DOCSLIB.ORG

Heyde Syndrome: Gastrointestinal Bleeding and Aortic Stenosis

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Heyde Syndrome: Gastrointestinal Bleeding and Aortic Stenosis Early release, published at www.cmaj.ca on June 29, 2015. Subject to revision. CMAJ Practice CME Cases Heyde syndrome: gastrointestinal bleeding and aortic stenosis Bartosz Hudzik MD PhD, Krzysztof Wilczek MD PhD, Mariusz Gasior MD PhD n 82-year-old man presented with a two- time, diminished ristocetin cofactor activity and Competing interests: week history of increasing shortness of depletion of high-molecular-weight multimers of None declared. Abreath and exercise intolerance. His medi- von Willebrand factor on gel electrophoresis) This article has been peer cal history included chronic obstructive pulmonary confirmed type IIA acquired von Willebrand syn- reviewed. disease, hypertension and chronic kidney disease. drome (deficit of high-molecular-weight multi- The authors have obtained He had undergone left nephrectomy and splenec- mers of von Willebrand factor). patient consent. tomy for abdominal trauma and had had three epi- Given the patient’s comorbidities and an Correspondence to: sodes of lower gastrointestinal bleeding for which extremely high risk of intraoperative death (logistic Bartosz Hudzik, blood transfusions had been required. Prior workup Euro SCORE 42.7% and Society of Thoracic Sur- [email protected] for gastrointestinal bleeding included colonoscopy geons adult cardiac surgery risk score 29.3%; CMAJ 2015. DOI:10.1503 and argon plasma coagulation for angiodysplasia. sources available in Appendix 1, at www.cmaj.ca/ /cmaj.150194 The patient’s vital signs were normal. On lookup/suppl/doi:10.1503/cmaj.150194/-/DC1), the chest examination, there were audible crackles at patient was not considered a suitable candidate for the bases of both lungs and a grade 4/6 systolic surgical aortic valve replacement and was referred murmur at the second right intercostal space for transcatheter aortic valve implantation. radiating toward the right carotid artery. The Following implantation of a CoreValve 31 findings of a rectal examination (including test- aortic valve, the valve area was 3.7 cm2. The ing for fecal occult blood) were normal. Oxygen patient did not experience gastrointestinal bleed- saturation was 94% on room air. ing in the periprocedural period. However, Laboratory tests showed hemoglobin 95 (nor- because of procedural blood loss (bleeding at the mal 130–170) g/L, hematocrit 30% (normal 40%– access site), two units of packed red blood cells 52%), platelets 201 (normal 150–400) × 109/L, were transfused. The patient was discharged creatinine 150 (normal 70–110) µmol/L, estimated seven days later with a six-month prescription for glomerular filtration rate 37 (normal > 90) mL/min a single antiplatelet agent (clopidogrel). The per 1.73 m2 and N-terminal pro-B-type natriuretic 12-month follow-up was unremarkable, with no peptide 5670 (normal < 125) pg/mL. Troponins further episodes of gastrointestinal bleeding were within the normal range. Electrocardiography reported. Left ventricular ejection fraction had on admission was suggestive of left ventricular increased to 37%, and the patient’s respiratory hypertrophy with no ischemic changes. Radio- symptoms had improved (New York Heart Asso- graphic signs of cardiac enlargement were present. ciation functional class II). A follow-up coagula- Transthoracic echocardiography showed severe tion study showed no deficit of high-molecular- depression of left ventricular systolic function with weight multimers of von Willebrand factor. an ejection fraction of 24%, along with severe aor- tic stenosis, a heavily calcified aortic valve with Key points aortic valve area of 0.7 cm2 and a mean aortic valve gradient of 37 mm Hg (Figure 1). • An association exists between severe aortic stenosis and recurrent The history of lower gastrointestinal bleeding bleeding from intestinal angiodysplasia. (angiodysplasia) and the presence of aortic steno- • For patients with recurrent gastrointestinal bleeding, the differential diagnosis should include Heyde syndrome. sis were consistent with Heyde syndrome. An enhanced coagulation study was requested, • Management of Heyde syndrome is challenging, with treatment options that include medical therapy, endoscopic interventions, colonic including platelet function and measurement of surgery and valve replacement. the function and concentration of von Willebrand • If valve replacement is performed, antiplatelet and anticoagulant complex:factor VIII. The results (prolonged agents should be used with caution, to minimize the risk of rebleeding. platelet function analyzer [PFA-100] closure ©2015 8872147 Canada Inc. or its licensors CMAJ 1 Practice Discussion much lower prevalence (see references available in Appendix 1, www.cmaj.ca/lookup/suppl/ The association between chronic gastrointesti- doi:10.1503/cmaj.150194/-/DC1). In patients for nal bleeding due to angiodysplasia and calcific whom aortic stenosis is the index diagnosis, there aortic stenosis was first described in 1958 by is a 100-fold greater risk of gastrointestinal bleed- Edward Heyde and has since been termed Heyde ing, relative to those without aortic stenosis.3 Still, syndrome. Not until 1992 did Warkentin and col- angiodysplasia is the most common vascular leagues elucidate the role of acquired coagulo- abnormality of the gastrointestinal tract and the pathy (depletion of high-molecular-weight multi- second leading cause (after diverticulosis) of mers of von Willebrand factor) in the patho genesis lower gastrointestinal bleeding in patients over of Heyde syndrome (historical sources listed the age of 60.7 in Appendix 1, available at www.cmaj.c a/lookup/ suppl/doi:10.1503/cmaj.150194/-/DC1). Although Pathophysiology there is no consensus definition, many authors There are several plausible explanations for Heyde affirm that Heyde syndrome refers to a triad of syndrome, but the most convincing link between aortic stenosis, acquired type IIA von Willebrand aortic stenosis and gastrointestinal bleeding from syndrome and recurrent bleeding from gastroin- angiodysplasia is a deficiency of high-molecular- testinal angiodysplasia (Figure 2).1–5 weight multimers of von Willebrand factor.3,4 Fig- ure 2 summarizes the pathophysiologic mechanisms Epidemiology underlying Heyde syndrome. Aortic stenosis or Degenerative aortic stenosis is the most common sclerosis is associated with high shear stress, which valvular heart disease in older patients and is one elevates von Willebrand factor–cleaving metallo- of the main causes of morbidity and mortality in protease activity, leading to proteolysis of von this age group. Its prevalence increases with age, Wille brand factor, and increases interactions reaching 2%–7% after the age of 65 years.6 The between von Willebrand factor and platelets, lead- presence of symptoms from aortic stenosis heralds ing to degradation or clearance of von Willebrand poor prognosis and warrants surgery.6 However, factor.4 the role of aortic valve replacement in patients Von Willebrand factor, an adhesive glycopro- who are asymptomatic remains controversial.6 tein that is synthesized in endothelial cells and Angiodysplasia is another age-related degen- megakaryocytes, has two major functions in erative process, characterized by dilated, thin- hemostasis. It helps with platelet–subendothelium walled tortuous vessels in the mucosa and sub- adhesion and platelet–platelet interactions (i.e., mucosa of the gastrointestinal tract, including aggregation), and it carries factor VIII in plasma. arterioles, capillaries and venules. Angiodysplasia Von Willebrand factor also prolongs the half-life accounts for 1%–6% of hospital admissions for of factor VIII by protecting it from proteolytic gastrointestinal bleeding.2 It may occur through- degradation. It delivers factor VIII to the site of out the gastrointestinal tract, but most particularly vascular injury, thus enhancing the hemostatic in the right colon and cecum.2,3,7 process.8 Defects or deficiencies in von Wille- Proving an association between aortic stenosis brand factor underlie both inherited von Wille- and angiodysplasia is challenging, because both brand disease and acquired von Willebrand syn- entities are common in older patients. Some drome.8 Changes in the function of von Willebrand authors have suggested that the rate of aortic ste- factor are not specific to aortic valve disease. Con- nosis among patients with gastrointestinal bleed- ditions linked to von Willebrand syndrome are ing is as high as 30%–40%.3 Others have reported listed in Box 1. Figure 1: Transthoracic echocardiography shows (A) severe aortic stenosis with heavily calcified aortic valve (AV); (B) aortic valve area (AVA) of 0.7 cm2; and (C) mean aortic valve gradient of 37 mm Hg. LA = left atrium, LV = left ventricle. 