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Angiodysplasia: Current Concepts Postgrad Med J: first published as 10.1136/pgmj.64.750.259 on 1 April 1988. Downloaded from Postgraduate Medical Journal (1988) 64, 259-263 Review Arficle Angiodysplasia: current concepts Anne P. Hemingway Professor ofDiagnostic Radiology, Sheffield University, Sheffield, UK. Angiodysplasia is a condition of unknown aetiology diagnosis of angiodysplasia, establishing that it is in which microvascular abnormalities are found in the cause of the blood loss. the mucosa and submucosa of the bowel wall. The lesions are found predominantly in the caecum and right side of the colon and are frequently associated How common? with either intermittent acute or continuous chronic intestinal blood loss. There is no family history and It has been stated that angiodysplasia may no recognized association with vascular abnor- represent the commonest single cause of obscure malities of the skin or other organs. The lesions of gastrointestinal bleeding in the elderly population.4 angiodysplasia which are small (less than 5mm) Indeed a number of series have established that in and usually multiple are diagnosed by selective patients undergoing visceral angiography in the visceral angiography and/or colonoscopy but investigation of obscure gastrointestinal bleeding cannot be detected on barium enema or by the the most commonly detected abnormality is angio- naked eye at laparotomy. Localization by the histo- dysplasia.5 6 In our own published series,5 angio- copyright. pathologist is greatly facilitated by special injection dysplasia was diagnosed in 40% of patients techniques demonstrating the blood vessels of examined. It must be remembered however that resected colonic specimens prior to fixation and patients undergoing angiography represent a highly section. The lesions are thought to represent a selected group since the cause of gastrointestinal distinct benign pathological entity characterized in haemorrhage will be identified by routine their early stage by dilated tortuous submucosal investigations in between 80% and 95% of cases.7 veins. In the more advanced stages there is further Angiodysplasia without doubt represents the dilatation of the submucosal veins and venules commonest cause of bleeding in the residual 5 to http://pmj.bmj.com/ and capillaries.' These characteristic features of right 20% of patients. Extrapolating from these figures it colonic vascular ectasias correspond to the can be seen that angiodysplasia accounts for definition given by Gentry et al.2 of telangectasias, between 2% and 8% of all patients presenting with i.e. dilatation of pre-existing vascular structures. gastrointestinal bleeding. This estimate is supported Galdabini in 19743 first used the term 'angio- by the work of Richter et al.8 who diagnosed dysplasia' to describe the pathological abnormality angiodysplasia colonoscopically in 26 patients, in a found in a patient who presented with what is now period when 1044 patients were colonoscoped for on September 26, 2021 by guest. Protected recognized as a characteristic history' and the angio- bleeding, a prevalence of 2.6%. The same group of graphic features of the condition defined above. workers detected the lesion in 13 patients out of a There are two main clinical problems related to group of 1400 examined for reasons other than angiodysplasia; firstly, the fact that true prevalence bleeding, a prevalence of 1.4%. Three principal in of the condition in the general population is vitro studies have been performed in an attempt to unknown and secondly the difficulty in detecting address the question of the incidence of angio- the disorder in patients with gastrointestinal dysplasia in the general population.4'9"0 In one bleeding of uncertain origin and, having made the study employing an injection/radiography technique,9 no lesions were detected in 39 autopsy specimens. Correspondence: Professor A.P. Hemingway B.Sc., M.B., The other two studies employed an injection and B.S., M.R.C.P., D.M.R.D., F.R.C.R., Floor P, Royal clearing technique followed by examination using Hallamshire Hospital, Glossop Road, Sheffield S1O 2JF, trans-illumination and microscopy and both groups UK found lesions in up to 50% of specimens examined. Received: 28 October 1987 We have recently reviewed over 450 visceral © The Fellowship of Postgraduate Medicine, 1988 Postgrad Med J: first published as 10.1136/pgmj.64.750.259 on 1 April 1988. Downloaded from 260 A.P. HEMINGWAY angiograms performed for reasons other than advocate that the colon should be distended with gastrointestinal bleeding. Out of 166 patients in air at the time of angiography and that direct serial whom the caecum and the right colon were magnification radiography should be used to adequately visualized the characteristic features