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Azancot S, Dray X, Moshiri P, Soualy A, Guilloux A, Michel PA, Boffa JJ, Becq A. Gastrointestinal Angiectasia in patients with chronic kidney disease: A matched case-control study. Clin Res Hepatol Gastroenterol 2024; 48:102454. [PMID: 39179202 DOI: 10.1016/j.clinre.2024.102454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/16/2024] [Accepted: 08/20/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND AND STUDY AIMS Chronic kidney disease (CKD) is a well-known risk factor of gastrointestinal angiectasia (GIA). The aim was to compare this population with CDK patients without GIA. METHODS Patients followed in the Nephrology Department of Tenon Hospital for which an endoscopy was performed between 2012 and 2022 were identified. Those with at least one GIA lesion were included ("GIA+" group). A matched control group for age, sex and GFR stage of patients with CKD and no GIA lesion ("GIA-" group) was constituted. A subgroup analysis compared patients with (SB+) and without (SB-) small-bowel involvement. RESULTS A total of 55 patients were included in the GIA+ group. 36.3 % (n = 20) were active smokers and 29.1 % (n = 16) had peripheral arterial disease versus 16.4 % (n = 9) (OR 2.89, p = 0.03), and 9.1 % (n = 5) (OR 4.05, p = 0.015) in the GIA- group. Thirteen patients (23.6 %) had a SB lesion. Duodenal involvement was present in 69.2 % of cases in the SB+ group versus 28.6 % in the SB- group (p = 0.02). Median number of endoscopies, hemostatic technics and hospitalizations was 7, 3 and 6, versus 2 (p = 0.0001), 1 (p = 0.001) and 1 (p = 0.0002) in the SB- group. CONCLUSIONS CKD patients with GIA had a greater cardiovascular risk with a higher incidence of vascular nephropathy. Small-bowel GIA were associated with a higher morbidity.
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Affiliation(s)
- Sarah Azancot
- Sorbonne University, Nephrology Department, APHP, Tenon Hospital, Paris, France
| | - Xavier Dray
- Sorbonne University, Center for Digestive Endoscopy, Saint Antoine Hospital, APHP, Paris, France
| | | | - Adil Soualy
- Paris-Est Creteil University, Gastroenterology Department, Henri Mondor Hospital, APHP, Creteil, France
| | - Antoine Guilloux
- Sorbonne University, Center for Digestive Endoscopy, Saint Antoine Hospital, APHP, Paris, France
| | | | - Jean Jacques Boffa
- Sorbonne University, Nephrology Department, APHP, Tenon Hospital, Paris, France; Sorbonne University, INSERM U1155 CORAKID, Paris, France
| | - Aymeric Becq
- Paris-Est Creteil University, Gastroenterology Department, Henri Mondor Hospital, APHP, Creteil, France.
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Strategic Management of Bleeding Small Bowel Gastrointestinal Angiodysplasias (GIADs): A 12 Year Retrospective Review in a Veteran Population and Cost Comparison. Diagnostics (Basel) 2023; 13:diagnostics13030525. [PMID: 36766630 PMCID: PMC9914120 DOI: 10.3390/diagnostics13030525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/18/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIADs), also known as gastrointestinal angioectasias, are dilated, abnormally thin-walled blood vessels that occur in the mucosa and submucosa throughout the gastrointestinal tract. As a common cause of small bowel bleeding, GIADs have a significant impact on patient's morbidity and healthcare costs. Presently, somatostatin has been used widely to treat GIADs, but it is unclear if other therapies are as beneficial and cost-effective as somatostatin in managing GIADs. (2) Methods: A retrospective chart review was performed, which included subjects treated with Lanreotide, a somatostatin analog, and other therapies at the VA Loma Linda Healthcare System (VALLHCC) from January 2006 to December 2018. Patients who had symptomatic GIADs were detected by video capsule