Severe thrombocytopenia associated to bevacizumab in a patient with scleroderma, gastrointestinal angiodysplasias and refractory gastrointestinal bleeding

This case report discusses the medical history of a 64-year-old woman diagnosed with scleroderma and diffuse gastrointestinal angiodysplasia. The patient received bevacizumab (BVZ) therapy to address gastrointestinal bleeding that was unresponsive to endoscopic treatment. Subsequently, she developed severe thrombocytopenia. Although there were suspicions of an immune-mediated mechanism resulting from BVZ treatment, the laboratory results did not provide conclusive evidence. The patient underwent transfusions, received gamma globulin, and was treated with Romiplostim. Over time, her platelet levels gradually improved, and the bleeding was successfully controlled. It's worth noting that BVZ-induced thrombocytopenia is a relatively rare yet severe adverse effect. Recognizing and understanding the mechanisms behind thrombocytopenia is essential for developing safer treatment approaches. Further research is required to identify potential risk factors associated with this condition.

In small-intestinal angiodysplasia with recurrent bleeding, thalidomide reduced bleeding episodes at 1 y

SOURCE CITATION

Chen H, Wu S, Tang M, et al. Thalidomide for recurrent bleeding due to small-intestinal angiodysplasia. N Engl J Med. 2023;389:1649-1659. 37913505.

Glanzmann's thrombasthenia associated with gastrointestinal angiodysplasias successfully treated with bevacizumab

Glanzmann's Thrombasthenia (GT) is a rare hemorrhagic condition caused by a platelet surface receptor disorder of the glycoprotein (GP) IIb/IIIa. Symptoms of GT are various forms of hemorrhages, such as purpura, epistaxis and menorrhagia. Gastrointestinal bleeding (GIB) is a rare expression of the condition and may occur due to traumas in the GI tract or as a consequence of gastrointestinal angiodysplasia (GIADs). In this case report, we present a middle-aged woman with recurrent GIB consequent to GIADs with persistent melena and iron deficiency anemia. After several unsuccessful therapeutic interventions, the patient was studied by the hereditary hemorrhagic telangiectasia's (HHT - Osler-Weber-Rendu disease) unit, where she received bevacizumab, showing a complete improvement in symptoms as well as a reduction in her GIADs. This case shows that bevacizumab could be a possible line of treatment for patients with coagulation disorders with GIADs.

Thalidomide for Recurrent Bleeding Due to Small-Intestinal Angiodysplasia

BACKGROUND

Recurrent bleeding from the small intestine accounts for 5 to 10% of cases of gastrointestinal bleeding and remains a therapeutic challenge. Thalidomide has been evaluated for the treatment of recurrent bleeding due to small-intestinal angiodysplasia (SIA), but confirmatory trials are lacking.

METHODS

We conducted a multicenter, double-blind, randomized, placebo-controlled trial to investigate the efficacy and safety of thalidomide for the treatment of recurrent bleeding due to SIA. Eligible patients with recurrent bleeding (at least four episodes of bleeding during the previous year) due to SIA were randomly assigned to receive thalidomide at an oral daily dose of 100 mg or 50 mg or placebo for 4 months. Patients were followed for at least 1 year after the end of the 4-month treatment period. The primary end point was effective response, which was defined as a reduction of at least 50% in the number of bleeding episodes that occurred during the year after the end of thalidomide treatment as compared with the number that occurred during the year before treatment. Key secondary end points were cessation of bleeding without rebleeding, blood transfusion, hospitalization because of bleeding, duration of bleeding, and hemoglobin levels.

RESULTS

Overall, 150 patients underwent randomization: 51 to the 100-mg thalidomide group, 49 to the 50-mg thalidomide group, and 50 to the placebo group. The percentages of patients with an effective response in the 100-mg thalidomide group, 50-mg thalidomide group, and placebo group were 68.6%, 51.0%, and 16.0%, respectively (P<0.001 for simultaneous comparison across the three groups). The results of the analyses of the secondary end points supported those of the primary end point. Adverse events were more common in the thalidomide groups than in the placebo group overall; specific events included constipation, somnolence, limb numbness, peripheral edema, dizziness, and elevated liver-enzyme levels.

