Decreased health-related quality of life in angiodysplasia patients: A cross-sectional cohort

Gastrointestinal angiodysplasias may cause anemia. Quality of life (QoL) is a valid patient reported outcome and improvement of QoL represents an important treatment goal. There is a paucity of data on the effect of angiodysplasias on QoL. Therefore, we aim to evaluate QoL and fatigue in angiodysplasia patients. We performed a cross-sectional patient-reported outcome study. We included patients with endoscopy proven angiodysplasias and measured QoL with Short Form-36 and level of fatigue using Multi Fatigue Inventory-20. We distinguished three subgroups of patients according to disease severity: 1) with treatment for angiodysplasias, 2) without treatment for angiodysplasias and 3) without recent hospital visits. The primary outcome was the physical component summary (PCS) score on the SF-36. Multivariate regression analysis were performed to correct for differences at baseline. A total of 144 patients completed the questionnaires (response rate = 62%; mean age 68 years; 65% men). Angiodysplasia patients have a significant lower PCS compared to the age-matched general population (respectively 41.0 vs. 43.3, p = 0.01). Disease severity is independently associated with a negative outcome on QoL (ß -4.6, 95% CI -7.8–-1.3). Similarly patients score lower on multiple QoL subdomains, i.e. role limitations due to physical health problems (40.8 vs. 44.0, p<0.01), general health (39.7 vs. 47.3, p<0.01). Angiodysplasia patients are more fatigued compared to the general population (male 56.1 vs. 48.5, p<0.01, female 59.2 vs. 51.5, p = 0.01). In conclusion, angiodysplasias are independently associated with clinically significant impairments in multiple domains of health-related QoL, especially in measures of functional limitation.

Importance of Heparin Provocation and SPECT/CT in Detecting Obscure Gastrointestinal Bleeding on 99mTc-RBC Scintigraphy: A Case Report

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.

[MASSIVE RECTORRHAGIA MIMICKING POSSIBLE GENITAL HAEMORRHAGE]

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.

A capillary hemostasis mechanism regulated by sympathetic tone and activity via factor VIII or von Willebrand's factor may function as a "capillary gate" and may explain angiodysplasia, angioneurotic edema, and variations in systemic vascular resistance

The sympathetic nervous system (SNS) may directly or indirectly govern the release of von Willebrand's factor (VWB), which may be a hormone, from the vascular endothelium, which may be a gland. VWB is known to stabilize the labile VIIIC component of Factor VIII complex, and may thereby determine its half-life and activity level in the blood. Rising blood levels of Factor VIII may increase the speed of thrombin production during the "propagation" phase of blood coagulation and thereby elevate peak levels and duration of thrombin activity to produce and stabilize insoluble fibrin in quantities necessary to initiate clot formation. At the capillary level, microvascular receptor sites may bring fibrinogen and fibronectin, which are basic "building blocks" of insoluble fibrin, into close proximity with rising levels of Factor VIII to facilitate insoluble fibrin production and serve as binding sites for an expanding mass of insoluble fibrin that adheres to blood components to cause capillary hemostasis. Capillary hemostasis may serve as a "capillary gate mechanism" (CGM) that increases systemic vascular resistance and blood pressure and decreases cardiac output in accord with increased tone and activity levels of the SNS by obstructing capillary bed flow. Angiodysplasia may be caused by persistent defects in the VWB molecule that impair CGM function and cause visible capillary damage. Angioneurotic edema may be caused by sudden complement system attack on VWB that results in widespread paralysis of CGM function and sudden shift of blood from arteries and arterioles to capillaries to cause tissue edema and hypotension. The hypothesis may offer improved insight into the nature of circulatory physiology, the surgical stress syndrome, "vasoactive" drugs, and numerous disease states. It may be tested by using videomicroscopy to monitor changes in bowel capillary flow in response to stepwise increases of VWB or Factor VIII intravenous boluses in animals anesthetized using combined epidural-general technique to minimize SNS activity levels.

Persistent anemia in otherwise asymptomatic severe aortic stenosis: a possible indication for valve replacement?

BACKGROUND

The indication for aortic valve replacement in patients with significant aortic stenosis is symptomatology. Aortic stenosis may be associated with bleeding from colonic angiodysplasia, resulting in anemia. Persistent anemia in such patients, despite lack of an identifiable source of bleeding, is not considered an indication for valve replacement.