endoscopy (VCE), a device-assisted enteroscopy (DAE) or, in our case, push enteroscopy (PE) with an Endocuff. (3) Results: Three hundred twelve patients were diagnosed with GIADs. In this group of patients, 72 underwent ablation (endoscopic BICAP) with the addition of Lanreotide (SST), 63 underwent ablation therapy, eight were treated with SST only, 128 received iron replacement only, 25 received iron plus SST therapy, and 61 were observed with no therapy. Each group was followed via their hemoglobin (Hgb) level immediately thereafter, and Hgb levels were then obtained every 3 months for a 12-month period. After ablation therapy, 63 patients maintained stable Hgb levels over the course of the study, suggesting a significant therapeutic effect by controlling active bleeding. The 27 patients receiving ablation +SST therapy did not show improvements when compared to ablation only and the 128 patients who received iron therapy alone. (4) Conclusions: Importantly, 12 years of managing these patients has given us a cost- and time-sensitive strategy to maintain the patients' Hgb levels and avoid hospital admissions for acute bleeding. Iron treatment alone is effective compared to SST treatment in recovering from GIADs. Eliminating SST treatment from therapeutic intervention would save $89,100-445,550 per patient, depending on the number of doses for private care patients and $14,286-28,772 for VA patients, respectively. A suggested therapy would be to perform DAE on actively bleeding patients, ablate the lesions using a coagulation method, and place the patient on iron. If that fails, gastroenterologists should repeat VCE and perform either PE with Endocuff or balloon enteroscopy (all DAEs).
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Nationwide cohort study identifies clinical outcomes of angioectasia in patients with acute hematochezia. J Gastroenterol 2022; 58:367-378. [PMID: 36564578 DOI: 10.1007/s00535-022-01945-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND While angioectasia is an important cause of acute hematochezia, relevant clinical features remain unclear. This study aims to reveal risk factors, clinical outcomes, and the effectiveness of therapeutic endoscopy for patients with acute hematochezia due to angioectasia. METHODS This retrospective cohort study was conducted at 49 Japanese hospitals between January 2010 and December 2019, enrolling patients hospitalized for acute hematochezia (CODE BLUE-J study). Baseline factors and clinical outcomes for angioectasia were analyzed. RESULTS Among 10,342 patients with acute hematochezia, 129 patients (1.2%) were diagnosed with angioectasia by colonoscopy. The following factors were significantly associated with angioectasia: chronic kidney disease, liver disease, female, body mass index < 25, and anticoagulant use. Patients with angioectasia were at a significant increased risk of blood transfusions compared to those without angioectasia (odds ratio [OR] 2.61; 95% confidence interval [CI] 1.69-4.02). Among patients with angioectasia, 36 patients (28%) experienced rebleeding during 1-year follow-up. The 1-year cumulative rebleeding rates were 37.0% in the endoscopic clipping group, 14.3% in the coagulation group, and 32.8% in the conservative management group. Compared to conservative management, coagulation therapy significantly reduced rebleeding risk (P = 0.038), while clipping did not (P = 0.81). Multivariate analysis showed coagulation therapy was an independent factor for reducing rebleeding risk (hazard ratio [HR] 0.40; 95% CI 0.16-0.96). CONCLUSIONS Our data showed patients with angioectasia had a greater comorbidity burden and needed more blood transfusions in comparison with those without angioectasia. To reduce rebleeding risk, coagulation therapy can be superior for controlling hematochezia secondary to angioectasia.
