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Abouzid M, Abdelhakeem A, Elshafie S, Ghorab A. Heyde's syndrome: a challenging case of severe aortic stenosis and gastrointestinal bleeding. BMJ Case Rep 2024; 17:e258316. [PMID: 38631812 PMCID: PMC11029456 DOI: 10.1136/bcr-2023-258316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
We present the case of an elderly man with a history of diastolic congestive heart failure, severe aortic stenosis and atrial fibrillation, who presented with fatigue, weakness, coffee ground emesis and black tarry stool. Haemoglobin was 68 g/L. Lactate dehydrogenase was elevated at 1038. Evaluation by cardiology and gastroenterology specialists revealed reflux oesophagitis and a mild hiatal hernia on oesophagogastroduodenoscopy, normal colonoscopy and small bowel series without obstruction. Capsule endoscopy identified angiodysplasia in the small intestine.The patient was diagnosed with Heyde's syndrome based on the triad of severe aortic stenosis, gastrointestinal bleeding from angiodysplasia and acquired von Willebrand syndrome. The patient underwent transcatheter aortic valve replacement, resulting in the resolution of symptoms.Heyde's syndrome represents a challenging clinical entity requiring a multidisciplinary approach for accurate diagnosis and management. Early recognition, prompt intervention and interdisciplinary collaboration are crucial in optimising patient outcomes.
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Affiliation(s)
- Mohamed Abouzid
- Department of Medicine, Baptist Hospitals of Southeast Texas, Beaumont, Texas, USA
| | - Ahmed Abdelhakeem
- Department of Medicine, Baptist Hospitals of Southeast Texas, Beaumont, Texas, USA
| | - Shorouk Elshafie
- Department of Medicine, Baptist Hospitals of Southeast Texas, Beaumont, Texas, USA
| | - Ahmad Ghorab
- Department of Hematology and Oncology, Mayo Clinic, Jacksonville, Florida, USA
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Goltstein LCMJ, Grooteman KV, Bernts LHP, Scheffer RCH, Laheij RJF, Gilissen LPL, Schrauwen RWM, Talstra NC, Zuur AT, Braat H, Hadithi M, Brouwer JT, Nagengast WB, Oort FA, Tenthof van Noorden J, Kievit W, van Geenen EJM, Drenth JPH. Standard of Care Versus Octreotide in Angiodysplasia-Related Bleeding (the OCEAN Study): A Multicenter Randomized Controlled Trial. Gastroenterology 2024; 166:690-703. [PMID: 38158089 DOI: 10.1053/j.gastro.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/18/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND & AIMS Gastrointestinal angiodysplasias are vascular anomalies that may result in transfusion-dependent anemia despite endoscopic therapy. An individual patient data meta-analysis of cohort studies suggests that octreotide decreases rebleeding rates, but component studies possessed a high risk of bias. We investigated the efficacy of octreotide in reducing the transfusion requirements of patients with angiodysplasia-related anemia in a clinical trial setting. METHODS The study was designed as a multicenter, open-label, randomized controlled trial. Patients with angiodysplasia bleeding were required to have had at least 4 red blood cell (RBC) units or parental iron infusions, or both, in the year preceding randomization. Patients were allocated (1:1) to 40-mg octreotide long-acting release intramuscular every 28 days or standard of care, including endoscopic therapy. The treatment duration was 1 year. The primary outcome was the mean difference in the number of transfusion units (RBC + parental iron) between the octreotide and standard of care groups. Patients who received at least 1 octreotide injection or followed standard of care for at least 1 month were included in the intention-to-treat analyses. Analyses of covariance were used to adjust for baseline transfusion requirements and incomplete follow-up. RESULTS We enrolled 62 patients (mean age, 72 years; 32 men) from 17 Dutch hospitals in the octreotide (n = 31) and standard of care (n = 31) groups. Patients required a mean number of 20.3 (standard deviation, 15.6) transfusion units and 2.4 (standard deviation, 2.0) endoscopic procedures in the year before enrollment. The total number of transfusions was lower with octreotide (11.0; 95% confidence interval [CI], 5.5-16.5) compared with standard of care (21.2; 95% CI, 15.7-26.7). Octreotide reduced the mean number of transfusion units by 10.2 (95% CI, 2.4-18.1; P = .012). Octreotide reduced the annual volume of endoscopic procedures by 0.9 (95% CI, 0.3-1.5). CONCLUSIONS Octreotide effectively reduces transfusion requirements and the need for endoscopic therapy in patients with angiodysplasia-related anemia. CLINICALTRIALS gov, NCT02384122.
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Affiliation(s)
- Lia C M J Goltstein
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Karina V Grooteman
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lucas H P Bernts
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert C H Scheffer
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Robert J F Laheij
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Lennard P L Gilissen
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology, Bernhoven Hospital, Uden, the Netherlands
| | - Nynke C Talstra
- Department of Gastroenterology, Bernhoven Hospital, Uden, the Netherlands
| | - Abraham T Zuur
- Department of Gastroenterology, Tjongerschans, Heerenveen, the Netherlands
| | - Henri Braat
- Department of Gastroenterology, Gelre Hospital, Apeldoorn, the Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Johannes T Brouwer
- Department of Gastroenterology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Frank A Oort
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, the Netherlands
| | | | - Wietske Kievit
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands.
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Zen K, Inoue K, Yashige M. Gastrointestinal Angiodysplasia before and after TAVR. Reply. N Engl J Med 2024; 390:95-96. [PMID: 38169506 DOI: 10.1056/nejmc2313153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Kan Zen
- Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ken Inoue
- Kyoto Prefectural University of Medicine, Kyoto, Japan
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Chen M, Ma J, Yang P, Zhang Y. A case of atypical colonic angiodysplasia. Asian J Surg 2024; 47:554-555. [PMID: 37758575 DOI: 10.1016/j.asjsur.2023.09.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Affiliation(s)
- Miao Chen
- Department of General Surgery, The Third People's Hospital of Chengdu, Chengdu, 610031, China; The Affiliated Hospital of Southwest Jiao Tong University, Chengdu, 610031, China.
| | - Jinman Ma
- Department of General Surgery, The Third People's Hospital of Chengdu, Chengdu, 610031, China; The Affiliated Hospital of Southwest Jiao Tong University, Chengdu, 610031, China.
| | - Peng Yang
- Department of Pathology, The Third People's Hospital of Chengdu, Chengdu, 610031, China; The Affiliated Hospital of Southwest Jiao Tong University, Chengdu, 610031, China.
| | - Yuanchuan Zhang
- Department of General Surgery, The Third People's Hospital of Chengdu, Chengdu, 610031, China; The Affiliated Hospital of Southwest Jiao Tong University, Chengdu, 610031, China.
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Nasr S, Khsiba A, Hamzaoui L, Mahmoudi M, Ben-Mohamed A, Yaakoubi M, Medhioub M, Azzouz M. Clinical features and bleeding risk factors of angiodysplasia lesions in a Tunisian population. Rev Gastroenterol Mex (Engl Ed) 2024; 89:31-41. [PMID: 36931959 DOI: 10.1016/j.rgmxen.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/04/2022] [Indexed: 03/17/2023]
Abstract
INTRODUCTION Gastrointestinal angiodysplasia (GIAD) is the most common vascular anomaly in the gastrointestinal (GI) tract, yet little is known about the factors favoring their bleeding. Our study aim was to determine the characteristics of patients with GIAD lesions in a Tunisian population and identify the risk factors of bleeding. PATIENTS AND METHODS A retrospective study was carried out from January 2010 to February 2020 at a tertiary care medical center in Tunisia. Clinical and endoscopic data were collected from each patient's medical reports. We divided the patients into two groups: group A, patients with symptomatic GIAD; and group B, patients with incidental lesions. Group A was subsequently divided into two subgroups, according to the presence or absence of recurrent bleeding. The groups were compared by clinical, laboratory, and endoscopic features. RESULTS GIAD was diagnosed in 114 patients, with a mean age of 70 ± 13.3 years. GIAD lesions were mainly located in the colon (n = 72, 63%). Fifty-four patients (47%) presented with GIAD-related bleeding. The bleeding diagnosis was made during endoscopic procedures by visualizing active bleeding and the stigmata of recent hemorrhage in 10 (18.5%) and 12 (22.2%) cases, respectively. Most of the patients were treated by argon plasma coagulation (93%). Predictive factors of bleeding were age > 75 years, number of lesions >10, chronic kidney disease, diabetes mellitus, and coronary artery disease (p: 0.008; 0.002; 0.016; 0.048; and 0.039, respectively). CONCLUSION Knowledge of the predictive factors of bleeding aids endoscopists in the decision-making process in cases of angiodysplasia.
