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Singh K, Zubair A, Prindle A, Nadeem AJ, Khan G. Diagnostic yield of capsule endoscopy for small bowel arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia: a systematic review and meta-analysis. Endosc Int Open 2019; 7:E282-E289. [PMID: 30705963 PMCID: PMC6353713 DOI: 10.1055/a-0799-9820] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/02/2018] [Indexed: 12/11/2022] Open
Abstract
Background and study aims Small bowel arteriovenous malformations (AVMs) pose a bleeding risk and have traditionally been diagnosed by invasive enteroscopic procedures in patients with hereditary hemorrhagic telangiectasia (HHT). Capsule endoscopy (CE) is emerging as a safe and non-invasive alternative for small intestinal evaluation, but its diagnostic yield and utility in diagnosing small bowel AVMs in HHT patients are understudied. The aim of this study was to meta-analyze the utility of CE for diagnosing AVMs in HHT patients. Methods A meta-analysis and systematic review of the literature on CE in HHT patients identified in the PubMed, EMBASE, Scopus, and Cochrane databases from inception to March 2018 were conducted. Summary effects were estimated using a random effects model. Results After applying exclusion criteria, five studies (n = 124 patients) were eligible for meta-analysis. The pooled diagnostic yield for visualization of small bowel AVMs by CE was 77.0 % (95 % CI 65.8 - 85.4 %, P < 0.001). Conclusions CE has a good diagnostic yield for small bowel AVMs in HHT. It can be regarded as a sufficient, noninvasive diagnostic modality for identifying small bowel AVMs in HHT patients.
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Affiliation(s)
- Kevin Singh
- Department of Internal Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, United States
| | - Ayla Zubair
- Department of Internal Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, United States
| | - Andrew Prindle
- Department of Internal Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, United States
| | - Ahmed Jamal Nadeem
- Department of Hematology and Oncology, Lehigh Valley Health Network, Allentown, Pennsylvania, United States
| | - Gulam Khan
- Department of Gastroenterology and Hepatology, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, United States
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Ardelean DS, Letarte M. Anti-angiogenic therapeutic strategies in hereditary hemorrhagic telangiectasia. Front Genet 2015; 6:35. [PMID: 25717337 PMCID: PMC4324154 DOI: 10.3389/fgene.2015.00035] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/26/2015] [Indexed: 01/22/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular dysplastic disorder, characterized by recurrent nosebleeds (epistaxis), multiple telangiectases and arteriovenous malformations (AVMs) in major organs. Mutations in Endoglin (ENG or CD105) and Activin receptor-like kinase 1 (ACVRL1 or ALK1) genes of the TGF-β superfamily receptors are responsible for HHT1 and HHT2 respectively and account for the majority of HHT cases. Haploinsufficiency in ENG and ALK1 is recognized at the underlying cause of HHT. However, the mechanisms responsible for the predisposition to and generation of AVMs, the hallmark of this disease, are poorly understood. Recent data suggest that dysregulated angiogenesis contributes to the pathogenesis of HHT and that the vascular endothelial growth factor, VEGF, may be implicated in this disease, by modulating the angiogenic–angiostatic balance in the affected tissues. Hence, anti-angiogenic therapies that target the abnormal vessels and restore the angiogenic–angiostatic balance are candidates for treatment of HHT. Here we review the experimental evidence for dysregulated angiogenesis in HHT, the anti-angiogenic therapeutic strategies used in animal models and some patients with HHT and the potential benefit of the anti-angiogenic treatment for ameliorating this severe, progressive vascular disease.
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Affiliation(s)
- Daniela S Ardelean
- Department of Pediatrics, The Hospital for Sick Children Toronto, ON, Canada
| | - Michelle Letarte
- Molecular Structure and Function Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children Toronto, ON, Canada ; Department of Immunology, University of Toronto Toronto, ON, Canada ; Heart and Stroke Richard Lewar Centre of Excellence, University of Toronto Toronto, ON, Canada
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3
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Abstract
Hereditary haemorrhagic telangiectasia, inherited as an autosomal dominant trait, affects approximately 1 in 5000 people. The abnormal vascular structures in HHT result from mutations in genes (most commonly endoglin or ACVRL1) whose protein products influence TGF-ß superfamily signalling in vascular endothelial cells. The cellular mechanisms underlying the generation of HHT telangiectasia and arteriovenous malformations are being unravelled, with recent data focussing on a defective response to angiogenic stimuli in particular settings. For affected individuals, there is often substantial morbidity due to sustained and repeated haemorrhages from telangiectasia in the nose and gut. Particular haematological clinical challenges include the management of severe iron deficiency anaemia; handling the intricate balance of antiplatelet or anticoagulants for HHT patients in whom there are often compelling clinical reasons to use such agents; and evaluation of apparently attractive experimental therapies promoted in high profile publications when guidelines and reviews are quickly superseded. There is also a need for sound screening programmes for silent arteriovenous malformations. These occur commonly in the pulmonary, cerebral, and hepatic circulations, may haemorrhage, but predominantly result in more complex pathophysiology due to consequences of defective endothelium, or shunts that bypass specific capillary beds. This review will focus on the new evidence and concepts in this complex and fascinating condition, placing these in context for both clinicians and scientists, with a particular emphasis on haematological settings.
