History

Fact Explanation
Asymptomatic [3] Angiodysplasia is also known as the vascular ectasia. [3] Many patients are asymptomatic, and the lesions are found incidentally, such as with screening colonoscopy.
Age [1] Commonly presents in the elderly population, usually between 60-69 years of age. There are some cases reported in the young people as well. [1,4]
Bleeding per rectum [1,5] Angiodysplasia commonly affects the caecum and ascending colon less commonly located in the jejunum and/or ileum and the remainder are throughout the alimentary tract. [4] It is a significant cause of bleeding in the elderly people. [1] Degenerative pathology with aging is known to be associated. Lesions occur due to the intermittent partial chronic obstruction of the submucosal veins at the points where they penetrate the muscle layers of the colon. [1] Gradual dilatation of these vessels produces arteriovenous communications. Appearance would be flat, red spots (2-5 mm) or slightly raised dilatations, It may cause either acute massive gastrointestinal bleeding or intermittent long term bleeding. [3,5] Usually it will be altered blood with a maroon-colored stool.Malena and haematamesis [4] is occasionally disease can be found in the duodenum and upper GI tract causing upper GI bleeding.
Dysentry and intermittent abdominal pain [4] This may present as recurrent episodes, which might be mistaken for the infectious dysentry. [4]
Symptos of anaemia [1] : Shortness of breath on exertion, lethargy Intermittent chronic blood loss may cause anaemia. [1] Low oxygen to the tissues due to the anaemia, causes lack of energy.
History of valvular heart disease [3] There can be nonoclusive mesenteric ischemiadue to the peripheral vasoconstriction and redistribution of sphanchnic blod flow associated with low cardiac output in this disorder. [3]
References
  1. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  2. TRENDELL-SMITH NJ, WARREN BF, SHEFFIELD EA, DURDEY P. An unusual case of colonic angiodysplasia. J Clin Pathol [online] 1995 Mar, 48(3):272-275 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC502477
  3. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  4. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 11 August 2014] Available from: doi:10.4103/0256-4947.51786
  5. MUN JB, OH AR, PARK HS, PARK CH, PARK KY, MOON J. The Unusual Suspect: Anemia-induced Systolic Anterior Motion of the Mitral Valve and Intraventricular Dynamic Obstruction in a Hyperdynamic Heart as Unexpected Causes of Exertional Dyspnea after Cardiac Surgery Korean J Thorac Cardiovasc Surg [online] 2013 Dec, 46(6):457-460 [viewed 10 September 2014] Available from: doi:10.5090/kjtcs.2013.46.6.457

Examination

Fact Explanation
Pallor [4] Anaemia due to intermittent chronic blood loss. [2]
Low blood pressure and tachycardia Sometimes bleeding may be massive; causing hypotension and shock. [3]
Ejection systolic murmer at aortic area radiating to the neck [4] Some studies have shown that there is increased incidence of aortic stenosis among the patients with angiodysplasia and other vascular malformations. [1]
References
  1. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  2. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  3. MUN JB, OH AR, PARK HS, PARK CH, PARK KY, MOON J. The Unusual Suspect: Anemia-induced Systolic Anterior Motion of the Mitral Valve and Intraventricular Dynamic Obstruction in a Hyperdynamic Heart as Unexpected Causes of Exertional Dyspnea after Cardiac Surgery Korean J Thorac Cardiovasc Surg [online] 2013 Dec, 46(6):457-460 [viewed 10 September 2014] Available from: doi:10.5090/kjtcs.2013.46.6.457
  4. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 10 September 2014] Available from: doi:10.4103/0256-4947.51786