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Affiliation(s)
- S Nasr
- Departamento de Gastroenterología y Hepatología, Hospital Mohamed Tahar Maamouri, Facultad de Medicina, Universidad El Manar, Tunis, Tunisia.
| | - A Khsiba
- Departamento de Gastroenterología y Hepatología, Hospital Mohamed Tahar Maamouri, Facultad de Medicina, Universidad El Manar, Tunis, Tunisia
| | - L Hamzaoui
- Departamento de Gastroenterología y Hepatología, Hospital Mohamed Tahar Maamouri, Facultad de Medicina, Universidad El Manar, Tunis, Tunisia
| | - M Mahmoudi
- Departamento de Gastroenterología y Hepatología, Hospital Mohamed Tahar Maamouri, Facultad de Medicina, Universidad El Manar, Tunis, Tunisia
| | - A Ben-Mohamed
- Departamento de Gastroenterología y Hepatología, Hospital Mohamed Tahar Maamouri, Facultad de Medicina, Universidad El Manar, Tunis, Tunisia
| | - M Yaakoubi
- Departamento de Gastroenterología y Hepatología, Hospital Mohamed Tahar Maamouri, Facultad de Medicina, Universidad El Manar, Tunis, Tunisia
| | - M Medhioub
- Departamento de Gastroenterología y Hepatología, Hospital Mohamed Tahar Maamouri, Facultad de Medicina, Universidad El Manar, Tunis, Tunisia
| | - M Azzouz
- Departamento de Gastroenterología y Hepatología, Hospital Mohamed Tahar Maamouri, Facultad de Medicina, Universidad El Manar, Tunis, Tunisia
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Johnson O, Mackenzie N, Choudhury J, Furtado S. Angiodysplasia of the appendix: a diagnostic challenge and the importance of colonoscopy. BMJ Case Rep 2023; 16:e255498. [PMID: 38086578 PMCID: PMC10729099 DOI: 10.1136/bcr-2023-255498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
The case report discusses the challenges in diagnosing gastrointestinal bleeding of unknown origin, with angiodysplasia (AD) of the appendix being a rare cause. The report presents a case of a man in his late 60s who presented with vomiting, diarrhoea and rectal bleeding. As a result of the bleeding, the patient developed a type II myocardial infarction (MI), which had to be simultaneously managed further complicating the diagnostic process. Despite a normal CT angiogram, ongoing bleeding led to suspicion of AD, which was diagnosed using colonoscopy with limited bowel preparation. The patient underwent an open appendicectomy and was found to have AD of the tip of the appendix as the cause of the bleeding. The case highlights the limitations of CT angiography in haemodynamically unstable patients and subsequent importance of colonoscopy with bowel preparation in diagnosing rare causes of bleeding, even with limited bowel preparation, and the potential life-threatening consequences of untreated AD.
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Affiliation(s)
| | | | - Jamil Choudhury
- Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Sanjay Furtado
- Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
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Giordano A, Escapa M, Urpí-Ferreruela M, Casanova G, Fernández-Esparrach G, Ginès À, Llach J, González-Suárez B. Diagnostic accuracy of artificial intelligence-aided capsule endoscopy (TOP100) in overt small bowel bleeding. Surg Endosc 2023; 37:7658-7666. [PMID: 37495849 PMCID: PMC10520091 DOI: 10.1007/s00464-023-10273-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/02/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Capsule endoscopy (CE) is the first-choice exploration in case of overt small bowel bleeding (SBB). An early CE is known to increase diagnostic yield, but long reading times may delay therapeutics. The study evaluates the diagnostic performance of the artificial intelligence tool TOP100 in patients with overt SBB undergoing early CE with Pillcam SB3. METHODS Patients who underwent early CE (up to 14 days from the bleeding episode) for suspected overt SBB were included. One experienced endoscopist prospectively performed standard reading (SR) and a second blind experienced endoscopist performed a TOP100-based reading (TR). The primary endpoint was TR diagnostic accuracy for lesions with high bleeding potential (P2). RESULTS A total of 111 patients were analyzed. The most common clinical presentation was melena (64%). CE showed angiodysplasias in 40.5% of patients (45/111). In per-patient analysis, TR showed a sensitivity of 90.48% (95% CI 82.09-95.80), specificity of 100% (95% CI 87.23-100) with a PPV of 100% (95% CI 94.01-100), NPV of 77.14% (95% CI 63.58-86.71) and diagnostic accuracy of 92.79 (86.29-96.84). At multivariate analysis, adequate intestinal cleansing was the only independent predictor of concordance between TR and SR (OR 2.909, p = 0.019). The median reading time for SR and TR was 23 min (18.0-26.8) and 1.9 min (range 1.7-2.1), respectively (p < 0.001). CONCLUSIONS TOP100 provides a fast-reading mode for early CE in case of overt small bowel bleeding. It identifies most patients with active bleeding and angiodysplasias, aiding in the prioritization of therapeutic procedures. However, its accuracy in detecting ulcers, varices and P1 lesions seems insufficient.
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Affiliation(s)
- Antonio Giordano
- Endoscopy Unit, Gastroenterology Department, ICMDM, Hospital Clínic de Barcelona, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Miriam Escapa
- Endoscopy Unit, Gastroenterology Department, ICMDM, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Miquel Urpí-Ferreruela
- Endoscopy Unit, Gastroenterology Department, ICMDM, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Gherzon Casanova
- Endoscopy Unit, Gastroenterology Department, ICMDM, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Gloria Fernández-Esparrach
- Endoscopy Unit, Gastroenterology Department, ICMDM, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Àngels Ginès
- Endoscopy Unit, Gastroenterology Department, ICMDM, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Josep Llach
- Endoscopy Unit, Gastroenterology Department, ICMDM, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Begoña González-Suárez
- Endoscopy Unit, Gastroenterology Department, ICMDM, Hospital Clínic de Barcelona, Barcelona, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.
- Faculty of Medicine, University of Barcelona, Barcelona, Spain.
