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Snapshot
  • A 62-year-old man is brought to the emergency room for blood in his stool this afternoon. He denies any prior episodes, straining, trauma, colon cancer, or alcohol abuse. His medical history is significant for stage 3 chronic renal failure. A physical examination yields hemoccult positive stool.
Introduction
  • Clinical definition
    • describes small vascular malformations frequently found in the gastrointestinal (GI) tract
      • most common vascular anomaly within the GI tract and a common cause of unexplained GI bleeding and anemia  
    • lesions are composed of ectatic, dilated, thin-walled vessels lined by endothelium alone or endothelium with small amounts of smooth muscle
      • small arteriovenous communications may be present  
    • often multiple lesions that frequently involve the cecum or ascending colon
  • Epidemiology
    • demographics
      • most often seen in patients older than 60 years of age
  • Pathogenesis
    • pathogenesis of the condition is not well understood though its development is probably related to age and strain on the bowel wall
    • degenerative lesion that is probably a result from the venous obstruction secondary to the chronic and intermittent contraction of the colon
      • obstruction of the submucosal veins at the level of muscularis propria leads to dilation and tortuosity of the draining areas
      • precapillary sphincters become incompetent, which allows for the formation of arteriovenous malformations
  • Associated conditions
    • end-stage renal disease
    • von Willebrand disease
    • aortic stenosis
Presentation
  • Symptoms 
    • hematochezia
    • melena
    • fatigue
    • hematemesis
      • if present in the upper GI tract
    • shortness of breath
    • weakness
    • dizziness
  • Physical exam
    • pallor
    • hemoccult positive stool
    • tachycardia
Studies
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is primarily based on endoscopy done for the evaluation of gastrointestinal bleeding
    • imaging
      • endoscopy
        • preferred method
        • options include upper endoscopy, colonoscopy, wireless video capsule endoscopy, and deep small bowel enteroscopy
          • a combination of the methods may be necessary
        • characteristic appearance of small (5-10mm), flat, cherry-red lesions with a fern-like pattern 
      • computed tomography (CT) angiography
        • may be especially useful in detecting angiodysplasias with an active hemorrhage
      • angiography
        • indicated in patients with negative endoscopic/CT angiography results and high clinical suspicion
        • allows for treatment
    • studies
      • laboratory studies
        • CBC and iron studies for evaluation of possible anemia
      • intaoperative enteroscopy
        • indicated in patients with significant bleeding but negative evaluation
Differential
  • Diverticulosis 
    • differentiating factors
      • will be visible on endoscopic studies of the colon
  • Colon/rectal cancer 
    • differentiating factors
      • may complain of symptoms (e.g., stool changes) and will be present on colonoscopy
Treatment
  • Treatment is dependent on the level bleeding, if the lesion is not actively bleeding or is discovered incidentally on screening colonoscopy, no treatment is needed
  • First-line
    • endoscopic treatment with cautery or argon plasma coagulation (APC)  
    • supportive care
      • IV fluids
      • blood transfusion if severe anemia
  • Second-line
    • angiography and embolization with particles
    • antifibrinolytics (e.g., tranexamic acid or aminocaproic acid)
      • indicated in patients with bleeding from multiple or inaccessible sites
    • estrogen
      • used in patients with end-stage renal disease and von Willebrand disease
    • other drugs such as thalidomide or octreotide
  • Third-line
    • surgery
      • indicated in patients not responsive to either endoscopic or medical treatment
      • resection of the affected part of the bowel
Complications
  • Anemia
  • Bleeding/hemorrhage
  • Exsanguination

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