CONCLUSIONS

In this placebo-controlled trial, treatment with thalidomide resulted in a reduction in bleeding in patients with recurrent bleeding due to SIA. (Funded by the National Natural Science Foundation of China and the Shanghai Municipal Education Commission, Gaofeng Clinical Medicine; ClinicalTrials.gov number, NCT02707484.).

Tranexamic acid may be a useful pharmacotherapy for endoscopically resistant small bowel angiodysplasia

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.

von Willebrand factor regulation of blood vessel formation

Several important physiological processes, from permeability to inflammation to hemostasis, take place at the vessel wall and are regulated by endothelial cells (ECs). Thus, proteins that have been identified as regulators of one process are increasingly found to be involved in other vascular functions. Such is the case for von Willebrand factor (VWF), a large glycoprotein best known for its critical role in hemostasis. In vitro and in vivo studies have shown that lack of VWF causes enhanced vascularization, both constitutively and following ischemia. This evidence is supported by studies on blood outgrowth EC (BOEC) from patients with lack of VWF synthesis (type 3 von Willebrand disease [VWD]). The molecular pathways are likely to involve VWF binding partners, such as integrin αvβ3, and components of Weibel-Palade bodies, such as angiopoietin-2 and galectin-3, whose storage is regulated by VWF; these converge on the master regulator of angiogenesis and endothelial homeostasis, vascular endothelial growth factor signaling. Recent studies suggest that the roles of VWF may be tissue specific. The ability of VWF to regulate angiogenesis has clinical implications for a subset of VWD patients with severe, intractable gastrointestinal bleeding resulting from vascular malformations. In this article, we review the evidence showing that VWF is involved in blood vessel formation, discuss the role of VWF high-molecular-weight multimers in regulating angiogenesis, and review the value of studies on BOEC in developing a precision medicine approach to validate novel treatments for angiodysplasia in congenital VWD and acquired von Willebrand syndrome.

[Thalidomide therapy for gastrointestinal angiodysplasia]

Patients with obscure recurrent intestinal bleeding refractory to standard treatment are a major clinical challenge. The bleeding is often a result of angiodysplasia. Most patients undergo numerous diagnostic and therapeutic procedures. In this article we present two cases with no response to standard treatment, but who were successfully treated with Thalidomide.

Long-acting octreotide as rescue therapy in chronic bleeding from gastrointestinal angiodysplasia

BACKGROUND

Octreotide has shown to be effective against rebleeding from gastrointestinal angiodysplasias, but a long-term daily parenteral administration is recommended. Long-acting octreotide (LAR-OCT) could overcome such a limitation, but it has not been studied extensively.

AIM

To investigate the usefulness of long-acting octreotide in the control of chronic bleeding from gastrointestinal angiodysplasias.

METHODS

Thirteen patients with chronic gastrointestinal bleeding because of angiodysplasias were enrolled. Diagnosis was made by endoscopy and wireless video capsule. Long-acting octreotide was administered intramuscularly at a dosage of 10 mg/monthly for 1 year. Patients were followed up for a minimum period of 1 year, and haemoglobin levels, blood transfusions, iron supplementation and hospitalizations were recorded 1 year before and after starting long-acting octreotide therapy.

RESULTS

Follow-up ranged from 12 to 60 months. Nine of 13 patients (69%) did not need blood transfusions and iron supplementation any longer; a partial improvement was observed in one patient; no effect was found in the others. No side effect was recorded in any patient.

CONCLUSIONS

Long-acting octreotide for 1 year may be beneficial as a rescue therapy for controlling chronic bleeding from gastrointestinal angiodysplasias in patients not eligible for surgery. Its monthly administration represents an advantage, which makes such a formulation the choice when a long-term treatment is mandatory.

Acute gastrointestinal bleeding following aortic valve replacement in a patient with Heyde's sindrome. Case report

A 58-year old man was admitted to the hospital because of melena. He had a 1-year history of mechanical aortic valve replacement and coronary stent placement because of myocardial infarction and he was taking warfarin and clopidogrel. Esophagogastroduodenoscopy and colonoscopy were negative for bleeding. Capsule endoscopy showed bleeding diffuse angiodysplasia of the small bowel. The patient was treated with octreotide 20 mg, at monthly interval. After 25 months there had been no recurrence of gastrointestinal bleeding. The case suggests that mechanical valve replacement may not prevent gastrointestinal bleeding in Heyde syndrome and that octreotide treatment should be considered in these cases.