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Sugino S, Inoue K, Zen K, Yashige M, Kobayashi R, Takamatsu K, Ito N, Iwai N, Hirose R, Doi T, Dohi O, Yoshida N, Uchiyama K, Takagi T, Ishikawa T, Konishi H, Matoba S, Itoh Y. Gastrointestinal Angiodysplasia in Patients with Severe Aortic Stenosis: The Endoscopic Features of Heyde's Syndrome. Digestion 2023; 104:468-479. [PMID: 37619533 DOI: 10.1159/000533237] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 07/22/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Aortic stenosis (AS) is sometimes associated with gastrointestinal bleeding, and this phenomenon is known as Heyde's syndrome. Such bleeding is most often considered to originate from gastrointestinal angiodysplasias, but the frequency and endoscopic features of such bleeding remain unclear. This study aimed to determine the frequency and endoscopic features of gastrointestinal angiodysplasia in patients with severe AS. PATIENTS AND METHODS In this multicenter, retrospective study, we evaluated consecutive patients who underwent transcatheter aortic valve implantation (TAVI) with severe AS from May 2016 to December 2019. We extracted the data on the clinicopathological features according to the status of anemia, the proportion of patients who underwent gastrointestinal endoscopic examinations and demonstrated gastrointestinal angiodysplasia, and identified the endoscopic features associated with such patients. RESULTS In 325 patients, the rates of moderate/severe anemia (hemoglobin < 11 g/dL) were 52%. Regarding medicine, there were no significant differences between the patients with and without moderate/severe anemia. Patients were examined by esophagogastroduodenoscopy (21%), colonoscopy (12%), and balloon-assisted enteroscopy or small bowel capsule endoscopy (1.5%). Patients with moderate/severe anemia had significantly more angiodysplasia (38.3% vs. 7.7%; p < 0.0001) and active bleeding (23.4% vs. 0%; p < 0.01). Angiodysplasia was detected in 21 patients (stomach, n = 9; small intestine, n = 5, and colon, n = 10). CONCLUSIONS The results suggest, for the first time, that patients with severe AS who underwent TAVI and moderate/severe anemia frequently had gastrointestinal angiodysplasia and active bleeding throughout the entire gastrointestinal tract.
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Affiliation(s)
- Satoshi Sugino
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan,
- Department of Gastroenterology and Hepatology, Asahi University Hospital, Gifu, Japan,
| | - Ken Inoue
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kan Zen
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Masaki Yashige
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Reo Kobayashi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuaki Takamatsu
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Nobuyasu Ito
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Naoto Iwai
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ryohei Hirose
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshifumi Doi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Osamu Dohi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuhiko Uchiyama
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomohisa Takagi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takeshi Ishikawa
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hideyuki Konishi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Ocran E, Chornenki NLJ, Bowman M, Sholzberg M, James P. Gastrointestinal bleeding in von Willebrand patients: special diagnostic and management considerations. Expert Rev Hematol 2023; 16:575-584. [PMID: 37278227 DOI: 10.1080/17474086.2023.2221846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/01/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Severe and recurrent gastrointestinal (GI) bleeding caused by angiodysplasia is a significant problem in patients with von Willebrand disease (VWD) and in those with acquired von Willebrand syndrome (AVWS). At present, angiodysplasia-related GI bleeding is often refractory to standard treatment including replacement therapy with von Willebrand factor (VWF) concentrates and continues to remain a major challenge and cause of significant morbidity in patients despite advances in diagnostics and therapeutics. AREAS COVERED This paper reviews the available literature on GI bleeding in VWD patients, examines the molecular mechanisms implicated in angiodysplasia-related GI bleeding, and summarizes existing strategies in the management of bleeding GI angiodysplasia in patients with VWF abnormalities. Suggestions are made for further research directions. EXPERT OPINION Bleeding from angiodysplasia poses a significant challenge for individuals with abnormal VWF. Diagnosis remains a challenge and may require multiple radiologic and endoscopic investigations. Additionally, there is a need for enhanced understanding at a molecular level to identify effective therapies. Future studies of VWF replacement therapies using newer formulations as well as other adjunctive treatments to prevent and treat bleeding will hopefully improve care.
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Affiliation(s)
- Edwin Ocran
- Department of Medicine, Queen's University, Kingston, Canada
| | | | | | - Michelle Sholzberg
- Division of Hematology-Oncology, St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Canada
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Canada
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Zhang C, Wang Y, Zhang D, Li S. Colonoscopic and Clinical Features of Colonic Angiodysplasia: A Study in 54 Patients. Surg Laparosc Endosc Percutan Tech 2023; 33:115-120. [PMID: 36944226 PMCID: PMC10065816 DOI: 10.1097/sle.0000000000001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 01/31/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVES Colonic angiodysplasia is a rare disease, it is nevertheless a common cause of lower gastrointestinal (GI) bleeding in older adults. The study summarized the colonoscopic and clinical features of colonic angiodysplasia to raise awareness among endoscopists regarding this disease. MATERIALS AND METHODS We performed a retrospective study of enrolled patients diagnosed with colonic angiodysplasia between September 2013 and April 2022. Clinical and colonoscopic features of the patients with active bleeding were analyzed and compared with those of patients without bleeding. The comparisons were also conducted between the patients with active lower GI bleeding caused by colonic angiodysplasia and those by other diseases. RESULTS In total, 54 eligible patients were included in this study; 55.55% of the participants were aged over 60 years. Ten patients (3 men and 7 women) with colonic angiodysplasia suffered from active lower GI bleeding, which was mainly located in the left and total colon. The patients with type 2 diabetes mellitus, radiotherapy history, antiplatelet drug use, and multiple lesions were more likely to endure lower GI bleeding. The duration between bleeding and admission was longer in the colonic angiodysplasia group than in the other diseases group ( P = 0.043). In the colonic angiodysplasia group, bleeding relapsed in 3 patients, and the recurrence rate was higher than in the other diseases group ( P < 0.001). CONCLUSION Endoscopists should perform colonoscopy scrupulously and consider colonic angiodysplasia as a differential diagnosis in patients with lower GI bleeding, especially for older women and adults with chronic diseases, such as type 2 diabetes mellitus.
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Fujimori S. Tranexamic acid may be a useful pharmacotherapy for endoscopically resistant small bowel angiodysplasia. World J Gastroenterol 2023; 29:1131-1138. [PMID: 36926669 PMCID: PMC10011953 DOI: 10.3748/wjg.v29.i7.1131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/23/2022] [Accepted: 02/01/2023] [Indexed: 02/21/2023] Open
Abstract
Small bowel angiodysplasia (SBAD) is reported to account for nearly 50% of cases of small bowel bleeding. When SBAD occurs frequently, it is difficult to treat all the angiodysplasias endoscopically, and gastrointestinal bleeding often recurs. Hormone therapy, somatostatin analogs, thalidomide and vascular endothelial growth factor (VEGF)-neutralizing antibodies have been reported to reduce gastrointestinal angiodysplasia (GIAD) bleeding. However, there is no strong evidence to recommend them. Also, there are no guidelines for their use. Hereditary hemorrhagic telangiectasia (HHT) is a hereditary disease caused by abnormalities in VEGF, resulting in multiple GIADs. A treatment guideline has been created for GIAD in HHT, and the use of tranexamic acid, an antifibrinolytic agent, is the first recommendation pharmacotherapy for GIAD with gastrointestinal bleeding that is difficult to treat endoscopically. It has been reported that fibrinolysis is accelerated in GIAD patients who are not HHT, similar to HHT patients. The use of tranexamic acid for gastric antral vascular ectasia in GIAD has been reported to be useful. However, there are very few reports of its use for SBAD. There are concerns with tranexamic acid use regarding the development of thrombosis/embolism, but there are few reports of such side effects. Future clinical trials including tranexamic acid for SBAD are desired.
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Affiliation(s)
- Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba 270-1694, Japan
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12
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Chu Y, Huang F, Gao M, Zou DW, Zhong J, Wu W, Wang Q, Shen XN, Gong TT, Li YY, Wang LF. Convolutional neural network-based segmentation network applied to image recognition of angiodysplasias lesion under capsule endoscopy. World J Gastroenterol 2023; 29:879-889. [PMID: 36816625 PMCID: PMC9932427 DOI: 10.3748/wjg.v29.i5.879] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/26/2022] [Accepted: 01/12/2023] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Small intestinal vascular malformations (angiodysplasias) are common causes of small intestinal bleeding. While capsule endoscopy has become the primary diagnostic method for angiodysplasia, manual reading of the entire gastrointestinal tract is time-consuming and requires a heavy workload, which affects the accuracy of diagnosis.
AIM To evaluate whether artificial intelligence can assist the diagnosis and increase the detection rate of angiodysplasias in the small intestine, achieve automatic disease detection, and shorten the capsule endoscopy (CE) reading time.
