In medicine (gastroenterology), angiodysplasia is a small vascular malformation of the gut.

It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions

are often multiple, and frequently involve the cecum or ascending colon, although they can
occur at other places. Treatment may be with colonoscopic interventions, angiography and
embolization, medication, or occasionally surgery.

Contents

1 Signs and symptoms

2 Diagnosis

3 Pathophysiology

4 Therapy

5 References

Signs and symptoms

Although some cases present with black, tarry stool (melena), the blood loss can be subtle,
with the anemia symptoms predominating. Fecal occult blood testing is positive when
bleeding is active. If bleeding is intermittent the test may be negative at times.

Diagnosis
Diagnosis of angiodysplasia is often accomplished with endoscopy, either colonoscopy or
esophagogastroduodenoscopy (EGD). Although the lesions can be notoriously hard to find,
the patient usually is diagnosed by endoscopy. A new technique, pill enteroscopy, has been a
major advance in diagnosis, especially in the small bowel which is difficult to reach with
traditional endoscopy. With this technique a pill that contains a video camera and radio
transmitter is swallowed, and pictures of the small intestine are sent to a receiver worn by the
patient. Recently, multiphase CT angiography (without positive oral contrast) has been shown
to play a promising role in the diagnoses of small and large bowel angiodysplasia, especially
when associated with active hemorrhage
Angiodysplasiae in the small bowel can also be diagnosed and treated with double-balloon
enteroscopy, a technique involving a long endoscopic camera and overtube, both fitted with
balloons, that allow the bowel to be accordioned over the camera.[1]
In cases with negative endoscopic findings and high clinical suspicion, selective angiography
of the mesenteric arteries is sometimes necessary, but this allows for interventions at time of
the procedure. An alternative is scintigraphy with red blood cells labeled with a radioactive
marker; this shows the site of the bleeding on a gamma camera but tends to be unhelpful
unless the bleeding is continuous and significant.[2]

Pathophysiology
Histologically, it resembles telangiectasia and development is related to age and strain on the
bowel wall.[3] It is a degenerative lesion, acquired, probably resulting from chronic and

intermittent contraction of the colon that is obstructing the venous drainage of the mucosa. As
time goes by the veins become more and more tortuous, while the capillaries of the mucosa
gradually dilate and precapillary sphincter becomes incompetent. Thus is formed an
arteriovenous malformation characterized by a small tuft of dilated vessels.[4][5]
Although angiodysplasia is probably quite common, the risk of bleeding is increased in
disorders of coagulation. A classic association is Heyde's syndrome (coincidence of aortic
valve stenosis and bleeding from angiodysplasia).[6] In this disorder, von Willebrand factor
(vWF) is proteolysed due to high shear stress in the highly turbulent blood flow around the
aortic valve. vWF is most active in vascular beds with high shear stress, including
angiodysplasias, and deficiency of vWF increases the bleeding risk from such lesions.[3]
Warkentin et al. argue that apart from aortic valve stenosis, some other conditions that feature
high shear stress might also increase the risk of bleeding from angiodysplasia.[3]

Therapy
If the anemia is severe, blood transfusion is required before any other intervention is
considered. Endoscopic treatment is an initial possibility, where cautery or argon plasma
coagulation (APC) treatment is applied through the endoscope. Failing this, angiography and
emolization with particles is another microinvasive treatment option, which avoids the need
for surgery and bowel resection. Here, the vessel supplying the angiodysplasia is selectively
catheterized and embolizaed with microparticles.[7] Resection of the affected part of the bowel
may be needed if the other modalities fail. However, the lesions may be widespread, making
such treatment impractical.
If the bleeding is from multiple or inaccessible sites, systemic therapy with medication may
be necessary. First-line options include the antifibrinolytics tranexamic acid or aminocaproic
acid. Estrogens can be used to stop bleeding from angiodysplasia. Estrogens cause mild
hypercoaguability of the blood. Estrogen side effects can be dangerous and unpleasant in both
sexes. Changes in voice and breast swelling is bothersome in men, but older women often
report improvement of libido and perimenopausal symptoms. (The worries about hormone
replacement therapy/HRT, however, apply here as well.)
In difficult cases, there have been positive reports about octreotide[8] and thalidomide.[9]
In severe cases or cases not responsive to either endoscopic or medical treatment, surgery
may be necessary to arrest the bleeding.