Angiodysplasia

The term gastrointestinal angiodysplasia (see footnote) is conventionally used to describe angiectatic lesions localized in the gastrointestinal mucosa and submucosa. Angiodysplasia may occur in any portion of the stomach, small intestine, and large intestine. Angiodysplasia may cause gastrointestinal bleeding and should be taken into consideration as a differential diagnosis of gastrointestinal bleeding.

Table 10.6.1. Classification of vascular malformations and tumors and/or tumor-like lesions of the gastrointestinal tract

Vascular malformation

Angiodysplasia (vascular ectasia) Arteriovenous malformation Dieulafoy's vascular malformation Vascular tumors and/or tumor-like lesions Hemangioma

Capillary hemangioma Cavernous hemangioma (single or diffuse) Mixed capillary and cavernous hemangioma Pyogenic granulomas (granulation tissue-type hemangioma) Hemangiomatosis and specific vascular syndromes Hemangiomatosis Blue rubber bleb nevus syndrome

Angiosarcoma (malignant hemangioendothelioma) Kaposi's sarcoma Perivascular tumors Benign tumors

Benign hemangiopericytoma Glomus tumor Malignant tumors

Malignant hemangiopericytoma

From Iwashita A, Oishi T, Yao T, et al. (2000) Pathological differential diagnosis of vascular diseases of gastrointestinal tract. Stomach Intestine (Tokyo) 35:774

Footnote: Angiodysplasia

According to the second edition of Gastroenterological Endoscopy Terminology (Tokyo: Igaku-Shion, 1997), the term "vascular malformation" or "angiodysplasia" was previously used to describe the lesion, which often causes lower gastrointestinal bleeding. However, the term "vascular ectasia" ("angiectasia" or "angiectasis") is more appropriate because the condition is attributable to vascular degeneration, an acquired cause.

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) Klippel-Trenaunay syndrome Maffucci's syndrome

Diffuse intestinal (neonatal) hemangiomatosis

A 31-year-old man with gastrointestinal bleeding underwent upper and lower endoscopy, which failed to identify the source of bleeding. Double-balloon endoscopy revealed angiodysplasia in the ileum (Fig. 10.6.1). About a dozen areas of angiodysplasia similar to that in the photograph were observed.

A 66-year-old woman with an unidentified source of gastrointestinal bleeding underwent double-balloon endoscopy, which revealed angiodysplasia in the jejunum (Fig. 10.6.2).

A 60-year-old woman underwent double-balloon endoscopy to investigate the cause of recurrent gastrointestinal bleeding. Multiple minute areas of angiodysplasia were found in the terminal ileum (Fig. 10.6.3).

Fig. 10.6.1. Case 1. Angiodysplasia in the ileum Fig. 10.6.2. Case 2. Angiodysplasia in the jejunum

Fig. 10.6.1. Case 1. Angiodysplasia in the ileum Fig. 10.6.2. Case 2. Angiodysplasia in the jejunum

A 62-year-old woman was found to have angiodysplasia approximately 10 mm in size in the horizontal part of the duodenum (Fig. 10.6.4a). It was determined to be the cause of her gastrointestinal bleeding and was treated after observation. Physiological saline was injected under the mucosa of the lesion (Fig. 10.6.4b). Because the wall of the small intestine is thin, injection of physiological saline under the mucosa of the lesion is done to minimize the effect of coagulation on the muscle layer. The lesion immediately after cauterization with the tip of a snare is shown in Fig. 10.6.4c. Cauterization was performed with an ICC 200 (Erbe) in the soft coagulation mode at 60 W. The lesion was adequately cauterized. An endoscopic view of the lesion on day 8 after cauterization is presented in Fig. 10.6.4d. The lesion was adequately cauterized, and the patient recovered uneventfully.

a Angiodysplasia approximately 10 mm in size in the horizontal part of the duodenum b Injection of physiological saline c Cauterization by electrocoagulation d Postoperative day 8

a Angiodysplasia approximately 10 mm in size in the horizontal part of the duodenum b Injection of physiological saline c Cauterization by electrocoagulation d Postoperative day 8

A 62-year-old woman with chronic gastrointestinal bleeding of unknown cause underwent double-balloon endoscopy, which revealed active bleeding from an area of angiodysplasia localized slightly caudal to the ligament of Treitz (Fig. 10.6.5a). The bleeding point was more clearly shown by underwater examination (Fig. 10.6.5b). Underwater examination in combination with balloon inflation at the endoscope tip helps visualize those lesions and provides an effective means of observation. This technique allows detection of minimal bleeding that is difficult to identify by routine examination. Underwater observation is also useful after hemostasis. Figure 10.6.5c shows the result of underwater observation after treatment of the lesion. No active bleeding was found. Underwater observation is effective in investigating overt bleeding (Fig. 10.6.5b) as well as minimal bleeding from microlesions (Fig. 10.6.5d).

c After electrocoagulation no active bleeding was found on underwater observation d Underwater observation is effective for identifying bleeding from minimal lesions

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