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Affiliation(s)
- Claire L Shovlin
- NHLI Cardiovascular Sciences, Imperial College London, UK and HHTIC London, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
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4
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Reply to Fernández-Fernández. Eur J Hum Genet 2010. [DOI: 10.1038/ejhg.2009.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Abstract
Hereditary haemorrhagic telangiectasia (also known as Osler-Weber-Rendu syndrome) is a relatively common, under-recognized autosomal-dominant disorder that results from multisystem vascular dysplasia. It is characterized by telangiectases and arteriovenous malformations of skin, mucosa and viscera. This article summarizes the clinical manifestations and the management of this disorder and its management. This review underscores an urgent need to conduct prospective multicentre studies to develop evidence-based management guidelines for this disease.
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Affiliation(s)
- A A Sharathkumar
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana 46260, USA
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Shayah A, Makura ZGG. Re: A laser end piece for the treatment of Epistaxis using the Pulsed Dye Laser. Clin Otolaryngol 2008; 33:371-2; author reply 372. [PMID: 18983353 DOI: 10.1111/j.1749-4486.2008.01733.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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dos Santos JWA, Dalcin TC, Neves KR, Mann KC, Pretto GLN, Bertolazi AN. Hereditary hemorrhagic telangiectasia: a rare cause of severe anemia. J Bras Pneumol 2007; 33:109-12. [PMID: 17568877 DOI: 10.1590/s1806-37132007000100020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2005] [Accepted: 03/17/2006] [Indexed: 11/22/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia is an autosomal dominant disease in which arteriovenous communications are typically seen in the skin, mucosal surfaces, lungs, brain and gastrointestinal tract. This disease typically presents as epistaxis, gastrointestinal bleeding and arteriovenous malformations (in the brain and lungs). Although the epistaxis and gastrointestinal bleeding can result in anemia, patients diagnosed with hereditary hemorrhagic telangiectasia rarely present severe anemia. Herein, we report the case of a 49-year-old man with severe anemia and undiagnosed hereditary hemorrhagic telangiectasia.
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Shields HM, Shaffer K, O'farrell RP, Travers R, Hayward JN, Becker LS, Lauwers GY. Gastrointestinal manifestations of dermatologic disorders. Clin Gastroenterol Hepatol 2007; 5:1010-7; quiz 1005-6. [PMID: 17825768 DOI: 10.1016/j.cgh.2007.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The skin and the gastrointestinal tract may be affected concurrently by the same diseases. Pathogenetically, these conditions may be primarily dermatologic diseases involving the gastrointestinal (GI) tract or systemic diseases involving the skin, GI tract, and liver simultaneously. The correct diagnosis of such conditions relies on the ability of the gastroenterologist to recognize the underlying dermatologic disorder. The goal of this clinical review article is to increase gastroenterologists' awareness and understanding of some of these conditions. Case vignettes are presented and the relevant literature reviewed for epidermolysis bullosa, mastocytosis, hereditary hemorrhagic telangiectasia, and melanoma. This review focuses on increasing gastroenterologists' ability to recognize, diagnose, comprehend, and manage patients with these dermatologic conditions who have GI manifestations. Advances in molecular genetics that provide insight into the underlying pathophysiology and histopathology of these lesions are highlighted.
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Affiliation(s)
- Helen M Shields
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Abstract
Liver involvement in hereditary hemorrhagic telangiectasia (HHT) consists of extensive intrahepatic vascular malformations associated with blood shunting (arteriovenous, arterioportal and/or portovenous). It is a rare disorder that nevertheless can result in significant systemic and hepatobiliary abnormalities. Although hepatic vascular malformations are present in a majority of patients with HHT, symptoms occur in a only a minority with a clear predominance for the female gender. Symptoms from liver vascular malformations are often misdiagnosed and this can lead to potentially harmful interventions. In this review article, clinical findings of liver involvement in HHT and their pathophysiology are discussed as well as diagnostic methodologies, therapies used and their outcome. Data presented is based on a review of the literature performed in October 2006 using the following MEDLINE search terms: (hereditary hemorrhagic telangiectasia [ALL] OR Rendu-Osler-Weber [ALL]) AND (liver OR hepatic [ALL]). Papers were considered if they were published in English and if they included specific cases that were sufficiently described.
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Affiliation(s)
- Guadalupe Garcia-Tsao
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine and VA CT Healthcare System, 333 Cedar Street - 1080 LMP, P.O. Box 208019, New Haven, CT 06520, USA.
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Wheatley-Price P, Shovlin C, Chao D. Interferon for metastatic renal cell cancer causing regression of hereditary hemorrhagic telangiectasia. J Clin Gastroenterol 2005; 39:344-5. [PMID: 15758631 DOI: 10.1097/01.mcg.0000155137.73433.36] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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