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Angiodysplasia of Colon

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Presentation on theme: "Angiodysplasia of Colon"— Presentation transcript:

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

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