METHODS A convolutional neural network semantic segmentation model with a feature fusion method, which automatically recognizes the category of vascular dysplasia under CE and draws the lesion contour, thus improving the efficiency and accuracy of identifying small intestinal vascular malformation lesions, was proposed. Resnet-50 was used as the skeleton network to design the fusion mechanism, fuse the shallow and depth features, and classify the images at the pixel level to achieve the segmentation and recognition of vascular dysplasia. The training set and test set were constructed and compared with PSPNet, Deeplab3+, and UperNet.
RESULTS The test set constructed in the study achieved satisfactory results, where pixel accuracy was 99%, mean intersection over union was 0.69, negative predictive value was 98.74%, and positive predictive value was 94.27%. The model parameter was 46.38 M, the float calculation was 467.2 G, and the time length to segment and recognize a picture was 0.6 s.
CONCLUSION Constructing a segmentation network based on deep learning to segment and recognize angiodysplasias lesions is an effective and feasible method for diagnosing angiodysplasias lesions.
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Affiliation(s)
- Ye Chu
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Shanghai 200025, China
| | - Fang Huang
- Technology Platform Department, Jinshan Science & Technology (Group) Co., Ltd., Chongqing 401120, China
| | - Min Gao
- Technology Platform Department, Jinshan Science & Technology (Group) Co., Ltd., Chongqing 401120, China
| | - Duo-Wu Zou
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Shanghai 200025, China
| | - Jie Zhong
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Shanghai 200025, China
| | - Wei Wu
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Shanghai 200025, China
| | - Qi Wang
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Shanghai 200025, China
| | - Xiao-Nan Shen
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Shanghai 200025, China
| | - Ting-Ting Gong
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Shanghai 200025, China
| | - Yuan-Yi Li
- Technology Platform Department, Jinshan Science & Technology (Group) Co., Ltd., Chongqing 401120, China
| | - Li-Fu Wang
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Shanghai 200025, China
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13
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Abstract
Gastrointestinal (GI) bleeding is an important cause of morbidity and mortality in von Willebrand disease (VWD). It has been noted that GI bleeding caused by angiodysplasia is overrepresented in VWD patients compared to other causes. The bleeding from angiodysplasia is notoriously difficult to treat; recurrences and rebleeds are common. A growing body of basic science evidence demonstrates that von Willebrand factor negatively regulates angiogenesis through multiple pathways. VWD is clinically highly associated with angiodysplasia. The predisposition to angiodysplasia likely accounts for many of the clinical difficulties related to managing GI bleeding in VWD patients. Diagnosis and treatment are challenging with the current tools available, and much further research is needed to further optimize care for these patients with regard to acute treatment, prophylaxis, and adjunctive therapies. In this review we provide an overview of the available literature on GI bleeding in VWD and explore the molecular underpinnings of angiodysplasia-related GI bleeding. Considerations for diagnostic effectiveness are discussed, as well as the natural history and recurrence of these lesions and which therapeutic options are available for acute and prophylactic management.
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Affiliation(s)
| | - Edwin Ocran
- Department of Medicine, Queen's University, Kingston, Canada
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, Canada
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14
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Abstract
Lower gastrointestinal bleeding (LGIB), originating mainly in the colon, rectum and anus, occurs most often in older patients (7th decade) with co-morbidity, half of whom have coagulation abnormalities due to anti-coagulant or anti-aggregant therapy. In three cases out of four, bleeding regresses spontaneously but can recur in up to one third of patients. The main causes are diverticular disease, vascular disorders (hemorrhoids, angiodysplasia) and colitis. Ten to 15% of patients present in hypovolemic shock. The main problem is to determine the precise location and etiology of bleeding. First-line steps include correction of hemodynamics, correction of coagulation disorders and transfusion, as necessary. Rectal digital examination allows differentiation between melena and hematochezia. In patients with severe LGIB, upper endoscopy can eliminate upper gastro-intestinal bleeding (UGIB). Computerized tomography (CT) angiography can pinpoint the source. If contrast material extravasates, the therapeutic strategy depends on the cause of bleeding and the general status of the patient: therapeutic colonoscopy, arterial embolization and/or surgery. In the absence of severity criteria (Oakland score≤10), ambulatory colonoscopy should be performed within 14 days. Discontinuation of anticoagulant and/or antiplatet therapy should be discussed case by case according to the original indications.
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Affiliation(s)
- M Boullier
- Digestive surgery department, university hospital center, avenue de la Côte-de-Nacre, 14000 Caen, France.
| | - A Fohlen
- Uro-digestive imaging and interventional radiology department, university hospital center, avenue de la Côte-de-Nacre, 14000 Caen, France; Équipe CERVOxy, ISTCT UMR 6030-CNRS, CEA, University of Caen-Normandie, GIP Cycéron, boulevard H. Becquerel, BP5229, 14074 Caen cedex, France
| | - S Viennot
- Gastroenterology department, university hospital center, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - A Alves
- Digestive surgery department, university hospital center, avenue de la Côte-de-Nacre, 14000 Caen, France; Unité Inserm 1086 "ANTICIPE", Centre François Baclesse "Cancers & Préventions", avenue du Général Harris, BP5026, 14076 Caen cedex, France
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15
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Shaw MYV, Asokkumar R, Tan Kwong Wei EJ, Seow-En I. Colonic angiodysplasia: a culprit of obscure gastrointestinal bleeding in a patient with Heyde syndrome. BMJ Case Rep 2022; 15:15/1/e247595. [PMID: 35027388 PMCID: PMC8762101 DOI: 10.1136/bcr-2021-247595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
A 77-year-old woman presented with obscure gastrointestinal bleeding requiring multiple hospitalisations and blood transfusions. The patient underwent repeated investigations over four hospital admissions across a span of two months. These included upper and lower gastrointestinal endoscopy, video capsule endoscopy as well as CT enterography, without definitive localisation or treatment of the source of bleeding. Finally, a technetium-99m-labelled red blood cell scan demonstrated a ‘blush’ at the proximal transverse colon on delayed imaging. Targeted colonoscopic evaluation showed a subcentimetre angiodysplastic lesion in the corresponding spot at the proximal transverse colon with slow persistent oozing. Endoscopic clips were applied with successful haemostasis. The patient recovered well without further symptom recurrence 5 months postdischarge. We review the literature on colonic angiodysplasias and discuss the diagnostic challenges in obscure gastrointestinal bleeding.
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Affiliation(s)
| | | | | | - Isaac Seow-En
- General Surgery, Singapore General Hospital, Singapore
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16
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Khan A, Gupta K, Chowdry M, Sharma S, Maheshwari S, Patel C, Naseem K, Pervez H, Bilal M, Ali Khan M, Singh S. Thirty-day readmission rates, reasons, and costs for gastrointestinal angiodysplasia-related bleeding in the USA. Eur J Gastroenterol Hepatol 2022; 34:11-17. [PMID: 33405425 DOI: 10.1097/meg.0000000000002027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Patients with gastrointestinal angiodysplasia (GIA)-related bleeding are at high risk for readmissions, resulting in significant morbidity and an economic burden on the healthcare system. AIM The aim of the study was to determine the 30-day readmission rate with reasons, predictors, and costs associated with GIA-related bleeding in the USA. METHODS We queried the National Readmission Database to identify patients hospitalized with GIA-related bleeding in the year 2016 using the International Classification of Diseases, Tenth Revision (ICD-10) codes. Primary outcomes included the 30-day readmission rate, and secondary outcomes were in-hospital mortality and resource utilization for index and re-hospitalizations. We also performed univariate and multivariate cox regression analysis to identify predictors of readmissions. RESULTS A total of 25 079 index hospitalizations for GIA-related bleeding were identified in 2016. Out of these, 5047 (20.34%) patients got readmitted within the next 30 days. The most common diagnosis associated with readmissions were related to recurrent gastrointestinal bleeding. Readmissions compared to index hospitalization has significantly higher length of stay (5.38 vs. 5.11 days, P = 0.03), but mean hospitalization charges ($52 114 vs. $49 691, P = 0.11) and mean total hospitalization costs ($12 870 vs. $12 405, P = 0.16) were similar. Patients with multiple co-morbidities, length of stay >5 days, and end-stage renal disease were found to be independent predictors for 30-day readmissions. CONCLUSION Our study shows that one in five patients hospitalized with GIA-related bleeding was readmitted within 30 days of index hospitalization, placing a heavy economic burden on the healthcare system. Further research identifying strategies to reduce readmissions in these patients is needed.