Differential Diagnoses

Fact Explanation
Diverticular disease [3] Acute painless bleeding, with mild abdominal cramping due to the intraluminal blood may be the presenting symptoms. Majority will have pain in the left lower quadrant, Fever may also present. May be recurrent. Sometimes bleeding may be massive causing hypotension and shock. Pneumaturia is a significant finding in colovesical fistula. [1] Perforated disease may have features of generalized peritonitis like tenderness, rebound tenderness, rigidity in the abdomen. Water-soluble contrast enema, CT scan, and ultrasound are the investigations done during the acute phase of diverticular disease.
Colonic polyps These are overgrowths of the colonic mucosa that carry < 1% risk of becoming malignant. Bleeding per rectum which is persistent or intermittent is a common symptom in polyps. Inflammatory, juvenile, peutz-Jeghers, are the various types of polyps. [6] Colonoscopy allow both diagnosis and the immediate therapeutic polypectomy. [2] Adenomatous and Peutz-Jeghers polyps need follow up with fibre optic colonoscopy for the recurrence and malignant changes.
Colonic malignancies [6] Right-sided colonic bleeding present with bright red blood in the case of massive bleeding is brisk. Otherwise it presents with dark altered blood or malena. Left-sided bleeding may be bright red. Intestinal obstruction can occur in colonic malignancies. Presentation would be abdominal pain, constipation, vomiting and abdominal distension. Loss of appetite and loss of weight and other features of dissemination of the malignancy may be present. Right sided bleeding may be present with iron-deficiency anemia. There may be a family history of colonic malignancies. [5]
Rectal malignancy [8] Painless rectal bleeding may be associated with altered bowel habits such as alternating constipation and diarrhoea, tenesmus (pain during defecation) and sense of incomplete evacuation of the rectum. Loss of appetite and loss of weight and other features of dissemination of the malignancy may be present. [8]
Haemorrhoids [4] These are highly vascular submucosal cushions that in the anal canal in three columns : the left lateral, right anterior, and right posterior positions. [4] It can occur at any age, and in both men and women. [7] This usually presents with painless rectal bleeding with passage of mucous which is usually noticed during defecation. Person may notice a lump at anus which is manually or spontaneously reducible at the early stages and not reducible at later stages( stage 3) In advanced cases such as complicated with fibrosis, gangrene formation, necrosis and infections, it may cause pain.
References
  1. KLARENBEEK BR, DE KORTE N, VAN DER PEET DL, CUESTA MA. Review of current classifications for diverticular disease and a translation into clinical practice Int J Colorectal Dis [online] 2012 Feb, 27(2):207-214 [viewed 12 August 2014] Available from: doi:10.1007/s00384-011-1314-5
  2. LATT TT, NICHOLL R, DOMIZIO P, WALKER-SMITH JA, WILLIAMS CB. Rectal bleeding and polyps. Arch Dis Child [online] 1993 Jul, 69(1):144-147 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1029431
  3. GALLAGHER HW. Diverticulitis and Rectal Bleeding Ulster Med J [online] 1954 Nov, 23(2):142 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC248019
  4. SANCHEZ C, CHINN BT. Hemorrhoids Clin Colon Rectal Surg [online] 2011 Mar, 24(1):5-13 [viewed 10 September 2014] Available from: doi:10.1055/s-0031-1272818
  5. JASPERSON KW, TUOHY TM, NEKLASON DW, BURT RW. Hereditary and Familial Colon Cancer Gastroenterology [online] 2010 Jun, 138(6):2044-2058 [viewed 10 September 2014] Available from: doi:10.1053/j.gastro.2010.01.054
  6. LEE TK, BARRINGER M, MYERS RT, STERCHI JM. Multiple primary carcinomas of the colon and associated extracolonic primary malignant tumors. Ann Surg [online] 1982 Apr, 195(4):501-507 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352535
  7. AGBO SP. Surgical Management of Hemorrhoids J Surg Tech Case Rep [online] 2011, 3(2):68-75 [viewed 10 September 2014] Available from: doi:10.4103/2006-8808.92797
  8. GéRARD A, BUYSE M, NORDLINGER B, LOYGUE J, PèNE F, KEMPF P, BOSSET JF, GIGNOUX M, ARNAUD JP, DESAIVE C. Preoperative radiotherapy as adjuvant treatment in rectal cancer. Final results of a randomized study of the European Organization for Research and Treatment of Cancer (EORTC). Ann Surg [online] 1988 Nov, 208(5):606-614 [viewed 10 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1493780

Investigations - for Diagnosis

Fact Explanation
Angiography [3] Clusters of small arteries during the arterial phase at the antimesenteric border, accumulation of vascular spaces and opacification of the bowel during the capillary phase, early opacification of the veins draining the caecum and ascending colon are the features for the diagnosis on angiography. [1] Superior mesenteric arteriography is done using 50- 60 ml of meglumine diatrizoate injected at 5-6 mI/sec and is followed by serial radiographs. [2]
Colonoscopy/sigmoidoscopy [3] Colonoscopy is more sensitive and accurate than sigmoidoscopy in diagnosing angiodysplasia.These may be operator dependent. Active bleeding will limit the use of the investigation. It is also important as to exclude the other lesions in the colon before the hemicolectomy. [2]
Barium meal and follow through As it is difficult to detect them by barium studies as the lesions are small and focal in distribution. [2]
Stool occult blood test [2] Stool for occult blood is positive even in asymptomatic people. [2]
References
  1. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  2. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  3. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 10 September 2014] Available from: doi:10.4103/0256-4947.51786