2 CMAJ Practice Other possible factors implicated in the patho- electrophoresis (quantification of high-molecular- genesis of Heyde syndrome include mucosal weight multimers) > PFA-100 closure time > von ischemia, cholesterol embolization, acquired plate- Willebrand factor ristocetin cofactor > bleeding let dysfunction and inflammatory reactions.3 Bleed- time > von Willebrand factor antigen.4 ing from angiodysplasia may reflect an interac- tion between an uncommon coagulopathy (caused Treatment by a common valvular disease) and a common Management of Heyde syndrome often requires a vascular disease of the gastrointestinal tract. multidisciplinary approach, and treatment options include medical therapy, endoscopic interven- Diagnostic workup tions, colon surgery and aortic valve replacement.3 Initial investigations should explore other
Load more

Recommended publications
  • Heyde's Syndrome
    Cease Report Adv Res Gastroentero Hepatol Volume 2 Issue 4 - January 2017 DOI: 10.19080/ARGH.2017.04.555592 Copyright © All rights are reserved by Deepankar Kumar Basak Heyde’s syndrome: Rarely heard and often missed Deepankar Kumar Basak1*, Richmond Ronald Gomes2 and Md Samsul Arfin3 1Specialist-Gastroenterology, Square Hospitals Ltd., Bhangladesh 2Assistant Professor, Internal Medicine, Ad-din Sakina Medical College & Hospital, Bhangladesh 3Gasroenterology, Square Hospitals Limited., Bhangladesh Submission: November 11, 2016; Published: January 19, 2017 *Corresponding author: Deepankar Kumar Basak, MBBS, FCPS (Medicine), Specialist-Gastroenterology, Square Hospital Ltd., Dhaka, Bangladesh, Tel: Email: Abstract Bleeding from the gastrointestinal tract is very common and important problem in clinical practice. There are lots of causes of GI bleeding, gastrointestinal bleeding in an elderly female patient who is also suffering from HCV related decompensated CLD with multiple myeloma. Heyde’sbut sometimes syndrome it is is very now difficult known to belocate gastrointestinal and treat gastrointestinal bleeding from bleeding. angiodysplasic Here we lesions discuss due Heyde’s to acquired syndrome, vWD-2A an secondaryimportant tocause aortic of stenosis, and the diagnosis is made by confirming the presence of those three things. For this, a wide range of investigations and treatment showingmodalities gastrointestinal are now available. bleeding One aftershould aortic therefore valve makereplacement. an aggressive Old age attempt and co-morbidities to localize the may bleeding create site.a hindrance Newer endoscopic in valve replacement technologies or resectionmay prove surgery. beneficial. Some Aortic newer valve treatment replacement options is claimed like hormonal to minimize and orthalidomide even stop thetherapy bleeding look in promising such patients.
    [Show full text]
  • Ment of Portal Hypertensive Gastropathy
    THIEME Original article E1057 Efficacy of argon plasma coagulation in the manage- ment of portal hypertensive gastropathy Authors Amr Shaaban Hanafy, Amr Talaat El Hawary Institution Internal Medicine Department – Hepatology Division, Zagazig University, Zagazig, Egypt submitted Objectives: Evaluation of the outcome and experi- deviation) number of sessions was 1.65±0.8; six 29. September 2015 ence in 2 years of management of portal hyper- patients needed four sessions (3.2%), 19 patients accepted after revision tensive gastropathy (PHG) by argon plasma coag- needed three sessions (10.1%), 74 patients need- 29. July 2016 ulation (APC) in a cohort of Egyptian cirrhotic pa- ed two sessions (39.4 %), and 89 patients needed tients. one session (47.3 %). Patients with fundic and cor- Bibliography Methods: This study was conducted over a 2-year poreal PHG required the lowest number of ses- DOI http://dx.doi.org/ period from January 2011 to February 2013. Up- sions (P=0.000). Patients were followed up every 10.1055/s-0042-114979 per gastrointestinal endoscopy was performed to 2 months for up to 1 year; the end point was a Published online: 6.10.2016 evaluate the degree and site of PHG. APC was complete response with improved anemia and Endoscopy International Open 2016; 04: E1057–E1062 applied to areas with mucosal vascular lesions. blood transfusion requirement which was © Georg Thieme Verlag KG Results: In total, 200 cirrhotic patients were en- achieved after one session in 89 patients (75.4 %), Stuttgart · New York rolled; 12 patients were excluded due to death two sessions in 24 patients (20.3 %) and three ses- E-ISSN 2196-9736 (n=6) caused by hepatic encephalopathy (n=3), sions in five patients (4.3%).
