Definitive therapy of colonic angioectasia by submucosal coagulation

Contrast-enhanced computed tomography assisted diagnosis of bleeding caused by colonic angiodysplasia: A case report

RATIONALE

Angiodysplasia (AD) in the gastrointestinal tract is a degenerative vascular condition characterized by vascular dilation, tortuosity, and arteriovenous connections within the mucosal and submucosal layers. AD is a significant cause of lower gastrointestinal bleeding in the elderly, often presenting as chronic, intermittent hemorrhage. The research challenge lies in the potential for multiple and minute AD lesions to be missed during endoscopy, which may lead to post-hemostatic rebleeding.

PATIENT CONCERNS

An 82-year-old female with a history of coronary artery disease treated with aspirin, presenting with recurrent melena and anemia. The patient exhibited a suboptimal response to blood transfusions and octreotide therapy.

DIAGNOSIS

After excluding tumorous bleeding in the initial contrast-enhanced computed tomography (CECT), we suspect vascular bleeding as the most probable etiology.

INTERVENTIONS

The initial colonoscopy was unsuccessful due to the occurrence of ventricular tachycardia. Considering the patient's advanced age, cardiac dysfunction, and frailty, a repeat CECT were conducted during episodes of suspected active bleeding. Vascular dilatation within the colonic hepatic flexure wall was visualized during the venous phase, accompanied by contrast agent extravasation into the intestinal lumen. The subsequent urgent colonoscopy and pathological specimens from surgical resection supported the diagnosis of colonic AD.

OUTCOMES

After the surgery, the patient did not experience melena thereafter.

LESSONS

We highlight that CECT for diagnosing AD-related bleeding offers higher safety and convenience, potentially superior to digital subtraction angiography, particularly in critically ill elderly patients.

Review article: Advances in the management of lower gastrointestinal bleeding

BACKGROUND

Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved.

AIMS

To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion.

RESULTS

The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients.

CONCLUSIONS

The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.

Safety and efficacy of a new cold snare technique with clipping for colorectal angioectasia

Colorectal angioectasia is a major cause of lower gastrointestinal bleeding. Use of antithrombotic agents is expected to increase with aging of the population, and bleeding from angioectasia is an important issue. Although the effectiveness of endoscopic mucosal resection for colorectal angioectasia has been reported, there are no reports of cold snare technique for angioectasia (CSA). From February 2018 to February 2022, the safety of CSA was evaluated at Omori Red Cross Hospital. We investigated the incidence of bleeding (delayed post-polypectomy bleeding (DPPB) and immediate bleeding) after CSA and the incidence of rebleeding requiring repeated endoscopic treatment. During the study period, 106 angioectasias were identified during colonoscopy. We only targeted patients with bloody stools and/or anemia requiring treatment for bleeding from angioectasia. Finally, we included 11 angioectasias in this study. Rates of DPPB and rebleeding after CSA were 0 %. The rate of immediate bleeding during CSA was 27.3 % (3/11). Dilated capillaries could be observed pathologically in nine of 11 lesions (81.8 %). CSA was safe and can be a new treatment option in the future. To confirm our results and verify the long-term safety and efficacy of CSA, further studies are desirable.

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.

Jejunal Angiodysplasia in an Elderly Patient with Aortic Stenosis: Significance of Von Willebrand Factor as an Etiologic Factor

Heyde's syndrome is a disease in which patients with aortic stenosis (AS) bleed from angiodysplasia. An 80-year-old woman with a history of severe AS was referred to our hospital with melena and anemia. The patient underwent jejunal resection after repeated blood transfusions. A pathological examination revealed angiodysplasia, and the patient's plasma lacked high-molecular-weight von Willebrand factor (VWF) multimers, leading to the diagnosis of Heyde's syndrome. The patient underwent transcatheter aortic valve implantation (TAVI) one year after the diagnosis, and the VWF index recovered. This is a valuable case in which the pathological analysis of angiodysplasia associated with Heyde's syndrome was possible.

Rebleeding after hemoclip versus argon plasma coagulation for gastrointestinal angiodysplasias: a retrospective multicenter study

BACKGROUND

Hemoclips are utilized for treating bleeding gastrointestinal angiodysplastic lesions (GIADs); however, the supporting evidence is limited.

AIMS

Our aim is to evaluate the efficacy of hemoclips in preventing bleeding secondary to GIADs compared to argon plasma coagulation (APC).

METHODS

This retrospective study included patients with bleeding gastric, small bowel or colonic GIADs that were endoscopically treated between January 2009 and November 2016. Patients that received hemoclips as monotherapy or in combination were compared to a randomly selected similar number of patients treated with APC.

RESULTS

We included 157 patients that underwent APC and 141 who received hemoclips. During a median follow-up of 17 months, those with hemoclips had a 32.6% rebleeding vs. 46.5% in the APC group (P = 0.017). On multivariate regression analysis, use of hemoclips was not a significant predictor of rebleeding when compared to APC; hemoclips monotherapy (HR, 0.92; 95% CI, 0.54-1.59) and hemoclips combination (HR, 0.65; 95% CI, 0.41-1.01). When the multivariate analysis was restricted to subjects that resumed antithrombotics after endoscopy, rebleeding risk was lower when hemoclips were used in combination (HR, 0.46; 95% CI, 0.25-0.84) compared to APC. We noted a similar effect in the antithrombotic subgroup even after propensity score matching (HR, 0.51; 95% CI, 0.27-0.95).

CONCLUSION

Treatment modality was not a significant predictor of rebleeding when studied for the entire population. However, the risk of rebleeding was lower with hemoclips combination therapy compared to APC in patients that resumed antithrombotic therapy, suggesting a potential role for a combined approach in this subgroup of patients.