OBJECTIVES

To report our experience with two elderly female patients who suffered from severe asymptomatic aortic stenosis, low levels of large von Willebrand factor multimer (10% and 5% respectively) and persistent anemia requiring multiple blood transfusions.

METHODS

Both patients underwent an intensive work-up, but a source of bleeding could not be identified. Aortic valve replacement was performed in both patients.

RESULTS

Aortic valve replacement abolished the need for further blood transfusions during a follow-up period of 20 months with normalization of the vWF multimer level (20% and 30% respectively).

CONCLUSION

We suggest that aortic valve replacement be considered in selected patients with severe, otherwise asymptomatic aortic stenosis, who suffer from persistent anemia requiring multiple blood transfusions, lack an identifiable source of bleeding and have low levels of large vWF multimers.

Lymphangiogenesis and lymphangiodysplasia: from molecular to clinical lymphology

The lymph vascular system parallels the blood vasculature and as one of its key functions returns liquid and solutes to the bloodstream, including macromolecules that have escaped from blood capillaries and entered the interstitium. In conjunction with interspersed lymph nodes and lymphoid organs, the lymphatic vasculature also acts as a conduit for trafficking immune cell populations. Echoing the explosion of knowledge about blood vessel angiogenesis (properly termed "hemangiogenesis"), the past two decades have also witnessed a series of significant, yet less-noticed discoveries bearing on "lymphangiogenesis," along with delineation of the spectrum of lymphedema-angiodysplasia syndromes. Failure of lymph transport promotes a brawny proteinaceous edema of the affected limb, organ, or serous space that is disfiguring, disabling, and on occasion even life-threatening. Key members of the vascular endothelial growth factor (VEGF) and angiopoietin families of vascular growth factors (and their corresponding tyrosine kinase endothelial receptors) have been identified which preferentially influence lymphatic growth and, when manipulated in genetically engineered murine models, produce aberrant "lymphatic phenotypes." Moreover, mutations in VEGF receptor and forkhead family developmental genes have now been linked and implicated in the pathogenesis of two familial lymphedema-angiodysplasia syndromes. Thus, recent advances in "molecular lymphology" are elucidating the poorly understood development, physiology, and pathophysiology of the neglected lymphatic vasculature. In combination with fresh insights and refined tools in "clinical lymphology," these advances should lead not only to earlier detection and more rational classification of lymphatic disease but also to better therapeutic approaches, including designer drugs for lymphangiostimulation and lymphangioinhibition and gene therapy to modulate lymphatic growth.

[Aortic stenosis and intestinal blood loss from angiodysplasia: valve replacement is a therapeutic option]

Three patients, men aged 67, 68 en 61, had for many years suffered from recurrent iron deficient anaemia and were found to have an aortic stenosis. Coloscopy identified angiodysplastic lesions, and we suspected additional lesions in the small intestine. Despite surgical and endoscopic treatment, gastrointestinal bleeding recurred. Replacement of the stenosed aortic valve with a bioprosthesis led to a recovery in the haemoglobin levels of all three patients. Angiodysplasias are a common source of gastrointestinal bleeding with an invisible origin. Data from the literature suggest an association between aortic stenosis and angiodysplasia although epidemiological evidence is lacking.

[Angiodysplasia of moya-moya type disclosed by choreic unvoluntary abnormal movements during oral contraception. Apropos of 2 cases]

Two seventeen year-old women, developed acute onset left choreic movements following two months and two weeks use of oral contraceptives. Left hemiparesia appeared a few days later, while involuntary movements discontinued. Cranial CT scan and MRI showed bilateral ischemic lesion in the frontal region for the first case and isolated lesion in the right centrum ovale for the second. Angiography showed nearly complete obstruction of the terminal portion of the internal carotid artery with an outline Moya-Moya network. After discontinuing oral contraceptives, there has been no relapse of neurologic dysfunction for more than three years for the first case and twelve months for the second one. The role of perfusion insufficiency in limb-shaking carotid transient ischemic attack is discussed and the possible relations between oral contraceptives, chorea and angiographic features resembling Moya-Moya disease are evaluated.