    [Show full text]
  • Core Curriculum for Endoscopic Ablative Techniques
    Communication from the ASGE Training CORE CURRICULUM Committee Core curriculum for endoscopic ablative techniques Prepared by: ASGE TRAINING COMMITTEE Hiroyuki Aihara, MD, PhD, FASGE,1 Vladimir Kushnir, MD, FASGE,2 Gobind S. Anand, MD,3 Lisa Cassani, MD,4 Prabhleen Chahal, MD,5 Sunil Dacha, MD,6 Anna Duloy, MD,7 Sahar Ghassemi, MD,8 Christopher Huang, MD,9 Thomas E. Kowalski, MD,10 Emad Qayed, MD,11 Sunil G. Sheth, MD, FASGE,12 C. Roberto Simons-Linares, MD,5 Jason R. Taylor, MD,13 Sarah B. Umar, MD,14 Stacie A. F. Vela, MD, FASGE,15 Catharine M. Walsh, MD, MEd, PhD,16 Renee L. Williams, MD,17 Mihir S. Wagh, MD, FASGE (Chair, ASGE Training Committee)7 This is one of a series of documents prepared by the developed as an overview of techniques currently favored American Society for Gastrointestinal Endoscopy for the performance and training for endoscopic abla- Training Committee. This document contains recommen- tion and to serve as a guide to published references, dations for a training curriculum intended for use by videos, and other resources available to the trainer. endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was Acquiring the skills to perform gastrointestinal (GI) mucosal ablative techniques requires a thorough understand- ing of the histology and pathology of the GI tract and indica- Abbreviations: APC, argon plasma coagulation; RFA, radiofrequency tions, technical performance, risks, and limitations of the ablation. techniques. Trainees should be experienced in upper endos- ª Copyright 2020 by the American Society for Gastrointestinal Endoscopy copy, colonoscopy, and hemostasis before pursuing training 0016-5107/$36.00 1-3 https://doi.org/10.1016/j.gie.2020.06.055 in mucosal ablative techniques.
    [Show full text]
  • Dieulafoy's Lesion Treated with Argon Plasma Coagulation
    CASE REPORT 2014; 22(1): 18-20 Dieulafoy’s lesion treated with argon plasma coagulation and injection sclerotherapy: A rare case report Dieulofaloy lezyonunun kombine tedavisi: Olgu sunumu Şehmus ÖLMEZ1, Bünyamin SARITAŞ2, Mehmet ASLAN3, Ahmet Cumhur DÜLGER1, İbrahim AYDIN3 Departments of 1Gastroenterology, and 3Internal Medicine, Yüzüncü Yıl University Medical Faculty, Van 2Department of Gastroenterology, Muş Public Hospital, Muş Dieulafoy’s lesion is an uncommon, but important, cause of upper gastroin- Dieulafoy lezyonu nadir görülen ancak önemli bir üst gastrointestinal ka- testinal bleeding. Dieulafoy’s lesion is usually seen in the stomach, but some- nama nedenidir. Sıklıkla midede görülmekle birlikte ince ve kalın bağırsak- times can be seen in the small or large bowel. Typically, it is located within larda da görülebilir. Tipik olarak gastroözofageal bileşkeden sonraki 6 cm 6 cm of the esophagogastric junction, generally along the