Management of Gastrointestinal Angiodysplastic Lesions

A Systemic Review. Gastrointestinal angiodysplasia (GIAD) can be referred to as pathologically dilated capillaries and veins communications, leading to gastrointestinal bleeding (Jackson & Strong, 2017). It has been shown that GIAD is the main small intestine bleeding cause in persons above 40 years of age (Jackson & Gerson, 2014). Clinical Presentation Bleeding GIADs present in different form, ranging from occult blood to serious events that can threaten a person’s life, and hence require emergent interventions to stop bleeding. Studies have described that during the first clinical presentations, more than ninety percent of GIADs usually stop bleeding spontaneously (Sami, Al-Araji, & Ragunath, 2014). This was then referred to as Heyde’s Syndrome. Research has shown that patients with aortic stenosis experience unexplained gastrointestinal bleeding, especially OGIB. Moreover, there is evidence of GI bleeding that is recurrent or idiopathic with aortic stenosis and other cardiac valvular diseases.

A study conducted in 2012 concerning heart diseases and aortic stenosis as a risk factor for OGIB or GIT bleeding in AD was performed. According to Bartos et al (2012), AS and intestinal AD are grouped as chronic degenerative diseases, which have been shown to be quite asymptomatic with greater preference in GIT bleeding population than normal population. This has caused the scientists to believe that vWF, which is not normal could be the origin of increased GIT hemorrhage in AS and AD bleeding patients. vWD has been implicated in causing GIT bleeding, especially from colonic AD (Selvam & James, 2017). These patients possess lwer than normal levels of HMW vWF multimers that can be hereditary like in vWD type 2a, or acquired like in AS.

Research indicate that VWF is necessary in mediating platelet aggregation and adhesion to sub-endothelium of bleed vessels that were damaged. HMW have been shown to be very effective in stoppage of bleeding via this process according to Selvam & James (2017). AVR has been the most effective option in AS patients and noteworthy GIT bleeding caused by AD, however, bowel resection can be equaly effective. Chronic kidney failure has also been implicated in GIT bleeding because AD is common in these patients. Studies indicate that chronic renal failure (CRF) that has been present for long has high chances of causing AD (Thomas et al. AD has been shown to account for about 26% of lower GIT bleeding in CRF patients compared to 6% in the normal population.

AD of the small bowel and stomach have been shown to cause OGIB and upper GIT bleeding in these patients (Kurien & Lobo, 2015). Pathogenesis Angiodysplasia (AD) has a complicated development mechanism and aetiology. However, the mostly understood and doped hypothesis is the one described by a stuy conducted in 1977. Resected colon specimens from persons who had undergone angiography and evidence of vascular lesions caecum were used. Evaluation of these specimens showed tortuous and dilated veins of submucosa irrespective of mucosal veins’ presence. Scientists suggested that the lesions developed as the patients’ age because of low-grade obstruction of veins in submucosa that are intermittent and chronic, mostly due to increased contractility at muscularis propria (Boley et al. This is due to blood vessels formation via a process caused neovascularization, an essential process that occurs because of imbalance between anti-angiogenetic and pro-angiogenetic factors (Jadvar, 2017).

Some research studies show that VEGF expression in hypoxia is high as compared to in normoxia (Boey, Hahn, Sagheer, & Mcrae, 2015). High angiogenetic factors’ expression, especially basic fibroblast GF and VEGF, has always been demonstrated in AD of the human colon and is hence more likely to have a big influence in lesions development and increasing bleeding risk (Sami et al. Therefore, this has been a breakthrough in development of therapeutic solutions targeting interventions to prevent and treat bleeding. Hence, thalidomide was developed as an anti-angiogenic agent to stop GIT bleeding (Engelen, van Galen, & Schutgens, 2015). A study that was performed patients who underwent UGIB endoscopy over 40 months showed that about 4 percent of these participants, of whom about 77 percent have history of upper GIT bleeding and 23 percent featured occult GIT bleeding, several wounds were noted in 62 percent of these cases.

Moreover, 50 percent of these patients had colonic AD in those participants that underwent colonoscopy. This describes that even though AD of the upper GIT in quite uncommon, it should be noted that this procedure can cause overt and occult GIT bleeding (Sami et al. Patients who are aged below 50 years and have obscured gastrointestinal bleeding (OGIB) and small intestine tumors have been identified in about 7 percent. However, patients with age above 50 years have been shown to have the bleeding source in the small intestines AD (Sidhu, Sanders, Morris, & McAlindon, 2008). percent and according to studies, none of these participants developed GIT bleeding over years. This showed that treatment of lesions that do not bleed is not recommended. Colonic AD frequency as a major bleeding of the lower GIT varies from 3% - 40% (Lasson, Kilander, & Stotzer, 2008).

Colonic AD can cause recurrent, chronic, or mild bleeding, and can stop naturally in about 90% of the cases. However, this can also be dangerous and life threatening (Lasson et al. Moreover, another retrospective study conducted in 2007 on evaluation of obscured gastrointestinal bleeding showed that small intestine GIADs formed more than sixty percent of all the clinically noteworthy lesions in persons who underwent capsule endoscopy (Carey et al. Another study conducted in 2012 showed that GIADs are located in duodenum and jejunum and also throughout the GIT. According to this study, deep enteroscopy and capsule endoscopy have promoted better GIADs visualization and also their presence along the entire small intestine (Bollinger et al. Diagnosis and investigations should be made in OGIB patients and it depends on bleeding severity and clinical scenario.

