Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points

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.

Prevalence of Angiodysplasia Detected in Upper Gastrointestinal Endoscopic Examinations

“…Gastrointestinal angiodysplasia is an important vascular lesion as associated bleeding is a significant factor related to morbidity [1][2][3][4][5][10][11][12][13][14]. These lesions are considered to be likely responsible for approximately 3-40% of colonic bleeding cases and 50% of the cases with bleeding in the small intestine [10][11][12][13][14].…”

“…Gastrointestinal angiodysplasia, also termed angioectasia, is a vascular malformation composed of dilated and tortuous arterial or venous capillaries, usually smaller than 5 mm in diameter, and located in the mucosal and submucosal layers of the gastrointestinal tract [1,2]. It has been reported that gastrointestinal angiodysplasia is responsible for 4-7% cases of nonvariceal upper gastrointestinal bleeding [3][4][5].…”

Impact of Acute Hemoglobin Falls in Heart Failure Patients: A Population Study

“…The potential causes of Hb falls in these patients can be numerous and combine treatment with anticoagulants or antiplatelet drugs and frequent gastrointestinal lesions. Gastrointestinal reflux, duodenal ulcers, and angiodysplasia occur in more than 30% of this aged population [8,20]. In addition, patients with HF are at risk of developing AKI [21], due to a low cardiac output or congestive status, as well as the use of drugs blocking the renin-angiotensin system or diuretics.…”

Intra‐operative enteroscopy for the identification of obscure bleeding source caused by gastrointestinal angiodysplasias: through a balloon‐tip trocar is better

“…Selective embolization by angiography (SEA) can be a therapeutic alternative with haemostatic effectiveness from 80% to 90% and complications rate ranging from 5% to 9%. However, SEA is a complex procedure which requires special technical equipment and highly trained operators in endovascular radiology, not available in all centres [8]. Non‐operative procedures are associated with high re‐bleeding rates (63%–78%) [9], which can be explained by the multiplicity of angiodysplasias in the small bowel.…”