Long-term efficacy of octreotide in the prevention of recurrent bleeding from gastrointestinal angiodysplasia

OBJECTIVES

Preliminary studies suggested that octreotide may be therapeutic in bleeding angiodysplasia. Our aim was to investigate the efficacy of long-term octreotide therapy in the prevention of rebleeding from gastrointestinal angiodysplasia.

METHODS

A cohort of 32 patients diagnosed with bleeding from angiodysplasia was treated with octreotide 50 mu 12 h subcutaneously for a 1-2 yr period. This cohort was compared with an external control group (38 patients who had received placebo [1 tablet/day] in a concurrent randomized clinical trial for the same period.

RESULTS

Two patients of the octreotide group were lost to follow-up. Treatment failure occurred in seven of 30 (23%) patients in the octreotide group and in 17 of 35 (48%) in the placebo group (three dropouts before first visit) (P= 0.043). The actuarial probability of remaining free of rebleeding at 1 and 2 yr of follow-up was 77% and 68%, respectively, for the octreotide group and 55% and 36%, respectively, for the placebo group (log rank P= 0.030). Multivariate proportional hazards-regression analysis showed that octreotide therapy and previous bleeding episodes were positive and negative predictors of efficacy, respectively. No significant differences between the groups were observed according to number of bleeding episodes (0.4 +/- 0.7 vs 0.9 +/- 1.5, P= 0.070) and transfusion requirements (1.1 +/- 2.6 vs 0.7 +/- 1.5 units); however, iron requirements were lower in the octreotide than in the placebo group (22 +/- 62 vs 166 +/- 267 units; P < 0.001). Likewise, major adverse events (1 vs 1) and mortality (0 vs 1) were similar between groups.

CONCLUSIONS

This study suggests that octreotide treatment may be beneficial in preventing rebleeding from gastrointestinal angiodysplasia.

Thalidomide as treatment for digestive tract angiodysplasias

An 80-year-old man with von Willebrand's disease was admitted with severe melaena. Despite suppletion with von Willebrand concentrate he continued to be dependent on blood transfusions. Endoscopic examination did not show a bleeding focus. Video capsule endoscopy showed active bleeding from angiodysplasias in the proximal section of the small intestine. Ultimately, treatment with thalidomide was initiated at a dose of 100 mg/day. Soon after starting treatment his stools became normal and his haemoglobin level stabilised. No bleeding problems occurred for 11 months, after which the thalidomide treatment was stopped because of the potential side effects. Two months later he again developed melaena and treatment with thalidomide was restarted with a successful outcome. Trying to lower the dose to 50 mg resulted in rebleeding after three months with stabilisation after increasing the dose to 100 mg again. Monotherapy with thalidomide improves the clinical picture but may not be sufficient in the long term. Additional therapy, such as argon plasma coagulation or the use of the novel drug lenalidomide, might be necessary.

Macroscopic appearance of intestinal angiodysplasias under antiangiogenic treatment with thalidomide

BACKGROUND AND STUDY AIMS

Angiodysplasias are the main cause of bleeding from the small intestine. Single lesions may be treated by endoscopic coagulation or surgical resection. However, multiple disseminated angiodysplasias are frequently present, making local therapy an unfavorable choice or impossible. Currently there is no established medical treatment available for these patients. Thalidomide is a potent inhibitor of angiogenesis in experimental models. As angiodysplasias are a result of unregulated vessel growth, antiangiogenic treatment may inhibit growth of angiodysplasias.

PATIENTS AND METHODS

We studied the effect of thalidomide on the macroscopic appearance of angiodysplasias in three patients with bleeding due to multiple angiodysplasias of the small intestine. During the previous 12 months patients had experienced 3 - 7 bleeding episodes and had received a mean of 16.7 blood units.

RESULTS

After start of treatment with thalidomide at a dose of 100 mg daily, no further bleeding episodes occurred. Although thalidomide was stopped after 3 months, bleeding did not recur and hemoglobin reached and maintained normal levels without further transfusions for the whole observation period (mean follow-up 34 months). Repeat wireless capsule endoscopy after 3 months' thalidomide demonstrated substantial reductions in the number, size, and color intensity of angiodysplasias.