of improve the chances of detection of these lesions. angiodysplasia were detected in 6 (3.6%). It is clear We have not employed these techniques in our from the wide variation in these figures that further institution, finding that selective catheterization, the research is necessary to establish the true prevalence use of adequate volumes of contrast media and of angiodysplasia in the non-bleeding population. high quality radiography are the most important factors. An important point to note is that the Diagnosis angiographic features of angiodysplasia can be mimicked by other conditions including inflam- The second major clinical problem relating to matory bowel disease, such as Crohn's disease, and angiodysplasia is its recognition and this affects malignancy and the possible existence of these three groups of medical practitioner: clinicians alternative pathologies should not be ignored. If (physicians and surgeons), radiologists and angiography suggests the diagnosis of angio- pathologists. These problems are summarized in dysplasia then other disease must be excluded by Table I. colonoscopy, barium enema or even laparotomy. It would seem that when both angiography and colonoscopy are available to a clinician then it is advantageous to utilize both techniques to make a Treatment positive diagnosis of angiodysplasia and exclude other pathology. Once the diagnosis of angiodysplasia has been The radiologist having accepted a patient for made the clinician is faced with the question of angiography must perform a 3-vessel study of high treatment. Having excluded malignant disease, and quality (i.e. coeliac, superior mesenteric and inferior if the blood loss is not severe, simple supportive mesenteric examinations). The characteristic features treatment for the anaemia may be adequate. If copyright. of angiodysplasia include vascular tufts visualized the lesions are small in number colonoscopic in the arterial phase, an early filling draining vein fulguration is, in experienced hands, readily and a slowly emptying, dilated, tortuous intramural performed, relatively non-invasive and easily vein. In our institution we normally require at least repeated. When the disease is more extensive, or two of these three features to be present before the other methods are failing to control the anaemia diagnosis is suggested (Figure 1). Angiodysplasia then surgical resection is the treatment of choice. can only definitely be implicated as the cause of Laparotomy also allows the surgeon the chance to blood loss if the lesions are seen to be actively detect or exclude the presence of other lesions http://pmj.bmj.com/ bleeding at the time of the study. Some authorities which may be the cause of the bleeding. In our own Table I Problems relating to the diagnosis and management of angiodysplasia The clinician's problems The radiologist's problems The pathologist's problems (i) Awareness of condition (i) Awareness of condition (i) Awareness of condition on September 26, 2021 by guest. Protected (ii) Mode of presentation (ii) Selection of patients for (ii) Identification of lesion(s) in angiography specimen (iii) Proof of the presence of (iii) Performing an adequate (iii) Classification of abnormality angiodysplasia angiogram (iv) Proof that angiodysplasia is (iv) Interpreting the angiogram causative lesion (v) Management decisions (v) Post-resection specimen radiography (vi) Lack of visibility of lesion at surgery Postgrad Med J: first published as 10.1136/pgmj.64.750.259 on 1 April 1988. Downloaded from ANGIODYSPLASIA 261 a copyright. Figure la & b A selective ileocolic subtraction arteriogram. In the arterial phase (a) a prominent vessel is seen supplying the antimesenteric border of the caecum (arrow). In the venous phase (b) vascular lakes can be seen on the antimesenteric border (arrow); there is a prominent 'intramural' vein (arrow head) and a large draining vein (curved arrow). http://pmj.bmj.com/ series, over 20% of patients who underwent Non-colonic angiodysplasia laparotomy were found to have a second lesion which could have been responsible for the blood Traditionally the term angiodysplasia has only been loss.' I used to describe lesions found in the colon. Pathological confirmation of angiodysplasia in a Recently similar vascular abnormalities have been resected specimen may be difficult. The lesions are diagnosed by both endoscopy and angiography in very small, not detectable by the naked eye and it is the stomach'13"4 and small intestine.15 The on September 26, 2021 by guest. Protected impossible for a pathologist to section the entire occurrence of the condition at these sites is less specimen. Injection of the specimen with either a common and it is important to be certain that barium gelatin mixture or latex material allows the
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