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Affiliation(s)
- Ahmad Khan
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Kamesh Gupta
- Department of Medicine, UMass Medical Center, Springfield, Massachusetts
| | - Monica Chowdry
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Sachit Sharma
- Department of Medicine, The Toledo Hospital, Toledo, Ohio
| | | | - Chirag Patel
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Khadija Naseem
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Hira Pervez
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mohammad Bilal
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Muhammad Ali Khan
- Division of Gastroenterology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama
| | - Shailendra Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
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Rauch A, Paris C, Repesse Y, Branche J, D'Oiron R, Harroche A, Ternisien C, Castet SM, Lebreton A, Pan-Petesch B, Volot F, Claeyssens S, Chamouni P, Gay V, Berger C, Desprez D, Falaise C, Biron Andreani C, Marichez C, Pradines B, Zawadzki C, Itzhar Baikian N, Borel-Derlon A, Goudemand J, Gerard R, Susen S. Gastrointestinal bleeding from angiodysplasia in von Willebrand disease: Improved diagnosis and outcome prediction using videocapsule on top of conventional endoscopy. J Thromb Haemost 2021; 19:380-386. [PMID: 33113216 DOI: 10.1111/jth.15155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/09/2020] [Accepted: 10/21/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Despite a high prevalence of angiodysplasia, no specific guidelines are available for the modalities of endoscopic exploration of gastrointestinal (GI) bleeding in von Willebrand disease (VWD). Whether VWD patients could benefit from video capsule endoscopy (VCE) looking for angiodysplasia eligible to endoscopic treatment or at high risk of bleeding is unknown. OBJECTIVES To assess the diagnostic efficacy for angiodysplasia and the prognostic value of VCE on top of conventional endoscopy in VWD patients with GI bleeding. PATIENTS/METHODS A survey was sent to the 30 centers of the French-network on inherited bleeding disorders to identify VWD patients referred for endoscopic exploration of GI bleeding from January 2015 to December 2017. Data obtained included patient characteristics, VWD phenotype/genotype, GI bleeding pattern, results of endoscopic investigations, and medical management applied including endoscopic therapy. We assessed by Kaplan-Meier analysis the recurrence-free survival after the first GI bleeding event according to endoscopic categorization and, in patients with angiodysplasia, to the presence of small-bowel localizations on VCE exploration. RESULTS GI bleeding source localization was significantly improved when including VCE exploration (P < .01), even in patients without history of angiodysplasia (P < .05). Patients with angiodysplasia had more GI bleeding recurrences (P < .01). A lower recurrence-free survival was observed in patients with angiodysplasia (log-rank test, P = .02), and especially when lesions were located in the small bowel (log-rank test, P < .01), even after endoscopic treatment with argon plasma coagulation (log-rank test, P < .01). CONCLUSION VCE should be more systematically used in VWD patients with unexplained or recurrent GI bleeding looking for angiodysplasia eligible to endoscopic treatment or at high risk of relapse.
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Affiliation(s)
- Antoine Rauch
- Department of Hematology and Transfusion, CHU Lille, Institut d'Hématologie Transfusion, Lille, France
| | - Camille Paris
- Department of Hematology and Transfusion, CHU Lille, Institut d'Hématologie Transfusion, Lille, France
| | | | - Julien Branche
- Department of Gastroenterology, CHU Lille, Lille, France
| | - Roseline D'Oiron
- Center for Hemophilia and Rare Congenital Bleeding Disorders, University Hospital Paris-Sud, AP-HP, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | | | | | | | | | | | | | | | | | - Valérie Gay
- CH Métropole Savoie - Site de Chambéry, Chambéry, France
| | | | | | - Céline Falaise
- Centre régional de traitement des hémophiles, Hôpital de La Timone, AP-HM, Marseille, France
| | | | - Catherine Marichez
- Department of Hematology and Transfusion, CHU Lille, Institut d'Hématologie Transfusion, Lille, France
| | - Benedicte Pradines
- Department of Hematology and Transfusion, CHU Lille, Institut d'Hématologie Transfusion, Lille, France
| | - Christophe Zawadzki
- Department of Hematology and Transfusion, CHU Lille, Institut d'Hématologie Transfusion, Lille, France
| | - Nathalie Itzhar Baikian
- Laboratoire d'Hématologie, GH St-Louis Lariboisière F.Widal - Hôpital Lariboisière APHP, Paris, France
| | | | - Jenny Goudemand
- Department of Hematology and Transfusion, CHU Lille, Institut d'Hématologie Transfusion, Lille, France
| | - Romain Gerard
- Department of Gastroenterology, CHU Lille, Lille, France
| | - Sophie Susen
- Department of Hematology and Transfusion, CHU Lille, Institut d'Hématologie Transfusion, Lille, France
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18
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Sakai E, Ohata K, Nakajima A, Matsuhashi N. Diagnosis and therapeutic strategies for small bowel vascular lesions. World J Gastroenterol 2019; 25:2720-2733. [PMID: 31235995 PMCID: PMC6580356 DOI: 10.3748/wjg.v25.i22.2720] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/21/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.
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Affiliation(s)
- Eiji Sakai
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
| | - Atsushi Nakajima
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Nobuyuki Matsuhashi
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
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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: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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20
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Ganesananthan S, Barlow J, Durai D, Hawthorne AB. Multiple venous malformations in the left colon and rectum: a long-standing case managed conservatively and an update of current literature. BMJ Case Rep 2019; 12:e227700. [PMID: 30902841 PMCID: PMC6453398 DOI: 10.1136/bcr-2018-227700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2019] [Indexed: 12/15/2022] Open
Abstract
Venous or cavernous malformations of the colon or rectum are a rare cause of lower gastrointestinal bleeds. It has been previously described as a diffuse cavernous haemangioma which was thought to be a benign vascular tumour. It mainly affects the rectosigmoid area of the gastrointestinal tract and is most common in children and young adults. Misdiagnosis is common with patients averaging a total of 19 years delay to this final diagnosis. We report a case of a 65-year-old patient who presented with occult, painless rectal bleeding and prior to this presentation, had been managed variously as colitis and angiodysplasia. This article aims to delineate the updated classification of this disease, principal clinical clues to aid the diagnosis while discussing patient treatment options and potential challenges faced in patient management.