CONCLUSION

Thalidomide seems to inhibit growth of intestinal angiodysplasias and may be useful for treatment of patients with bleeding related to angiodysplasias. Wireless capsule endoscopy allows monitoring of the macroscopic effects of antiangiogenic therapy.

Von Willebrand's disease and angiodysplasia treated with thalidomide

A 54-year-old man with type IIB VWD and severe angiodysplasia had such a large blood loss from the bowel that it was difficult to keep up with transfusion requirements. Treatment with factor eight concentrate barely slowed the loss. D.D.A.V.P., Octreotide, and recombinant activated Factor VII, tried separately, were ineffective. The use of Thalidomide at a dose of 150 mg daily has rendered him free from blood loss for the last six months and we suggest would be worth a trial in similar cases.

Gastric angiodysplasia in a child with Bernard-Soulier syndrome: efficacy of octreotide in long-term management

Gastrointestinal angiodysplasia in association with Bernard-Soulier syndrome has been previously described in adults. The authors report on a 14year-old boy presenting with massive upper gastrointestinal bleeding due to a large gastric angiodysplasia, in whom medical history and laboratory investigations were consistent with Bernard-Soulier syndrome. The vascular lesion was so widespread that surgical or endoscopic therapy was not considered. Therefore, treatment with octreotide, a somatostatin analog, was commenced, following a short course of tranexamic acid and proton pump inhibitor. During the 16-month follow-up with octreotide therapy, no occult or gross bleeding occurred. This case illustrates the utility of using octreotide for the long-term treatment of children with bleeding disorders and angiodysplasia.

[Octreotide in the treatment of angiodysplasia in patients with advanced chronic renal failure]

Angiodysplasia is an important cause of gastrointestinal bleeding in patients with chronic renal failure. Octreotide, a long-acting synthetic somatostatin analogue that reduces splachnic blood flow have been used to treat esophageal varicose hemorrhage, but its efficacy for bleeding vascular ecstasies is awaiting support. We present three patients with chronic renal failure (two with diabetic nephropaty and the third with mesangiocapilar glomerulonephritis and hepatic cirrosis), seric creatinine 3-4,5 mg/dl, and recurrent gastrointestinal bleeding due to diffuse angiodysplasia and vascular ecstasies, diagnosed by oral endoscopy, colonoscopy and video capsule. They all were treated with octreotide, administered subcutanesly 0.1 mg twice a day for six months, with significantly decreased blood requirements in all of them, as well as the occurrence of bleeding episodes. It was well tolerated and none side-effects occurred in any subject. In our experience, octreotide is an effective and safe drug in bleeding angiodysplasia and ecstasies vascular of the gastrointestinal tract in patients with chronic renal failure, and it may be a good option especially in patients who are not candidates for surgery or endoscopic treatment due to inaccessible sites, spread of the lesion, old age and/or concomitant disorders.

Judicious Usage of Estrogen/Progesterone for Angiodysplasia

We recently experienced a case of a female hemodialysis patient with multiple intestinal angiodysplasias. In 2001, she complained of melena, and angiographic embolization halted bleeding from ileum angiodysplasia. In 2002, she again complained of black stool. Abdominal angiography found jejunum angiodysplasia, and pharmacological therapy with estrogen/progesterone was required to stop the bleeding. Ethical demands to develop new hemodialyzers that do not release estrogen-like substances are discussed.

Angiodisplasia múltiple de intestino delgado. Un reto diagnóstico y terapéutico

Small bowel bleeding is infrequent and presents a challenge to the clinician. Approximately 30-40% of gastrointestinal bleeding localized in the small bowel is due to angiodysplasia, a vascular malformation. We present the case of a patient with multiple angiodysplasia of the small bowel who required push enteroscopy and capsule endoscopy to establish the diagnosis. Treatment with subcutaneous octreotide was successful. In conclusion, in doubtful cases or in patients with persistent hemorrhage, capsule endoscopy can improve the diagnostic yield of enteroscopy in bleeding gastrointestinal vascular lesions such as angiodysplasia. Endoscopic treatment (laser coagulation) and drug therapy (somatostatin or analogs) are valid alternatives in inoperable or non-resectable cases.