Investigations - Fitness for Management

Fact Explanation
Full blood count [3] Chronic intermittent bleeding can cause iron deficiency anaemia [2] , which will manifest as low haemoglobin, reduced mean corpuscular volume and mean corpuscular haemoglobin with microcytic anaemia and increased red cell distribution width.
References
  1. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  2. MUN JB, OH AR, PARK HS, PARK CH, PARK KY, MOON J. The Unusual Suspect: Anemia-induced Systolic Anterior Motion of the Mitral Valve and Intraventricular Dynamic Obstruction in a Hyperdynamic Heart as Unexpected Causes of Exertional Dyspnea after Cardiac Surgery Korean J Thorac Cardiovasc Surg [online] 2013 Dec, 46(6):457-460 [viewed 10 September 2014] Available from: doi:10.5090/kjtcs.2013.46.6.457
  3. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 10 September 2014] Available from: doi:10.4103/0256-4947.51786

Investigations - Followup

Fact Explanation
Full blood count [2] Chronic intermittent bleeding can cause iron deficiency anaemia, which will manifest as low haemoglobin. [1]
References
  1. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  2. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 10 September 2014] Available from: doi:10.4103/0256-4947.51786

Investigations - Screening/Staging

Fact Explanation
99 Tc scintigraphy [1,2] This is commonly used as a screening tool. [1] There is a possibility of detecting very low rates of blood loss by this method using 99 Tc sulfur colloid or 99 Tc labelled red blood cells.
Echocardiogram [3] Some patients have the underlying cardiac disorders that can cause low perfusion and ischaemia of the walls of intestines. [2]
References
  1. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  2. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 11 August 2014] Available from: doi:10.4103/0256-4947.51786
  3. MUN JB, OH AR, PARK HS, PARK CH, PARK KY, MOON J. The Unusual Suspect: Anemia-induced Systolic Anterior Motion of the Mitral Valve and Intraventricular Dynamic Obstruction in a Hyperdynamic Heart as Unexpected Causes of Exertional Dyspnea after Cardiac Surgery Korean J Thorac Cardiovasc Surg [online] 2013 Dec, 46(6):457-460 [viewed 10 September 2014] Available from: doi:10.5090/kjtcs.2013.46.6.457

Management - General Measures

Fact Explanation
Resuscitation [2] Patients can present with acute massive gastrointestinal haemorrhage [2] needing resuscitation. Special attention should be focused on circulation due to the massive blood loss. Volume resuscitation may be needed.
Embolization [2] Angiodysplasia with acute hemorrhage can be treated with embolization to control the bleeding. [3] It is better than selective infusion of vasopressin as it causes less bleeding rate.
Vasopressin and octreotide [2] Intra-arterial vasopressin is used to control massive lower gastrointestinal bleeding. [2] Octreotide treatment will be useful in patients with refractory gastrointestinal bleeding especially in those need anticoagulant treatment.
Management of anaemia [2] Anaemia can be due to chronic intermittent blood loss, If significant anaemia present with clinical features they need to get treatment and if needed even blood transfusion. [2]
Pre op angiography Selective angiography is recommended for the preoperative localization of bleeding sites. [1]
References
  1. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  2. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 11 August 2014] Available from: doi:10.4103/0256-4947.51786
  3. VRAKAS G, PRAMATEFTAKIS MG, RAPTIS D, KANELLOS D, KANELLOS I. Selective embolization for massive upper gastrointestinal bleeding deriving from gastric angiodysplasia J Surg Case Rep [online] , 2012(3):11 [viewed 13 September 2014] Available from: doi:10.1093/jscr/2012.3.11

Management - Specific Treatments

Fact Explanation
Conservative approach [3] Conservative approach is suitable for the hemodynamically stable patients as bleeding can stop spontaneously in the majority of patients.[2] Blood transfusion, management of anaemia are important. [4]
Surgery [4] Surgery is the management option with highest cure rate. It is done when the endoscopic ablation is not suitable or if life-threatening hemorrhage occurs. Right hemicolectomy or if relevant total colectomy is done. Histological examination will show angiodysplastic lesions in different parts of the colon. [2]
Endoscopic obliteration techniques [2] Gastric and duodenal angiodysplastic lesions are treated in this way, endoscopic laser photocoagulation is a method used for the colonic angiodysplasia. Endoscopic band ligation is also done. [4]
References
  1. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  2. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 11 August 2014] Available from: doi:10.4103/0256-4947.51786
  3. MUN JB, OH AR, PARK HS, PARK CH, PARK KY, MOON J. The Unusual Suspect: Anemia-induced Systolic Anterior Motion of the Mitral Valve and Intraventricular Dynamic Obstruction in a Hyperdynamic Heart as Unexpected Causes of Exertional Dyspnea after Cardiac Surgery Korean J Thorac Cardiovasc Surg [online] 2013 Dec, 46(6):457-460 [viewed 10 September 2014] Available from: doi:10.5090/kjtcs.2013.46.6.457
  4. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 10 September 2014] Available from: doi:10.4103/0256-4947.51786