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21
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Cedrón Cheng HG, Chirinos Vega JA. [Single balloon enteroscopy in the management of small bowel pathology. Experience of the Small Bowel Unit - British American Hospital from December 2012 to December 2018]. Rev Gastroenterol Peru 2019; 39:27-37. [PMID: 31042234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
UNLABELLED Objetive: To describe our experience with single balloon enteroscopy in the management of small bowel disease in British American Hospital, Lima - Perú. MATERIAL AND METHODS Descriptive and prospective study. We include all patients that come to perform a single balloon enteroscopy in small bowel unit of British American Hospital within December 2012 to December 2018. RESULTS We performed 80 procedures of single balloon enteroscopy, 49 were done by oral approach, 31 by rectal approach. Mean age were 60.78 years-old (20 - 88 years). 48 patients (60%) were male. The mean insertion time for oral approach was 80 minutes (55-141 minutes), and for rectal approach was 110 minutes (55-180 minutes). The main indication for single balloon enteroscopy was obscure gastrointestinal bleeding. 6 enteroscopies were performed in patients with altered surgical anatomy (7.5%). 70 of 80 procedures (87.5%) were performed with gastroenterology-administered sedation, using midazolam, pethidine and propofol, without any respiratory or hemodinamic complication. Diagnostics achieved by single balloon enteroscopy were small bowel angiodysplasias (20%), yeyuno ileal ulcers (17.5%) and small bowel neoplasia (7.5%). Paralytic ileus was the most common complication of single balloon enteroscopy, 2 cases, and both cases were associated after no using carbon dioxide insufflation during procedure. CONCLUSION Obscure gastrointestinal bleeding was the main indication for single balloon enteroscopy. Diagnostics achieved by single balloon enteroscopy were small bowel angiodysplasias (20%), yeyuno ileal ulcers (17.5%) and small bowel neoplasia (7.5%). Paralytic ileus was the most common complication of single balloon enteroscopy, 2 cases, and both cases were associated after no using carbon dioxide insufflation during procedure.
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22
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Cálamo-Guzmán B, De Vinatea-Serrano L, Piscoya A. Polypoid angiodysplasia mimicking diverticular disease. Gastroenterol Hepatol 2018; 41:574-575. [PMID: 29884485 DOI: 10.1016/j.gastrohep.2018.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/18/2018] [Accepted: 04/25/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Bernardo Cálamo-Guzmán
- Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Peru; Sociedad Científica de Estudiantes de Medicina de la Universidad Peruana de Ciencias Aplicadas (SOCIEMUPC), Lima, Peru.
| | - Luis De Vinatea-Serrano
- Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Peru; Sociedad Científica de Estudiantes de Medicina de la Universidad Peruana de Ciencias Aplicadas (SOCIEMUPC), Lima, Peru
| | - Alejandro Piscoya
- Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Peru; Complejo Hospitalario Guillermo Kaelin de la Fuente, Lima, Peru
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Lin MC, Chen PJ, Shih YL, Huang HH, Chang WK, Hsieh TY, Huang TY. Outcome and Safety of Anterograde and Retrograde Single-Balloon Enteroscopy: Clinical Experience at a Tertiary Medical Center in Taiwan. PLoS One 2016; 11:e0161188. [PMID: 27548619 PMCID: PMC4993377 DOI: 10.1371/journal.pone.0161188] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 08/01/2016] [Indexed: 02/07/2023] Open
Abstract
Single-balloon enteroscopy (SBE) is designed for identifying possible small bowel lesions with balloon-assisted enteroscopy that allows deep intubation of the intestine. However, data regarding the outcome and safety of SBE remain limited. We conducted this study to evaluate the outcome and safety of anterograde and retrograde SBE approaches. This retrospective review from a tertiary medical center in Taiwan included endoscopic reports and chart data from 128 patients with 200 anterograde and retrograde procedures from September 2009 to November 2014. In this study, the most common indication for both anterograde and retrograde SBE was obscure gastrointestinal bleeding (64.4% vs. 60.6%). There were no significant differences between anterograde and retrograde approaches in terms of the diagnostic yield (69.3% vs. 52.5%) and intervention rate (23.8% vs. 17.2%). The procedure time was shorter for anterograde SBE than for retrograde SBE (68.1 ± 23.9 vs. 76.8 ± 27.7 min, P = 0.018). In addition, among the subgroup of patients with obscure gastrointestinal bleeding, the most common etiologies for those in different age-groups were angiodysplasia (≥ 65 years), non-specific ulcers (30–64 years), and Meckel’s diverticulum (< 30 years). The major complication rate during the study was 1.5%; the rate of asymptomatic hyperamylasemia was higher for patients who underwent anterograde SBE than for those who underwent retrograde SBE (13.9% vs. 2%, P = 0.005). The outcome and safety of anterograde and retrograde SBE are similar. However, anterograde SBE has a shorter procedural time and a higher rate of asymptomatic hyperamylasemia.
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Affiliation(s)
- Meng-Chiung Lin
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Internal Medicine, Taichiung Armed Forces General Hospital, Taichiung, Taiwan
| | - Peng-Jen Chen
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Lueng Shih
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsin-Hung Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tsai-Yuan Hsieh
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, 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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25
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Kim DB, Chung WC, Lee SJ, Sung HJ, Woo S, Kim HS, Jeong YO, Lee H, Kim YJ. Analysis of risk factor and clinical characteristics of angiodysplasia presenting as upper gastrointestinal bleeding. Korean J Intern Med 2016; 31:669-77. [PMID: 26828247 PMCID: PMC4939498 DOI: 10.3904/kjim.2015.087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/07/2015] [Accepted: 06/25/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND/AIMS Angiodysplasia is important in the differential diagnosis of upper gastrointestinal bleeding (UGIB), but the clinical features and outcomes associated with UGIB from angiodysplasia have not been characterized. We aimed to analyze the clinical characteristics and outcomes of angiodysplasia presented as UGIB. METHODS Between January 2004 and December 2013, a consecutive series of patients admitted with UGIB were retrospectively analyzed. Thirty-five patients with bleeding from angiodysplasia were enrolled. We compared them with an asymptomatic control group (incidental finding of angiodysplasia in health screening, n = 58) and bleeding control group (simultaneous finding of angiodysplasia and peptic ulcer bleeding, n = 28). RESULTS When patients with UGIB from angiodysplasia were compared with the asymptomatic control group, more frequent rates of nonantral location and large sized lesion (≥ 1 cm) were evident in multivariate analysis. When these patients were compared with the bleeding control group, they were older (mean age: 67.94 ± 9.16 years vs.55.07 ± 13.29 years, p = 0.03) and received less transfusions (p = 0.03). They also had more frequent rate of recurrence (40.0% vs. 20.7%, p = 0.02). CONCLUSIONS Non-antral location and large lesions (≥ 1 cm) could be risk factors of UGIB of angiodysplasia. UGIB due to angiodysplasia was more common in older patients. Transfusion requirement would be less and a tendency of clinical recurrence might be apparent.
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Affiliation(s)
| | - Woo Chul Chung
- Correspondence to Woo Chul Chung, M.D. Department of Internal Medicine, College of Medicine, St. Vincent’s Hospital, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea Tel: +82-31-249-7138 Fax: +82-31-253-8898 E-mail:
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26
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Andrei GN, Popa B, Gulie L, Diaconescu BI, Martian BV, Bejenaru M, Beuran M. Highlighted Steps of the Management Algorithm in Acute Lower Gastrointestinal Bleeding - Case Reports and Literature Review. Chirurgia (Bucur) 2016; 111:74-79. [PMID: 26988545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2016] [Indexed: 06/05/2023]
Abstract
Acute lower gastrointestinal bleeding is a major problem worldwide, being a rare and life threatening condition, with a mortality rate situated between 2 and 4%. Acute lower gastrointestinal bleeding is solvent for 1 - 2% of the entire hospital emergencies, 15% presenting as massive bleeding and up to 5% requiring surgery. Lower gastrointestinal bleeding can be classified depending on their location in the small or large intestine. The small bowel is the rarest site of lower gastrointestinal bleeding, at the same time being the commonest cause of obscure bleeding. 5% of total lower GI bleeding appears in the small bowel. When endoscopic therapy associated with medical treatment are insufficient, endovascular intervention can be lifesaving. Unfortunately in some rare cases of acute lower gastrointestinal bleeding with hemo-dynamic instability and the angiography performed being unable to locate the source of bleeding, the last therapeutic resource remains surgery. In the following we exemplify two cases of acute lower gastrointestinal bleeding which were resolved in different ways, followed by a thorough description of the different types of available treatment and finally, in the conclusions, we systematize the most important stages of the management algorithm in acute lower gastrointestinal bleeding.