A multicenter, randomized, clinical trial of hormonal therapy in the prevention of rebleeding from gastrointestinal angiodysplasia

BACKGROUND & AIMS

The efficacy of hormonal therapy for recurrent bleeding from gastrointestinal angiodysplasia remains uncertain. We investigated the efficacy of long-term estrogen-progestagen therapy in the prevention of rebleeding from gastrointestinal angiodysplasia.

METHODS

Seventy-two noncirrhotic patients bleeding from gastrointestinal angiodysplasia confirmed by endoscopy or angiography were randomized to receive in double-blind conditions treatment with ethinylestradiol (0.01 mg) plus norethisterone (2 mg) (1 tablet/d), or placebo (1 tablet/d) for a minimum period of 1 year (range: 1-2 years).

RESULTS

Four patients could not be assessed because they did not attend the first follow-up visit. Failure of treatment occurred in 13 of 33 (39%) patients in the treatment group and in 16 of 35 (46%) patients in the placebo group (P = NS). No significant differences between groups were found according to number of bleeding episodes (0.7 +/- 1.0 vs. 0.9 +/- 1.5) and transfusional requirements (0.9 +/- 1.9 vs. 0.7 +/- 1.5 units). Treatment received was not an independent predictor for rebleeding prevention in the multivariate regression analysis. Severe adverse events (2 vs. 1) and mortality (0 vs. 1 patient, respectively) were similar between the treatment and placebo groups.

CONCLUSIONS

Continuous estrogen-progestagen treatment is not useful in the prevention of rebleeding from gastrointestinal angiodysplasia.

Long-acting octreotide is effective in controlling rebleeding angiodysplasia of the gastrointestinal tract

BACKGROUND

Management of bleeding angiodysplasia of the gastrointestinal tract is often a major clinical problem. Lesions are frequently multiple, not detectable or missed during conventional endoscopy and patients are sometimes at high risk for complications because of advanced age and serious concomitant disorders.

AIMS

To determine the efficacy of a new formulation of somatostatin analogue (octreotide long-acting) in management of recurrent bleeding angiodysplasia in patients resistant to endoscopic treatment and not suitable for surgery.

PATIENTS AND METHODS

Three patients with recurrent bleeding angiodysplasia of gastrointestinal tract were treated with long-acting octreotide administered intramuscularly 20 mg monthly to each individual. The number of admissions for acute bleeding, hospital stay and number of blood units transfused before and after treatment (followup: 15-17 months) were regularly monitored.

RESULTS

In each patient, a relevant decrease in number of hospital admissions, duration of hospital stay, number of administered blood units was seen and mean haemoglobin values significantly increased in all of them after introducing long-acting octreotide therapy.

CONCLUSIONS

This is the first report on use of long-acting octreotide in bleeding angiodysplasia of gastrointestinal tract. Data suggest that long-acting octreotide is a safe drug and is successful in controlling recurrent gastrointestinal bleeding due to angiodysplasia in elderly patients not eligible for surgical or endoscopic therapy.

Octreotide in the treatment of gastrointestinal bleeding caused by angiodysplasia in two patients with von Willebrand's disease

Two cases of von Willebrand's disease and angiodysplasia with intractable gastrointestinal bleeding are presented. Replacement therapy with cryoprecipitate and variable purity von Willebrand factor (VWF) was ineffective, as were other treatments including steroids, immunoglobulin and hormonal replacement. Both patients required massive blood transfusion and product support. The efficacy of somatostatin and an analogue is described. In one patient, we observed a rise in von Willebrand factor activity after octreotide infusion.

[Severe gastrointestinal hemorrhage secondary to diffuse angiodysplasia: efficacy of estrogen-progesterone treatment]

BACKGROUND

Vascular abnormalities are being reported with increasing frequency as a cause of major lower gastrointestinal hemorrhage in the elderly. They are occasionally very difficult to treat by conventional means.