lesser curvature içinde, küçük kurvatur yönünde yerleşir. Bu lezyonlara bağlı kanamada, he- of the stomach. Various methods with endoscopy are used to control the mostazı sağlamak için değişik endoskopik yöntemler kullanılır ve kanayan hemostasis due to these lesions, but the most suitable endoscopic treatment Dieulafoy lezyonu tedavisi için en uygun endoskopik tedavi yöntemi henüz method for treating bleeding Dieulafoy’s lesion is not yet well established. iyi tanımlanmamıştır. Argon plazma koagülasyonu üst gastrointestinal kana- Argon plasma coagulation has been used successfully in upper gastrointes- mada başarılı bir şekilde kullanılmasına rağmen Dieulafoy lezyonuna bağlı tinal bleeding; however, the experience using argon plasma coagulation to kanamalarda kullanımı sınırlıdır. Burada enjeksiyon tedavisi ve argon plaz- treat Dieulafoy’s lesion is quite limited. Herein, we report a case with a bleed- ma koagülasyonu ile kombine olarak tedavi edilen, kanayan gastrik Dieula- ing gastric Dieulafoy’s lesion that was treated using a combined endoscopic foy lezyonu olan olguyu sunacağız.
    [Show full text]
  • Efficacy of Argon Plasma Coagulation in Gastric Vascular Ectasia in Patients with Liver Cirrhosis Muhammad Afzal Bhatti, Anwaar A
    ORIGINAL ARTICLE Efficacy of Argon Plasma Coagulation in Gastric Vascular Ectasia in Patients with Liver Cirrhosis Muhammad Afzal Bhatti, Anwaar A. Khan, Altaf Alam, Arshad K. Butt, Farzana Shafqat, Kashif Malik, Joher Amin and Waqar Shah ABSTRACT Objective: To determine the efficacy of Argon Plasma Coagulation (APC) in terms of improvement in hemoglobin level and disappearance of telangiectasia as endoscopic treatment for Gastric Antral Vascular Ectasia (GAVE) and Diffuse Antral Vascular Ectasia (DAVE) syndrome in liver cirrhosis. Study Design: Quasi experimental study. Place and Duration of Study: Department of Gastroenterology and Hepatology of Shaikh Zayed Hospital/ Federal Postgraduate Medical Institute, Lahore, from January, 2006 to July, 2007. Methodology: Cirrhotic patient with gastric vascular ectasia were enrolled and followed-up for 18 months with repeated sessions of APC. Efficacy of APC was evaluated on the basis of patient’s symptoms, transfusion requirements and hemoglobin levels. APC was performed by using ERBE generator set at 60 W and flow rate 2.0 L/min using primarily end- firing probes. Results: Fifty patients were enrolled in the study. Mean age was 55.78+1.24 years with 32 males and 18 females giving a male to female ratio 1.7:1. Forty two patients were in Child’s Class C and 8 in Child’s Class B. Presenting complaints were malena and anemia. Two hundred and fifty three APC sessions were carried out; mean 5.06+1.5 sessions per patient. Mean follow-up period after the last session was 8.5+3.7 months. Mean increase in the hemoglobin level was 1.35+0.24 g/dl.
