1. Angiodysplasia of Colon
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 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:
Heer M et al. Hepatogastroenterology. 1987; 34:
Hochter WJ et al. Endoscopy. 1985;17:
0.8% incidental
HA hospitals cases (1/1/ /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:
Navab F et al. Am J Gastroenterol. 1989;84:

9. Epidemiology
(b) Cirrhosis
Naveau S et al. Dig Ds Sci 1991; 36:
(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. Asymptomatic Presentation 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:
(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:

14. Diagnosis 2. Colonoscopy – pathognomonic
Richter JM et al. Angiodysplasia: clinical presentation and colonoscopic diagnosis. Dig Dis Sci. 1984; 29:
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. Investigations Pros Cons 1. Angiogram 2. Colonoscopy
Therapeutic
Detect synchronous lesions
- Invasive
- Timing important
- Availability
2. Colonoscopy
Pathognomonic
- Therapeutic
- Complications
- Miss small lesions
- Less sensitive in active bleeding
3. Radionuclide scan
Long half life – intermittent bleeding
- Non invasive
- Detect slow bleeding (0.1ml/min)
Availability
lack specificity
time consuming
4. Helical CT
- Radiation dose

17. Introduction
Diagnosis
Management
Controversial issue
Conclusion

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

19. 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

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

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

22. Introduction
Diagnosis
Management
Controversial issue
Conclusion

23. Controversial issue 1. Hormonal therapy
One RCT - few episodes of bleeding, decrease transfusion requirement
van Cutsem E et al. Lancet. 1990; 1:
small scale study
most are not angiodysplasia
Multicenter RCT – no benefit
Junquera F et al. Gastroenterology 2001; 121:
Small sample size
Dosage smaller
Retrospective cohort study – no benefit, side effects
Lewis B et al. J Clin Gastroenterology 1992; 15:99-103
Different drug regime
side effect – esp. on male patient
dosage & duration – no consensus

24. Controversial issue 2. Management on incidental angiodysplasia
(a) Follow up for clinical symptoms
Miss bleeding episodes
(b) Follow up colonoscopy
Perforation risk
Interval of surveillance
(c) Surgical resection
Operative mortality & morbidity

25. Introduction
Diagnosis
Management
Controversial issue
Conclusion

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

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

28. The End