CASE REPORT

A 66-year-old white man with a history of type 2 diabetes mellitus, coronary artery disease, congestive heart failure, severe peripheral arterial occlusion disease and chronic renal insufficiency presented for five years recurrent major bleeding due to gastrointestinal angiodysplasia, requiring repeated transfusions. He was treated with efficacy using ethinyl-estradiol (30 micrograms) and norethisterone acetate (1 mg) given orally once daily. After six months of treatment, transfusion requirements fell to 0 unit and the patient's hemoglobin was stable at 13 g/dl. Attempts to stop hormone therapy (by the patient himself, without complaint of side effects) led to a fall in hemoglobin.

CONCLUSION

Hormonal therapy should be considered when multiple degenerative mucosal vascular bleeding lesions are beyond the reach of therapeutic endoscopy leading to high transfusion needs and when surgical risk is unacceptably high.

The efficacy of octreotide therapy in chronic bleeding due to vascular abnormalities of the gastrointestinal tract

BACKGROUND

The treatment of angiodysplasia and watermelon stomach, vascular abnormalities implicated in gastrointestinal bleeding of obscure origin, is a major clinical problem.

AIM

To determine the efficacy of octreotide in patients with long-standing gastrointestinal bleeding due to acquired angiodysplasia and watermelon stomach, resistant to previous treatments and not suitable for surgery because of old age and/or concomitant disorders.

PATIENTS AND METHODS

We treated 17 patients (seven had isolated angiodysplasia, seven had multiple upper and lower gastrointestinal angiodysplasia, and three had watermelon stomach) with octreotide (0. 1 mg subcutaneous t.d.s. for 6 months). Six of the patients had liver cirrhosis, one had Glanzmann-type platelet derangement, two had cardiovascular diseases and one had chronic uraemia.

RESULTS

Octreotide treatment stopped bleeding in 10 patients. A transient improvement was observed in four, who needed subsequent cyclical retreatment to correct low haemoglobin levels. No effect was observed in three, probably due to the severity of the concomitant disorders.

CONCLUSIONS

Octreotide is a safe drug that may be useful to control the recurrent gastrointestinal bleeding due to acquired angiodysplasia and watermelon stomach, especially in patients who are not candidates for surgery due to old age and/or concomitant disorders.

Severe gastrointestinal bleeding in a uremic patient treated with estrogen-progesterone therapy

Gastrointestinal bleeding is a frequent complication in hemodialysis patients; angiodysplasia is a potential cause, with a higher incidence in uremic patients. We describe a case of severe anemia (Hemoglobin up to 3.5 g/dl) secondary to diffuse angiodysplastic lesions in a hemodialysis patient with mixed connective tissue disease. The case is characterised both by the severity of the clinical picture (extension and entity of angiodysplastic lesions, frequency of bleeding episodes) and by the patient's religious faith which made her reject blood transfusions. We underline the efficacy of estrogen-progesterone therapy in view of the modest results obtained with other therapeutic strategies on bleeding.

[Association of acquired Willebrand's disease, monoclonal gammopathy and angiodysplasia of the small bowel: a rare indication of high-dose intravenous immunoglobulins]

Acquired von Willebrand's disease associated with a monoclonal gammopathy and angiodysplasia of the gut is a rare disorder. It is sometimes complicated by chronic intestinal bleeding and severe anemia, that is poorly responsive to usual treatments. We report such a new case that has been revealed by anemia, and characterised by the absence of the high-molecular weight multimers. The correction of the hemostasis defect and of anemia were related to the reappearance of the high-molecular weight multimers, that was achieved only after high-dose intravenous immunoglobulin courses. The perfusions were performed every 3 weeks for 2 years without loss of efficiency, that could be explained by the dissociation of immunoglobulin-von Willebrand's factor complex.

Diagnosis and treatment control of bleeding intestinal angiodysplasias with an endoscopic Doppler device

OBJECTIVE

To investigate the effectiveness of prophylactic injection therapy in vascular malformations after acute hemorrhage. To review recent advances in diagnosis and treatment control of bleeding intestinal angiodysplasias with an endoscopic Doppler device.

DESIGN

Open prospective study involving 34 patients with bleeding from gastroduodenal and colorectal angiodysplasias.

INTERVENTIONS

In order to detect the superficial arterial vessels responsible for the bleeding, a total of 79 lesions were scanned by transendoscopic Doppler ultrasonography. 70 vascular ectasias (88.6%) were Doppler-positive and had injection therapy with epinephrine and polidocanol.