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27
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Haghighatafshar M, Gheisari F, Ghaedian T. Importance of Heparin Provocation and SPECT/CT in Detecting Obscure Gastrointestinal Bleeding on 99mTc-RBC Scintigraphy: A Case Report. Medicine (Baltimore) 2015; 94:e1325. [PMID: 26313771 PMCID: PMC4602913 DOI: 10.1097/md.0000000000001325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
We presented a pediatric case with a history of intermittent melena for 3 years because of angiodyplasia of small intestine. The results of frequent upper gastrointestinal endoscopies and colonoscopies as well as both Tc-red blood cell (RBC) and Meckel's scintigraphies for several times were negative in detection of bleeding site. However, Tc-RBC scintigraphy with single-photon emission computed tomography (SPECT)/computed tomography (CT) after heparin augmentation detected a site of bleeding in the distal ileum which later was confirmed during surgery with final diagnosis of angiodysplasia.It could be stated that heparin provocation of bleeding before Tc-RBC scintigraphy accompanied by fused SPECT/CT images should be kept in mind for management of intestinal bleeding especially in difficult cases.
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Affiliation(s)
- Mahdi Haghighatafshar
- From the Nuclear Medicine and Molecular Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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28
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Lorenzo-Rivero S, Sherwood LM. Angiodysplasia: an unusual case of gastrointestinal bleeding. Am Surg 2015; 81:E260-E262. [PMID: 26031261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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29
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Alsidawi S, Couto M, López-Candales A. Acquired Von Willebrand Syndrome In Aortic Stenosis: Case Report And Review. Bol Asoc Med P R 2015; 107:86-88. [PMID: 26434092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We present a case of a 61 year old man who presented with a 3 week history of easy bruising and ecchymoses in both thighs and right arm without significant trauma. Physical exam was remarkable for oozing gums, diminished second heart sound, a systolic ejection murmur at the aortic position with radiation to carotids, and delayed pulses. Laboratories were remarkable for iron deficiency anemia. Echocardiogram was consistent with severe aortic stenosis. Colonoscopy revealed several arteriovenous malformations throughout the colon. There is an association between severe aortic stenosis and gastrointestinal bleeding. The pathogenesis of Heyde's Syndrome involves iron deficiency anemia due to acquired von Willebrand factor (vWF) deficiency and ultimately gastrointestinal angiodysplasia. Correct diagnosis and management warrants a multidisciplinary approach.
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30
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Stiefelhagen P. [What is the origin of bright red blood in stool? Angiodysplasia]. MMW Fortschr Med 2015; 157 Suppl 1:7. [PMID: 26012962 DOI: 10.1007/s15006-015-2842-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Peter Stiefelhagen
- DRK-Krankenhaus, Alte Frankfurter Straße 12, D-57627, Hachenburg, Deutschland
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31
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32
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Habek JČ, Habek D. [MASSIVE RECTORRHAGIA MIMICKING POSSIBLE GENITAL HAEMORRHAGE]. Acta Med Croatica 2015; 69:487-489. [PMID: 29087097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A case is presented of a 76-year-old woman who was initially considered to have massive genital hemorrhage, but exclusion examination and treatment proved it to be massive rectorrhagia. The patient died due to irreversible hemorrhagic shock and rupture of rectal angiodysplasia was proved on autopsy.
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33
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Jeon SR, Kim JO. Author's reply: To PMID 25141313. Turk J Gastroenterol 2014; 25:454-455. [PMID: 25381668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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34
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Wan SH, Liang JJ, Rihal CS. 83-year-old man with chest pain, exertional dyspnea, and anemia. Mayo Clin Proc 2013; 88:e129-33. [PMID: 24182710 DOI: 10.1016/j.mayocp.2013.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 03/19/2013] [Accepted: 03/22/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Siu-Hin Wan
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
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35
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Godino C, Lauretta L, Pavon AG, Mangieri A, Viani G, Chieffo A, Galaverna S, Latib A, Montorfano M, Cappelletti A, Maisano F, Alfieri O, Margonato A, Colombo A. Heyde's syndrome incidence and outcome in patients undergoing transcatheter aortic valve implantation. J Am Coll Cardiol 2013; 61:687-9. [PMID: 23391203 DOI: 10.1016/j.jacc.2012.10.041] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 09/17/2012] [Accepted: 10/09/2012] [Indexed: 02/06/2023]
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36
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Negi SI, Xu R, Anand A. Medical image. A murmur and a bleed: the Heyde syndrome. N Z Med J 2013; 126:95-97. [PMID: 23793126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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37
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Gaibov AD, Safarova AN, Sultanov DD, Baratov AK, Malikov MK. [Present-day possibilities of surgical management of tumour-like forms of arteriovenous angiodysplasias]. Angiol Sosud Khir 2013; 19:143-149. [PMID: 24429572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Described herein is the treatment policy pursued in a relatively uncommonly encountered variant of congenital vascular pathology, i. e. arteriovenous angiodysplasias. We operated a total of twenty patients presenting with various localization of the pathology concerned. The patients average age amounted to 18 ± 8.6 years. In order to make the diagnosis of the disease and to accomplish the tactical missions we used duplex scanning and angiography. According to the opinion of the authors, in this form of angiodysplasias using any method of treatment independently cannot be efficient. Arteriovenous angiodysplasias were treated by a combined method including endovascular embolisation or sclerotherapy of the afferent vessels and surgical removal of vascular formations. The use of such therapeutic policy makes it possible to attain positive results in 75% of patients.
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38
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Dan VN, Sapelkin SV, Sharobaro VI, Timina IE, Tsygankov VN, Karmazanovskiĭ GG, Subbotin VV, Vafina GR. [Angiodysplasias of the head and neck: present-day principles of treatment using elements of plastic surgery]. Angiol Sosud Khir 2013; 19:136-142. [PMID: 24429571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The authors assessed the outcomes of treatment of fifty-one patients presenting with angiodysplasias of the head and neck. Of these, 24 patients suffered from the venous form and 27 had the arteriovenous form. The 51 patients accounted for 23.5% of the total number of patients with congenital vascular malformations over a five-year period. The topicity and angioarchitectonics of the lesion were specified by means of the standard diagnostic complex (i. e., duplex scanning of the vessels, ultrasonographic study of the soft tissues and osseous structures, computed and magnetic resonance tomography, echocardiography, and angiography). Radical excision of the angiomatous tissues was performed in 15 patients and palliative one - in 36 cases. Eight patients were subjected to stagewise resection interventions, ten patients underwent stagewise sessions of laser coagulation, and seven patients endured stagewise roentgenoendovascular embolisations of the afferent arteries. Two patients with the venous form were postoperatively subjected to sessions of sclerotherapy of the residual venous caverns. Two patients in the remote period (7-10 days) underwent autodermoplasty with a free perforated cutaneous flap. This technique was used while closing the wound surface after removing the angiomatous tissues of the parotid region and hairy portion of the head. In five patients the wound surface was closed with a mobilized cervical fat-cutaneous flap. Taking into consideration the importance of the cosmetic outcome after excising the angiomatous tissues on the face and neck, it is necessary to seek for wide application of plastic methods of closing the wound. These methods simultaneously allow of making operative interventions for angiodysplasias more radical.
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Mandelia A, Bhatnagar V. Conservative surgical treatment for jejuno-ileal angiodysplasia. Trop Gastroenterol 2012; 33:69-71. [PMID: 22803301 DOI: 10.7869/tg.2012.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- A Mandelia
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-1 10029, India
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40
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Korotkikh NG, Ol'shanskiĭ MS, Stepanov IV. [Multidisciplinary approach to diagnostics of extensive vascular head and neck malformations]. Stomatologiia (Mosk) 2012; 91:40-45. [PMID: 22678607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The article summarizes the experience of diagnostics in 60 patients with large face and neck angiodysplasia. Compression test, cytology, Doppler ultrasound with color Doppler mapping, X-ray computed tomography and angiography with intravenous contrast, magnetic resonance imaging with angiography and selective carotid angiography of branches of external carotid arteries were used for adequate diagnostics. The efficiency of a multidisciplinary approach in diagnosis and treatment of extensive face and neck angiodysplasias is shown in the study.