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Hung HJ, Chung CS, Tai CM, Chang CW, Tseng CM, Huang GS, Lin MC, Huang TY. Clinical characteristics and risk factors for rebleeding in uremic patients with obscure gastrointestinal bleeding undergoing deep enteroscopy: A multi-center retrospective study in Taiwan. PLoS One 2022; 17:e0277434. [PMID: 36449459 PMCID: PMC9710796 DOI: 10.1371/journal.pone.0277434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 10/26/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND/PURPOSE Recurrent obscure gastrointestinal bleeding (OGIB) in patients with chronic kidney disease is a challenge often faced by physicians, given the need for repeated hospitalizations, multiple extensive examinations, limited treatment options, and high medical costs. The purpose of this study was to identify the clinical characteristics of uremic patients undergoing deep enteroscopy for OGIB and analyze the risk factors for rebleeding in these patients after undergoing single-balloon enteroscopy (SBE). METHODS Out of 765 patients with OGIB who underwent 1004 procedures of SBE in four teaching hospitals, 78 uremic patients with OGIB were enrolled. Clinical characteristics and endoscopic findings were collected, and multiple variables were analyzed to determine the risk of rebleeding after SBE. RESULTS The diagnostic yield was 75.6%, and the rebleeding rate was 29.5% in the enrolled uremic patients. The most common etiology was angiodysplasia (74.6%) and the most common site was the jejunum (50.8%). The endoscopic intervention rate was 62.8% and most patients were treated with argon plasma coagulation (75.6%). Among the eight patients with valvular heart disease (VHD), four (50%) had severe aortic stenosis, and the remaining had non-aortic stenosis-VHD. VHD (p < 0.05) and angiodysplasia (p < 0.05) were both associated with a higher rebleeding rate. CONCLUSION VHD may be an independent risk factor associated with rebleeding after SBE in uremic patients with OGIB. Moreover, uremic patients with angiodysplasia-related bleeding appear to have a higher rebleeding rate than those with alternative causes of bleeding.
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Affiliation(s)
- Hsuan-Jen Hung
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan
| | - Chi-Ming Tai
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Chen-Wang Chang
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Chao-Ming Tseng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Go-Shine Huang
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Meng-Chiung Lin
- Division of Gastroenterology, Department of Internal Medicine, Taichiung Armed Forces General Hospital, Taichiung, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan
- * E-mail:
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García-Compeán D, Cueto-Aguilera ÁND, González-González JA, Jáquez-Quintana JO, Borjas-Almaguer OD, Jiménez-Rodríguez AR, Muñoz-Ayala JM, Maldonado-Garza HJ. Evaluation and Validation of a New Score to Measure the Severity of Small Bowel Angiodysplasia on Video Capsule Endoscopy. Dig Dis 2022; 40:62-67. [PMID: 33780938 DOI: 10.1159/000516163] [Citation(s) in RCA: 2] [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: 12/04/2020] [Accepted: 03/26/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Angiodysplasias are responsible of 50% of small bowel bleeding. An endoscopic method that allows measuring its severity is not available. AIMS The aim of the study was to validate a new endoscopic score with VCE to measure the severity of small bowel angiodysplasias (SBAD). METHODS Four endoscopists independently reviewed VCE videos of 22 patients with SBAD. The score graded 3 variables: A - extent of lesions: E1, located in one half of the intestine and E2, in both halves; B - number of lesions: N1, <5; N2, 5-10; and N3, >10 lesions; C - probability of bleeding: P1, pale red spots; P2, bright red spots; P3, bleeding stigmata; and P4, active bleeding. Capsule Endoscopy Small Bowel Angiodysplasia Activity Index (CESBAI) was calculated as follows: E × 1 + N × 2 + P × 3. Interobserver variability was analyzed by Spearman's correlation and agreement Kappa statistic tests. RESULTS The mean CESBAI scores by observers were O1= 11.6 ± 4.1; O2 = 11.3 ± 4.8; O3 = 11.1 ± 4.9; and O4 = 11.8 ± 4.2 (p > 0.05). Spearman's correlation values of CESBAI between every 2 observers were from 0.61 to 0.94 (p < 0.001) with a global correlation of 0.73 among all observers. Kappa values of CESBAI between every 2 observers ranged from 0.42 to 0.87 (p < 0.001) with a global agreement of 0.57 among all observers. All evaluators stated that the method was easy to use. CONCLUSIONS CESBAI is a reliable and reproducible score. Nevertheless, these results must be validated in other studies with larger population before assessing its power for predicting bleeding recurrence.
