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Comprehensive Overview of Angiodysplasia of Colon: Diagnosis, Management, and Controversial Issues

Learn about the incidence, presentation, diagnosis, and treatment of angiodysplasia, a common cause of lower gastrointestinal bleeding in the elderly. Explore management strategies and controversial topics in this informative grand round presentation.

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Comprehensive Overview of Angiodysplasia of Colon: Diagnosis, Management, and Controversial Issues

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  1. Joint Hospital Grand Round Angiodysplasia of Colon Yeung Kwan Lok Department of Surgery TKOH

  2. Angiodysplasia of Colon • Introduction • Diagnosis • Management • Controversial issue • Conclusion

  3. Introduction • Diagnosis • Management • Controversial issue • Conclusion

  4. Introduction • Acquired submucosal arteriovenous malformation • LGIB in elderly

  5. Introduction Bleeding after trauma • 0.5 -1 cm • Bright red, flat / slightly raised, covered by thin epithelium • 70-90% right colon • Majority – 2 or 3 lesions Angiodysplasia

  6. How common it is? • Exact incidence difficult to ascertain (0.2%-6.2%) Richter JM et al. Dig Dis Sci. 1984; 29:481-485 Heer M et al. Hepatogastroenterology. 1987; 34:127-131 Hochter WJ et al. Endoscopy. 1985;17:182-185 • 0.8% incidental • HA hospitals - 167 cases (1/1/2000-31/3/2006)

  7. Aetiology • Unknown • Degenerative disease Boley SJ et al. Severe lower intestinal bleeding: diagnosis and treatment. Clin Gastroenterol. 1981; 10:65-91

  8. Epidemiology • > 60 years old • F=M, no racial difference • Increase incidence with several medical conditions (a) CRF Zuckerman GR et al. Ann Intern Med. 1985; 102:588-592 Navab F et al. Am J Gastroenterol. 1989;84:1297-1300

  9. Epidemiology (b) Cirrhosis Naveau S et al.Dig Ds Sci 1991; 36: 1774-1781 (c) Aortic stenosis (d) von Willebrand's disease (e) pulmonary disease No study demonstrate the relationship • unrelated to inherited arteriovenous malformations (hereditary hemorrhagic telangiectasia)

  10. Presentation • Asymptomatic • GIB (1) Major bleed (2) Recurrent minor bleed (3) Positive FOB

  11. Introduction • Diagnosis • Management • Controversial issue • Conclusion

  12. Diagnosis 1. Angiogram - Extravasation (6-20%) - 3 signs correspond to development Boley SJ et al. Radiology. 1977; 125:615-621. (a) Densely opacified, dilated, tortuous, slow emptying intramural vein – 90% (b) Vascular tuft in arterial phase – 70-80% (c) Early filling vein within 45s. – 60-70%

  13. Diagnosis - Timing is important Delay >6 hrs. between time of presentation and angiogram – 28% fail to identify the source Browder W et al. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg. 1986; 204:530-536

  14. Diagnosis 2. Colonoscopy – pathognomonic Richter JM et al. Angiodysplasia: clinical presentation and colonoscopic diagnosis. Dig Dis Sci. 1984; 29:481-485 • Preoperative or intraoperative • Hidden behind mucosal fold in right colon 80-90 % - colonoscopy or angiogram

  15. Diagnosis 3. Radionuclide scan 4. Helical CT scan

  16. Introduction • Diagnosis • Management • Controversial issue • Conclusion

  17. Management • Amount of bleeding, extent and site of lesions • Asymptomatic • Massive hemorrhage - Resuscitation - Investigation - Surgical resection

  18. Management • Slow or intermittent 1. Surgical resection – rebleeding 15-25% 2. Endoscopic coagulation therapy (a) laser – argon preferable than Nd: YAG (b) electrocoagulation 10-30% rebleeding 7% perforation – usu. Nd: YAG laser

  19. Hot biopsy coagulation angiodysplasia Coagulated mucosa Angiodysplasia grasped and pulled up during electrocoagulation

  20. Management 3. Pharmacological (a) oestrogen-progesterone restore continuity of endothelium, shorten bleeding time, stasis in mesenteric microcirculation van Cutsem E et al. Lancet. 1990; 1: 953-955 (b) ß blocker (c) Somatostatin ↓splanchnic and portal blood flow Bowers et al. British Journal of Haematology 2000; 108: 524-527 Blich et al. Scandinavian Journal of Gastroenterology 2003; 38(7): 801-803 4. Angiographic

  21. Introduction • Diagnosis • Management • Controversial issue • Conclusion

  22. Controversial issue 1. Hormonal therapy

  23. Controversial issue 2. Management on incidental angiodysplasia

  24. Introduction • Diagnosis • Management • Controversial issue • Conclusion

  25. Conclusion • Angiodysplasia - common cause of LGIB of elderly • Diagnosis – difficult, combination techniques • Treatment – individualized • Controversial - systemic hormonal therapy - incidental angiodysplasia

  26. Conclusion • Prognosis • 90 % self limiting • Mortality related to severity of bleeding, age, co-morbidity

  27. The End

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