Angiodysplasia

(Vascular Ectasias)

A syndrome of gastrointestinal mucosal vascular ectasias not associated with cutaneous lesions, systemic vascular disease, or familial syndromes.

Angiodysplasia is found in about 1 to 2% of patients undergoing upper endoscopy. In the elderly, angiodysplasia may occur in the upper and lower gastrointestinal tract. Although gastric and duodenal lesions have occasionally been reported in patients in their 20s, the mean age of patients with upper tract lesions is > 60 years.

The etiology is uncertain. The ectasias may be a degenerative process of aging and result from chronic, low-grade obstruction of the submucosal vein or from chronic mucosal ischemia. Brisk or occult gastrointestinal bleeding may occur. Bleeding angiodysplasia is more likely to occur in patients with aortic valve disease, chronic renal failure requiring dialysis, or von Willebrand's disease. The clinical course of untreated lesions is unknown. However, retrospective reviews have suggested that in most persons the course is indolent.

Angiodysplasia is most readily diagnosed by endoscopy. The lesions are typically discrete, flat or slightly raised, and bright red and are often stellate in appearance. Celiac artery and superior mesenteric artery injections may fail to demonstrate the lesions.

Treatment

Gastric and duodenal angiodysplastic lesions are most frequently treated with endoscopic obliteration techniques (eg, electrocautery, heater probe, or multipolar coagulation devices). Argon and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers have also been used for endoscopic obliteration. Sclerotherapy (sodium tetradecyl sulfate 1.5% 0.5 to 1 mL) obliterates upper tract lesions, but bleeding recurs in half of these patients.

In patients who are not candidates for surgery, transcatheter embolization after selective cannulation of the branches of mesenteric artery has been successful. Selective infusion of vasopressin is less effective than embolization.

Surgical resection has been used to treat bleeding angiodysplasias that have been clearly identified. However, surgery may provide only short-term benefits; bleeding recurs in up to 50% of patients.

Although the causal relationship between aortic stenosis and angiodysplasia has been questioned, several cases have been reported in which bleeding from an angiodysplastic lesion ceased after aortic valve replacement. Estrogen-progesterone therapy (ethinyl estradiol 0.05 mg/day po and norethindrone 1 mg/day; norethynodrel 5 to 10 mg with mestranol 0.075 to 0.15 mg/day po) or conjugated estrogens (0.625 mg/day po) have been used in patients with chronic bleeding, with variable results.