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Affiliation(s)
- Diego García-Compeán
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Ángel Noe Del Cueto-Aguilera
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - José Alberto González-González
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Joel Omar Jáquez-Quintana
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Omar David Borjas-Almaguer
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Alan Rafael Jiménez-Rodríguez
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Juan Manuel Muñoz-Ayala
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Héctor Jesús Maldonado-Garza
- Gastroenterology Service and Department of Internal Medicine, University Hospital "Dr. José E. González" and Faculty of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
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Verma S, Attallah MA, Jarrin Jara MD, Gautam AS, Khan S. Angiodysplasia in Renal Disease Patients: Analysis of Risk Factors and Approach to Manage Such Patients. Cureus 2020; 12:e9784. [PMID: 32953300 PMCID: PMC7491692 DOI: 10.7759/cureus.9784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Gastrointestinal bleeding due to angiodysplasia is a common problem in patients with renal insufficiency. There are several theories to explain the increased occurrence of these lesions in this specific group of patients, including various metabolic factors and existence of comorbidities. Advancements made in diagnostic measures have helped route the approach in patients with different risk factors and have also helped solve the dual purpose involving therapeutic intervention with endoscopy. We conducted a thorough literature search on PubMed to extract relevant data. A total of 29 articles were chosen after applying the inclusion and exclusion criteria. Although the clinical presentations may vary in this cohort of patients, and bleeding is known to stop spontaneously, a conservative approach may not be enough. Endoscopic treatment, use of hormones like estrogen, octreotide, and vasopressin, arterial embolization, and lastly surgery are valuable therapeutic tools.
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Affiliation(s)
- Sadhika Verma
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfield, USA
| | - Marline A Attallah
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfiled, USA
| | | | - Avneesh S Gautam
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfield, USA
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García-Compeán D, Del Cueto-Aguilera ÁN, Jiménez-Rodríguez AR, González-González JA, Maldonado-Garza HJ. Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points. World J Gastroenterol 2019; 25:2549-2564. [PMID: 31210709 PMCID: PMC6558444 DOI: 10.3748/wjg.v25.i21.2549] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/19/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient’s quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.
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Affiliation(s)
- Diego García-Compeán
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Ángel N Del Cueto-Aguilera
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Alan R Jiménez-Rodríguez
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - José A González-González
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Héctor J Maldonado-Garza
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
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A Risk Assessment of Factors for the Presence of Angiodysplasias During Endoscopy and Factors Contributing to Symptomatic Bleeding and Rebleeds. Dig Dis Sci 2019; 64:2923-2932. [PMID: 31190204 PMCID: PMC6744377 DOI: 10.1007/s10620-019-05683-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 05/23/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Few studies have assessed factors associated with angiodysplasias during endoscopy or factors associated with symptomatic disease. AIMS To evaluate risk factors for the presence of and contribution to symptomatic disease in patients with angiodysplasias. METHODS We performed a systematic MEDLINE, EMBASE and Cochrane Library search according to the PRISMA guidelines for studies assessing risk factors involved in angiodysplasias detected during endoscopy and factors that lead to anemia or overt bleeding. Study quality was assessed with the Newcastle-Ottawa scale. A risk assessment was performed by selecting risk factors identified by two independent studies and/or by a large effect size. RESULTS Twenty-three studies involving 92,634 participants were included. The overall quality of the evidence was moderate. Risk factors for the diagnosis of angiodysplasias during endoscopy confirmed by at least two studies were increasing age (OR 1.09 per year, 95% CI 1.04-1.1), chronic kidney disease (OR 4.5, 95% CI 1.9-10.5) and cardiovascular disease (2.9, 95% CI 1.4-6.2). The risk of rebleeds was higher in the presence of multiple lesions (OR 4.2, 95% CI 1.1-16.2 and 3.8, 95% CI 1.3-11.3 and 8.6, 95% CI 1.4-52.6), liver cirrhosis (OR 4.0, 95% 1.1-15.0) and prothrombin time < 30% (OR 4.2, 95% 1.1-15.4) with a moderate effect size. Multiple comorbidities were associated with an increased in-hospital mortality (OR 2.29, 95% CI 1.2-4.3). CONCLUSIONS This systematic review identified age, chronic kidney disease and cardiovascular disease as the most important risk factors for the diagnosis of angiodysplasias during endoscopy. Multiple lesions increase the risk of recurrent bleeding.
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