VASCULAR ANOMALIES OF THE INTESTINE Angiodysplasia

VASCULAR ANOMALIES OF THE INTESTINE Angiodysplasia

Angiodysplasia is a vascular malformation that commonly causes haemorrhage from the colon in patients over the age of 60. The malformations consist of dilated tortuous submucosal veins. Clinical features In the majority of cases, the symptoms are subtle and patients can present with anaemia. About 10–15% have brisk bleeds, which may present as melaena or significant rectal bleeding. Many patients in whom rectal bleeding has been attributed to - diverticular disease have probably bled from angiodysplasia. - There is an association with aortic stenosis (Heyde’s syndrome). Investigation Colonoscopy may show the characteristic lesion in the right colon. The lesions are only a few millimetres in size and appear as reddish, raised areas at endoscopy . CT angiography shows the site and extent of the lesion by a ‘blush’ of contrast, provided bleeding is more rapid than 1 /uni00A0 mL/min. If this fails, a 99m Tc-labelled red cell scan may confirm and localise the source of haemorrhage. New In the context of a massive lower gastrointestinal bleed the first principle is to stabilise the patient. Following this, the bleeding needs to be localised. CT angiography allows not only localisation if bleeding is rapid but also therapeutic embolisation. If angiography fails or is unavailable careful colonoscopy (with copious lavage) may allow cauterisation to be carried out and an argon laser can be helpful. In severe uncontrolled bleeding, surgery becomes necessary . If preoperative localisation has not been successful, on-table colonoscopy is carried out to confirm the site of bleeding. Angiodysplastic lesions are sometimes demonstrated by trans- illumination through the caecum. If it is still not clear exactly which segment of the colon is involved a subtotal colectomy may be necessary . The management algorithm in Summary box 77.13 is adapted from the diagnosis and management acute lower gastrointestinal bleeding guidelines from the British Society of Gastroenterology . Summary box 77.13 Management of acute lower gastrointestinal bleeding /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Patients with active bleeding and features of hypovolaemic shock CT angiogram and embolisation Bleeding treated: inpatient colonoscopy Bleeding continues: consider therapeutic endoscopy or surgery Patients without features of hypovolaemic shock Signi /f_i cant bleeding: inpatient colonoscopy and consider oesophagogastroduodenoscopy; if normal consider capsule endoscopy, CT angiogram, nuclear medicine scanning Minor bleeding: arrange outpatient investigations All patients: consider withholding anticoagulants and transfuse blood products as required