    [Show full text]
  • Argon Plasma Coagulation in the Management of Symptomatic
    argon plasma coagulation in the management of symptomatic gastrointestinal angiodysplasia: experience in 69 consecutive patients traitement des angiodysplasies digestives hémorragiques par éléctrocoagulation au plasma argon : à propos de 69 cas Sondes Bizid, Mériam Sabbah, Hatem Ben Abdallah, Wafa Haddad, Riadh Bouali, Nabil Abdelli. Service d’hépatogastro-entérologie. Hôpital militaire principal d’instruction de Tunis résumé summary Prérequis: Les angiodysplasies gastro-intestinales représentent la Background: Gastrointestinal angiodysplasias are associated with principale cause de saignement gastro-intestinal occulte. But : a high bleeding risk. Aim: to evaluate the efficiency of argon plasma Evaluer l'efficacité de l'électrocoagulation au plasma argon dans le electrocoagulation in the treatment of gastrointestinal angiodysplasia traitement des angiodysplasies gastro-intestinales hémorragiques and to identify predictive factors of success of this technique. et identifier les facteurs prédictifs de succès de cette technique. Methods: Retrospective study of patients with bleeding Méthodes: Il s’agit d’une étude rétrospective incluant des patients gastrointestinal angiodysplasia treated with argon plasma ayant des lésions d’angiodysplasies gastro-intestinales electrocoagulation in the digestive endoscopy unit of the military hémorragiques traitées par électrocoagulation au plasma argon hospital in Tunis between January 2000 and December 2011. dans le service de gastro-entérologie de l'hôpital militaire de Tunis Results: 69 patients with a mean age of 68.7 years were included. entre Janvier 2000 et Décembre 2011. L'efficacité de la technique The endoscopic treatment resulted in a rise in hemoglobin value from d'hémostase a été jugée sur les besoins transfusionnels, le taux 7.3 to 9.3 g/ dl (p = 0.0001) and a decrease of transfusion d'hémoglobine avant et après APC et la récidive hemorragique.
    [Show full text]
  • Gastric Angiodysplasia Treated with Argon Plasma Coagulation: a Report of Two Cases
    CASE REPORT 2015; 23(2): 50-52 Gastric angiodysplasia treated with argon plasma coagulation: A report of two cases Argon plazma koagülasyon ile tedavi edilen gastrik anjiodisplazi: İki olgu sunumu Şehmus ÖLMEZ1, Süleyman SAYAR2, Ufuk AVCIOĞLU3, İlyas TENLİK4 1Department of Gastroenterology, Yüzüncü Yıl University School of Medicine, Van 2Department of Gastroenterology, Dr. Ersin Arslan State Hospital, Gaziantep 3Department of Gastroenterology, Koru Hospital, Ankara 4Department of Gastroenterology, Türkiye Yüksek İhtisas Research and Educational Hospital, Ankara Angiodysplasias are rare but important causes of gastrointestinal bleeding Anjiodisplaziler nadir fakat gastrointestinal kanamanın önemli bir sebebidir. thtat are commonly seen in the colon but rarely in the stomach. Although Yaygın olarak kolonda görülmekle birlikte nadir olarak midede de saptanır. various endoscopic modalities are used for the treatment of these lesions, ar- Bu lezyonların tedavisinde farklı endoskopik tedavi yöntemleri kullanıl- gon plasma coagulation is the most commonly used approach. We present a masına rağmen günümüzde argon plazma koagülasyon en sık kullanılan report of two cases of gastric angiodysplasias leading to overt gastrointestinal kullanılan yöntemdir. Burada argon plazma koagülasyon ile başarılı şekilde bleeding, which were successfully treated with argon plasma coagulation. tedavi edilmiş aşikar kanamaya sebep olan iki gastrik anjiodisplazi vakası The procedure is a safe, effective and easy to use modality for the treatment sunuyoruz. Bu lezyonların
    [Show full text]
  • Multicenter Case Series of Patients with Small-Bowel Angiodysplasias Treated with a Small-Bowel Radiofrequency Ablation Catheter
    VIDEO CASE SERIES Multicenter case series of patients with small-bowel angiodysplasias treated with a small-bowel radiofrequency ablation catheter Luis F. Lara, MD,1 Rogelio Silva, MD,2 Shyam Thakkar, MD,3 Peter P. Stanich, MD,1 Daniel Mai, MD,4 Jason B. Samarasena, MD4 Background and Aims: GI angiodysplasia is the most common cause of small-bowel bleeding. Argon plasma coagulation (APC) is preferred for ablation because of its availability, ease of use, and perceived safety, but it has limitations. An instrument capable of repeated use through the enteroscope, which covers more area of in- testinal mucosa per treatment with low risk of damage to healthy mucosa, and which improves ablation, is desir- able. A series of patients treated with a through-the-scope radiofrequency ablation (RFA) catheter is reported. Methods: Patients with a previous diagnosis of small-bowel angiodysplasia (SBA) and ongoing bleeding with me- lena, hematochezia, or iron-deficiency anemia were eligible for treatment. A small-bowel radiofrequency ablation (SBRFA) catheter was passed through the enteroscope instrument channel. The treatment paddle was pushed against the SBA, achieving coaptive coagulation, and the SBA was treated up to 2 times at standard settings of 10 J/cm2. The patients’ demographics, pretreatment and posttreatment hemoglobin levels, time to recurrence of bleeding, and need for more therapy were recorded. This study was approved by the institutional review boards of the respective institutions. Results: Twenty consecutive patients were treated from March until October 2018 and followed up until March 2019. There were 6 women (average age 68 years, standard deviation Æ 11.1), and 14 men (average age 73 years, standard deviation Æ 10.4).