RESULTS

Out of the 70 sclerosed angiodysplasias, 63% (90.0%) could not be found endoscopically 2 weeks later, confirming the success of therapy. Doppler noise was still recorded in 7 visible malformations, indicating insufficient treatment. Further injections were made into these lesions, and the vascular anomalies were finally eliminated. During 1 year of follow-up, 2 of the 34 treated patients (5.88%) relapsed with actively bleeding cecal angiodysplasias. After repeated endoscopic hemostasis, no more hemorrhage was observed in both patients. The results were partly published in previous publications.

CONCLUSION

Endoscopic Doppler ultrasonography may help in identification and treatment of intestinal angiodysplasias. The technically simple method allows objective evaluation of the endoscopic findings and enables monitoring of local endoscopic therapy.

Estrogen/progesterone treatment of diffuse antral vascular ectasia

A case of acute and chronic gastrointestinal bleeding secondary to antral vascular ectasia is presented. The pattern of antral vascular ectasia was the diffuse form. After attempted treatment with endoscopic laser photocoagulation proved ineffective, the bleeding was treated with an estrogen/progesterone combination. The bleeding ceased with this medical therapy. The lesion of antral vascular ectasia persisted, however, despite the cessation of bleeding. Attempted maintenance therapy, consisting of reduction in frequency of estrogen/progesterone therapy to every third day, resulted in resumption of bleeding, requiring reinstitution of daily therapy for control.

Gastrointestinal bleeding caused by angiodysplasia: a difficult problem in patients with chronic renal failure receiving hemodialysis therapy

Anemia in patients with renal failure is a common problem. Bleeding from small angiodysplastic lesions within the gastrointestinal tract appears to be a significant source of blood loss in some patients with renal failure receiving chronic hemodialysis. We describe a group of patients treated with estrogen therapy who had amelioration of their bleeding tendency. Correction of bleeding time may be one potential mechanism for this action.

[Successful treatment of recurrent lower gastrointestinal hemorrhage in intestinal angiodysplasia with an estrogen-progesterone combination]

A 75-year-old man with angiodysplasia of the sigmoid and rectum and recurrent lower gastrointestinal bleeding episodes, despite repeated endoscopic laser-coagulation, was successfully treated with oestrogen-progesterone. Besides angiodysplasia he had aortic valvular stenosis, monoclonal gammopathy, mild renal insufficiency, and moderate peripheral arteriosclerosis obliterans. Oestrogen-progesterone may be a valuable alternative therapy in elderly patients with repeated bleeding, despite endoscopic coagulation, secondary to gastrointestinal angiodysplasia which cannot be treated surgically, in patients who deny surgery, or with rebleeding after surgery.

Does hormonal therapy have any benefit for bleeding angiodysplasia?

Sixty-four patients took part in a cohort study measuring the efficacy of daily hormonal therapy in diminishing intestinal bleeding from small bowel angiodysplasia. Thirty patients received 5-10 mg norethynodrel either with mestranol, 0.075-0.15 mg (24 patients) or with conjugated estrogens, 0.625 mg (six patients). The cohort group consisted of 34 patients who either refused hormonal therapy (six patients) or were diagnosed early in our experience, before the resurgence of hormonal therapy (28 patients). Mean follow-up was 15.6 months (range 2-31 months) for the treated group and 13.4 months (range 1-23 months) for the untreated group. In addition, the change in monthly transfusion requirement with therapy was analyzed ("within group" analysis). Fifty percent (15 of 30) of the treated group required no further transfusion during therapy, while 44% (15 of 34) of the untreated group required no further therapy (not significant). During therapy, the mean monthly transfusion requirement of packed red blood cells in the treated group was not significantly different from that found before therapy (1.5 vs. 2.2 units, NS) or from that of the control group (1.5 vs. 1.6 units, NS). The findings do not support the use of hormonal therapy for bleeding from small intestinal angiodysplasia.

Cessation of recurrent bleeding from gastrointestinal angiodysplasia, after beta blocker treatment in a patient with hypertrophic subaortic stenosis--a case history

The authors present the case of an elderly patient suffering from obstructive cardiomyopathy and bleeding colonic angiodysplasia. After treatment with propranolol, the bleeding stopped without recurrence.