The main diagnostic methods include endoscopic imaging and radiographic imaging according to Sami et al (2014). Furthermore, these AD lesions can be diagnosed wrongly as an inflammation or trauma. Therefore, scientists suggest that examinations should be repeated in consideration of cases that are of high suspicion clinically or if initiation of assessment was performed sub-optimally, prior to embarking on assessment of small intestines (Sidhu et al. WCE has been shown to be the most preferred method in evaluating small intestines in diagnosis for OGIB because it is safe, offers high resolution, and is acceptable when compared to other endoscopic techniques. Moreover, it is less invasive compared to intra-operative enteroscopy, enteroscopy, and mesenteric angiography (Teshima et al. According to British Society of Gastroenterology (BSG) guidelines suggest that people with OGIB who are above 50 years of age and have negative colonoscopy and gastroscopy should be allowed to undergo WCE for assessment or determination of AD (Sidhu et al.

however, some studies have shown that Se is better than DBE concerning average procedure time, with SE taking averagely 43 minutes while DBE taking averagely 65 minutes. But the same study showed that DBE is slightly superior concerning maximum median insertion depth, with 310 cm results compared to 250 cm of SE technique (Messer, May, Manner, & Ell, 2013). Performance comparisons of these two techniques, SE and SBE, showed equal comparisons (Khashab et al. Studies have described that enteroscopy has other benefits such as having the capacity to perform biopsies, marking lesions, and performing mucosal flushing for better visibility (Sidhu et al. Therefore equipment availability and local expertise determine enteroscopy technique to be used. The techniques’ accuracy is between 24. and 91. Tabibian et al. Additional to this techniques, the patients should be given therapeutic interventions similar to typical angiography.

MRI and CT angiography have been shown to provide rapid diagnosis that is not invasive in the active bleeding cases. Treatment must hence be initiated in AD patients, especially AD that are not yet bleeding or those with occult blood or OGIB, especially where no bleeding has been evaluate. Invasive techniques should only be used in cases where the lesion size, location, and number have been determined, and also in blood loss situations or severely anemic patients with AD. There are medications, surgical, and endoscopic techniques, and are discussed below. Pharmacological therapies Surgical, endoscopic, and angiographic techniques have been shown to have complications that may be very serious. Cost effective and safe pharmacological agent can be used to replace the above methods and reduce chances of complications Hormonal therapy Hormonal therapy have been suggested to be used to reduce and prevent AD bleeding.

Moreover, this medication reduced hospitalization episodes caused be bleeding and also reduced transfusion rates, and the outcomes were retained for about a year. However, the study showed that thalidomide patients expressed more side effects that iron therapy. These side effects included fatigue, peripheral edema, dizziness, and constipation. Others were related to allies to the drug and reduced blood cells. Moreover, hepatotoxicity, peripheral neuropathy, and liver failure were reported, and birth defects (Ge et al. This technique has reduced possibility of causing tissue injury and coagulation strictly depends on the setting power of the equipment. APC has been shown to have 11 – 19% re-bleeding rate, especially from new lesions, and the follow-up duration was 18 months (Urs, Martinelli, Rao, & Thomson, 2014). APC has been shown to cause bleeding resolution in about 85% of the patients after 1 twenty month follow-up where 118 procedures were formed.

Requirement for transfusion ceased in approximately 90% of the participants, and hemoglobin levels were raised after the treatment. Moreover, re-bleeding possibilities were two percent and ten percent at 12 months and 24 months follow-up. Nd:YAG laser can lead to blood transfusion cessation in many patients with least serious complications (Fuccio, 2013). However, perforations of lower and upper GIT tract have been shown in some patients. The argon laser has not been studied very well but it has been shown to cause perforations of GIT bowels as well. The techniques are very costly and require high expertise. Endoscopic clips Endoscopic clips have shown efficacy and safety in some cases of AD bleeding as monotherapy (Takahashi et al. It is time consuming and challenging. Transcatheter angiography and intervention (TAI) TAI is used in GIT bleeding patients, especially those with active bleeding and have undergone endoscopic therapy and failed to achieve appropriate results, or those who cannot undergo endoscopy due to some clinical reasons.

This technique can be used in place of surgery or to localize GIT lesions before surgery (Millward, 2008). Vasopressin given intra-arterial can control AD bleeding but ischemia and systemic vasoconstrictions have been shown. However, super-selective trans-catheter embolization have been developed to treat AD bleeding (Kurien & Lobo, 2015). Quality Assessment All the data should be evaluated for quality including the case-control and cohort studies. The participant selection, outcome assessment, and study groups’ comparability will be performed. There will be about two study authors who will evaluate quality assessment performed and in case of discrepancies, they will be resolved via consensus. Data Analysis The outcomes of the studies will be evaluated on the lesion location, size, and severity. Moreover, the limitations and advantages will be evaluated, and the best diagnostic and treatment method or therapy be identified.

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