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41
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Nelly Manrique M, Frisancho O, Rivas Wong L, Palomino A. [Jejunal GIST with obscure gastrointestinal bleeding]. Rev Gastroenterol Peru 2011; 31:289-297. [PMID: 22086325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
We report the case of a woman of 84 years with a history of cardiac arrhythmia and hemorrhoids. She had multiple hospitalizations and transfusions for symptomatic iron deficiency anemia, endoscopic studies showed only small diverticula and colon polyps. He was later hospitalized with bloody stools red wines, upper endoscopy and colonoscopy showed gastritis, small colonic ulcers, colonic polyp and multiple diverticula. Readmitted with bleeding of obscure origin, on that occasion showed gastritis, antral erosions, small ulcers, colon polyps and colon ulcers in the process of healing, capsule endoscopy showed angiodysplasia in jejunum, anterograde enteroscopy detected some erythematous lesions in proximal jejunum without evidence of bleeding. Again hospitalized for melena and abdominal.
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Affiliation(s)
- María Nelly Manrique
- Departamento del Aparato Digestivo, Hospital Nacional Edgardo Rebagliati Martins, EsSALUD, Lima, Perú
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42
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Islam S, Cevik C, Islam E, Attaya H, Nugent K. Heyde's syndrome: A critical review of the literature. J Heart Valve Dis 2011; 20:366-375. [PMID: 21863647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Heyde's syndrome is an uncommon association between aortic stenosis and gastrointestinal bleeding. Although initially described during the late 1950s, with subsequent reports of a possible link between these disorders, controversy persists regarding the incidence, pathogenesis, and treatment of this syndrome. The main disagreements center on the actual association of aortic stenosis and angiodysplasia, though other controversies include the pathogenesis of Heyde's syndrome, ranging from von Willebrand factor deficiency and age-related degeneration to mucosal ischemia and cholesterol embolization. A variety of treatment modalities of the syndrome has been applied, including medical management, endoscopic therapy, embolization, and aortic valve replacement. Here, the controversies surrounding Heyde's syndrome, which focus on pathogenesis and treatment, are reviewed with the aim of providing a clearer understanding of the syndrome and the implications for patient care.
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Affiliation(s)
- Sameer Islam
- Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79430, USA.
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Abstract
PURPOSE Capsule endoscopy by enabling direct visualization of small bowel mucosa has conquered the last frontier of diagnostic endoscopy. However, its ability to simultaneously detect colonic lesions has not been evaluated. This study was done to evaluate frequency of detection of colonic abnormalities in patients undergoing small bowel capsule endoscopy and its impact on the clinical management. PATIENTS AND METHODS Eighty-seven patients (60 males; mean age: 51.2 ± 18.6 years) who had obscure gastrointestinal bleeding or unexplained abdominal pain or unexplained diarrhea underwent capsule endoscopy. The demographic data and capsule endoscopy findings were retrospectively evaluated. RESULTS Capsule endoscopy was normal in 26 (29.8%) patients and small bowel abnormalities were noted in 49 (56.3%) patients. Capsule endoscope did not reach the cecum during the battery life period of the capsule in five (5.7%) patients. Colonic abnormalities were noted in eight (9.1%) patients. These included cecal angiodysplasia (four), cecal carcinoma (one), transverse colon polyp (one), sigmoid colon ulcerations with histological diagnosis of Crohn's colitis (one), and cecal ulcers with final diagnosis of amebic colitis (one). CONCLUSION The colon should also be carefully evaluated in patients undergoing small bowel capsule endoscopy as significant lesions can be detected that helps in appropriate management.
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Affiliation(s)
- Surinder S Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India.
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Korotkikh NG, Ol'shanskiĭ MS, Stepanov IV, Shcherbinin AS, Timoshin IS. [Application of endovascular methods in complex diagnostics and treatment of tongue angiodysplasias]. Stomatologiia (Mosk) 2011; 90:45-48. [PMID: 21983615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In article experience of diagnostics and treatment of 30 patients with angiodysplasia of the tongue was given. The surgical treatment was made to 21 patients with vascular malformation of the tongue, selective bilateral catheterization of lingual arteries and endovascular microembolization by PVA - 250-400 μ was successfully performed in 4 cases, transcutaneus sclerotherapy with solution aethoxyskleroli 0,5% in 3 cases was successfully provided. Advantages of endovascular diagnostics and treatment methods angiodysplasias of the tongue were shown.
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Molina Infante J, Mateos Rodríguez JM. [Angiodysplasia. Information for the patient]. Rev Esp Enferm Dig 2010; 102:667. [PMID: 21142390 DOI: 10.4321/s1130-01082010001100010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- J Molina Infante
- Unidad de Aparato Digestivo. Hospital San Pedro de Alcántara, Cáceres
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47
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Gandhi V, Philip S, Nagral S. Heyde syndrome. Trop Gastroenterol 2010; 31:120-121. [PMID: 20862990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Vidhyachandra Gandhi
- Department of Surgical Gastroenterology, Jaslok Hospital & Research Centre, Mumbai
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48
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Lazebnik LB, Mikheeva OM, Shcherbakov PL, Efremov LI, Kirova MV. [Angiodysplasia and hemorrhages of the gastrointestinal tract as a particular manifestation of the connective tissue dysplasia]. Eksp Klin Gastroenterol 2010:114-120. [PMID: 20623960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The clinical case of hemorrhagic syndrome associated with alterations of gastrointestinal tract small vessels in the patient with connective tissue dysplasia, magnesium deficiency and with pathological addiction to alcohol is represented in this article.
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Dan VN, Kokov LS, Karmazanovskiĭ GG, Sapelkin SV, Timina IE, Tsygankov VN. [Current trends in diagnosis and treatment of arteriovenous angiodysplasia]. Vestn Ross Akad Med Nauk 2010:20-25. [PMID: 21260929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
A total of 240 patients with arteriovenous angiodysplasia (AVD) were examined and treated in A.V. Vishnevsky Institute of Surgery during 1997-2009. Embolization was performed in 196 (81.7%) patients. Staged embolization was the principal treatment modality in 84 (35%) patients presenting with inoperable lesions. The mean number of sessions was 3.6. Intraoperative embolization using hydrogel embols, Gianturco coils, and 96% alcohol was done in 17 (7.1%) patients. Radical surgery with the removal of angiomatous tissues was given to 33 (13.8%) patients. Palliative resections were made in patients with extensive lesions and impossibility of total removal of angiomatous tissues. Minor and major amputations were needed in 15 patients. It is concluded that intervention for microfistulous and confined macrofistulous lesions should be performed only in case of absolute indications for surgery. That in asymptomatic or subclinical cases is justified only for minor surface lesions fit for radical resection. Minor amputation is indicated in certain patients with arteriovenous fistulas on distal limb segments. Extensive delayed resections should be planned with the use of plastic surgical techniques (autodermoplasty using free flaps, mobilized flaps, and flaps with microvascular anastomosis).
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50
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Hui YT, Lam WM, Fong NMS, Yuen PK, Lam JTW. Heyde's syndrome: diagnosis and management by the novel single-balloon enteroscopy. Hong Kong Med J 2009; 15:301-303. [PMID: 19652242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
We present a case of obscure gastro-intestinal bleeding due to small bowel angiodysplasia in a 68-year-old woman with severe aortic valve stenosis. The diagnosis was confirmed and subsequently managed using single-balloon enteroscopy.
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Affiliation(s)
- Y T Hui
- Department of Medicine, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong.
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