    [Show full text]
  • Argon Plasma Coagulation: Clinical Applications in Gastroenterology
    ANNALS OF GASTROENTEROLOGY 2003, 16(2):131-137 Review Argon plasma coagulation: Clinical applications in Gastroenterology J. Robotis, P. Sechopoulos, Th. Rokkas SUMMARY sue and most importantly in a non-conduct mode. APC has revealed a remarkable spectrum of clinical applica- Argon plasma coagulation (APC) is a method of non-con- tions, raising questions as to whether it should replace tact endoscopic thermal coagulation. According to recent laser in clinical practice. The more gastroenterologists data, it can safely be used in clinical practice and there are familiarize themselves with this technique, the more they indications that APC is undoubtedly preferable to laser appreciate its usefulness. Among its many advantages, treatment in some cases. So, hemostasis of diffuse superfi- the following should be borne in mind: effective and safe cial vascular lesions, such as angiodysplasia, gastric an- coagulation, non-contact mode of action, marked desic- tral vascular ectasias, radiation proctitis, bleeding ulcers cation, no destruction of metal stents, little smoke or and obstructed stents are some of these clinical indications. vapor, easily handled device, lower cost compared to There is a lack of published experience of APC and abla- laser, and finally, no extended safety precautions. tion therapy, such as large villous adenomas, rectal and However, to date, no formal cost-effectiveness study has stomach cancer thus further studies are necessary to de- been published. In this review we summarize the main fine the results and technical details of the procedure. indications of APC in gastrointestinal diseases. We also describe basic physical principles, equipment and tech- Key words: Argon plasma coagulation, clinical indications, nique.
    [Show full text]
  • An Unrecognized Disease in Routine Clinical Practice: the Heyde's
    Emergency Care Journal 2014; volume 10:1649 An unrecognized disease lar subendothelium. The high molecular weight multimers are important for maintain- Correspondence: Raffaele Pezzilli, Department of in routine clinical practice: ing hemostasis during high shear stress, a Digestive Diseases and Internal Medicine, S. the Heyde’s syndrome condition that is found in patients with Orsola-Malpighi University Hospital, via angiodysplastyc malformations.4 Thus, the HS Massarenti 9, 40138 Bologna, Italy. Beatrice Casadei, Valentina Grasso, is a triade constituted by aortic-valve stenosis, Tel. +39.051.6364148 - Fax: +39.051.6364148. E-mail: [email protected] Giulio Cariani, Bahjat Barakat, GI angiodysplasia and deficiency of high- Raffaele Pezzilli molecular-weight von Willebrand factor multi- Key words: aortic stenosis, angiodysplasia, gas- mers. Until now few cases of Heyde’s syn- Department of Digestive Diseases and trointestinal bleeding, Heyde’s syndrome, von drome has been reported and we believe of Willebrand factor. Internal Medicine, S. Orsola-Malpighi interest to add a new case of patient having University Hospital, Bologna, Italy this syndrome. Contributions: the authors contributed equally. Conflict of interests: the authors declare no potential conflict of interests. Abstract Case Report Received for publication: 9 May 2013. Revision received: 28 June 2013. Heyde’s syndrome (HS) is a triade constitut- An 86-year-old female patient was hospital- Accepted for publication: 5 September 2013. ed by aortic stenosis, gastrointestinal angiodys- ized for the second episode of melena within 4 plasia and deficiency of high-molecular-weight months. The patient had a history of scleroder- This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0).
