. Techniques for diagnosis and treatment of bleeding hemorrhoids. Dis Colon Rectum 1994; 37:732-3. [PMID: 8026244 DOI: 10.1007/bf02054423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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