    [Show full text]
  • Treatment of Dieulafoy's Lesion of the Right Colon with Epinephrine
    E192 UCTN – Unusual cases and technical notes Treatment of Dieulafoy’s lesion of the right colon with epinephrine injection and argon plasma coagulation Dieulafoy’s lesion is a tiny submucosal J. L. S. Souza defect overlying an artery in the muscu- Department of Gastroenterology, laris mucosa [1]. Dieulafoy’s lesion of the Diagnostic Center in Gastroenterology, colon is a rare cause of lower gastrointes- University of Sao Paulo, Brazil tinal bleeding [2]. A 63-year-old woman with multiple mye- References loma underwent autologous bone mar- 1 Juler GL, Labitzke HG, Lamb R et al. The pa- row transplantation and after 6 weeks thogenesis of Dieulafoy’s gastric erosion. Am J Gastroenterol 1984; 79: 195 – 200 developed massive hematochezia with 2 Norton ID, Petersen BT, Sorbi D et al. Man- hemodynamic instability. Colonoscopy agement and long term prognosis of Dieula- demonstrated bright red blood in the foy lesion. Gastrointest Endosc 1999; 50: terminal ileum, all of the colon, and the 762 – 767 3 Suzuki N, Arebi N, Saunders BP. A novel rectum (l" Fig. 1). method of treating colonic angiodysplasia. After the area had been washed with wa- Fig. 1 Colonoscopy showing spurting active Gastrointest Endosc 2006; 64: 424– 427 ter, a point of spurting active bleeding bleeding in ascending colon. 4 Calvet X, Vergara M, Brullet E et al. Addition was located in the ascending colon. We of a second endoscopic treatment following injected epinephrine and the bleeding epinephrine injection improves outcome in high risk bleeding ulcers. Gastroenterology stopped; identification of a minute muco- 2004; 126: 441– 450 l" sal defect was then possible ( Fig.
    [Show full text]
  • The Incidence of Bacteraemia After Argon Plasma Coagulation in Patients with Chronic Radiation Proctocolitis
    Original article doi:10.1111/j.1463-1318.2010.02279.x The incidence of bacteraemia after argon plasma coagulation in patients with chronic radiation proctocolitis L. Lenz*§, J. Tafarel*, L. Correia*, D. Bonilha*, M. Monaghan†, M. Santos*, G. Gomes*, F. Martins‡, F. Nakao*§, E. Libera*§, R. Rohr*§ and A. P. Ferrari‡ *Universidade Federal de Sa˜o Paulo, Sa˜o Paulo, Brazil, †King’s Colllege London School of Medicine, London, UK, ‡Hospital Israelita Albert Einstein, Sa˜o Paulo, Brazil and §Fleury Medicina e Sau´de, Sa˜o Paulo, Brazil Received 12 December 2009; accepted 2 March 2010; Accepted Article online 6 April 2010 Abstract Aim Argon plasma coagulation (APC) is considered a All baseline blood cultures were negative and two safe treatment for haemorrhagic chronic radiation proc- (7%) of the 30-min blood cultures were positive tocolitis (CRPC), but bacteraemia is a rare complication. (Staphylococcus hominis n =1; Streptococcus bovis and The study aimed to evaluate the frequency of bacteraemia Rhodotorula sp n = 1). The first was likely to be a after APC. contaminant and the second patient had no evidence of any other colonic disease (neoplasia or polyps) beside Method A prospective study of 21 patients who under- CRPC. went APC (30 procedures) for CRPC was carried out. Blood cultures (BactecÒ) were obtained before and Conclusion APC is a low-risk procedure regarding 30 min after the procedure (60 samples total). Patients bacteraemia and does not warrant prophylactic antibiotic were monitored for 48 h after the procedure to detect administration. signs of infection. Keywords Bacteremia, argon plasma , chronic radiation Results None of the 21 patients had fever or any proctocolitis sign suggestive of infection after any of the 30 sessions.
    [Show full text]