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Acute bleeding from angiodysplasia of the cecum

A 73-year-old female t who was referred to our endoscopic unit by her geriatrician due to recurrent enterorrhagia of 4 months, who was admitted twice to a private hospital The first time for ten days and Two months later, she was readmitted for 7 days, despite the fact that on this occasion they performed a colonoscopy, removing a polyp from the sigmoid colon and finding diverticula, but the bleeding had continued and was profuse. We performed a complete colonoscopy up to the cecum, finding the exact cause of the bleeding. in the cecum. A bleeding angiodysplasia less than 1 mm in diameter. Patient undergoes a therapeutic colonoscopy.

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After washing with pressurized water, acute bleeding from angiodysplasia is seen. Due to the force of the bleeding, we can think that it is a Dieulafoy’s lesion.

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The exact site of bleeding is observed, a lesion with fibrin of 1 mm,

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Angiodysplasia of the Cecum. Hemostatic maneuvers are performed, first ablative therapy with argon plasma coagulator.

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Two hemoclips are applied

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Final status of hemostatic therapy, first hemostasis with argon plasma coagulator and then reinforced with two hemoclips.

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Cecum Angiodysplasia

This a 58 year-old, male who for two years
He had been admitted four times in a national social security hospital for lower GI bleeding.
In each hospitalization had transfused six units of blood,I had had several previous colonoscopies including endoscopic capsule.

The patient came at our unit for another opinion.

A colonoscopy was performed finding this angiodysplasia of the cecum.

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Endoscopic image of angiodysplasia of the cecum close to the appendix hole is observed.

Possibly the first colonoscopy had not reached the cecum or poor bowel preparation.Therefore had not had detected, in such hospitalizations elsewhere.

Due to recurrent re-bleeding we have succeeded in this therapy combination therapy with absolute alcohol infiltration injections and then argon plasma coagulation coagulator.

See Chapter Hereditary Hemorrhagic Telangiectasia, where we use similar therapy in another angiodysplasia of the cecum near of the appendix hole, without any recurrence as in this case.

Aberrant blood vessels are frequently found in the gastrointestinal tract, where they are probably more common than anywhere else in the body. Some are present from birth or develop as part of inherited syndromes, but the vast majority are acquired later in life. The reasons for the distortion of vascular structures observed with advancing age are poorly understood.

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Therapeutic endoscopy begins with injections of absolute alcohol.
Because these lesions can be recurrent. We practice combined therapy with absolute alcohol and electrocoagulation with argon plasma coagulator. (APC).

Argon plasma coagulation (APC) is a non-contact thermal method of hemostasis that has generated much attention and excitement in recent years. It was introduced as an alternative to contact thermal coagulation (heater probe and bipolar cautery) and to existing non-contact technologies (primarily laser). The theoretical advantages of APC include its ease of application, speedy treatment of multiple lesions in the case of angiodysplasias or wide areas (the base of resected polyps or tumor bleeding), safety due to reduced depth of penetration, and lower cost compared to laser.

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Image and video clip of Cecum Angiodysplasia

Image and Video of combination therapy with absolute alcohol and electrocoagulation with argon plasma coagulator. (APC).

Pathophysiology: Classically described in the colon, angiodysplasia can occur throughout the gastrointestinal tract. There may be multiple angiodysplasias in one gastrointestinal region or they may coexist in several different gastrointestinal locations.

Morphology — Angiodysplasias are composed of ectatic, dilated, thin-walled vessels that are lined by endothelium alone or endothelium along with small amounts of smooth muscle. Studies in which casts of angiodysplasias were made by injecting a silicone material demonstrated that the most prominent feature in angiodysplasias is the presence of dilated, tortuous submucosal veins.

Small arteriovenous communications are also present and are due to incompetence of the precapillary sphincter. Enlarged arteries may be seen in larger angiodysplasias and may be associated with arteriovenous fistulas, which explains why bleeding can be brisk in some patients

Histologic confirmation is often difficult. When obtained, it shows dilated vessels in the mucosa and submucosa, sometimes covered by only a single layer of surface epithelium.

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Angiodysplasias characteristically appear as small (5 to 10 mm), flat, cherry red lesions with a fern-like pattern of arborizing, ectatic blood vessels radiating from a central vessel The characteristic appearance may be more evident in the colon. Small intestinal lesions are often smaller than those seen in other parts of the GI tract. The fern-like pattern should be specifically looked for, since other erythematous mucosal lesions or normal blood vessels can be mistaken for angiodysplasias.

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Endoscopic treatment — A variety of endoscopic treatments can be used to treat angiodysplasia, with approaches employing cautery being the most widely used. The approach that is chosen depends upon the location and mode of access to the lesion, the experience of the endoscopist, and the availability of equipment. Endoscopic therapy should be performed cautiously in the right colon, which is thin-walled and more likely to perforate during treatment than other sections of the gastrointestinal tract. It has been estimated that following endoscopic therapy, approximately one-third of patients with angiodysplasia will experience rebleeding after a mean of 22 months. However, a higher rebleeding rate has been noted in the subgroup of patients with small bowel angiodysplasia.

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Argon plasma coagulation — Argon plasma coagulation (APC) uses high frequency energy transmitted to tissue by ionized gas. This technique has been used for a variety of bleeding lesions, including angiodysplasia. APC is safe and is the most common and most successful method used to treat angiodysplasia, especially in the right colon. Its popularity is due to its ease of use (especially for large superficial lesions), low cost, and reported limited depth of coagulation, although the depth of coagulation may be deeper than is commonly reported.

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Effectiveness — Determining the impact of treatment for angiodysplasia is difficult due to the variable natural history of angiodysplasia and the inconsistent impact that bleeding can have on quality of life.

Patients with bleeding diatheses have worse outcomes, regardless of the therapy employed, if the underlying coagulation defect cannot be reversed. Because endoscopic electrocoagulation can result in worsening bleeding in patients with a coagulopathy, we favor a mechanical hemostatic method, such endoscopic clips, if the coagulation defect cannot be corrected.

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Status Final of the therapy.

After a year there has been no recurrence of bleeding, after two years there was no recurrence.

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Cecum Angiodysplasia

This is a 55 year-old lady, has been hospitalized 6 times in a period of 2 years, in a hospital of the seguro
social in San Salvador because of hematoquezia

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Endoscopic Image of Angiodysplasia of the cecum

Also called angiodysplasia, arteriovenous malformation

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Absolute Alcohol Injection

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Therapy with Absolute Alcohol Injection in the Angiodysplasia of the cecum

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Therapy with Absolute Alcohol Injection in the Angiodysplasia of the cecum

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Absolute Alcohol Injection

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Therapy with Absolute Alcohol Injection in the Angiodysplasia of the cecum

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A Combined Therapy with absolute alcohol and argon plasma coagulator APC is performed.

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Final Status after a colonic angiodysplasia therapy.

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Image and video clip of a Angiodysplasia of the Cecum

This a 78 year-old lady that had multiple episodes of enterorrhagia.

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Colonic Angiodysplasia

Angiodysplasia is a degenerative lesion of previously healthy blood vessels found most commonly in the cecum and proximal ascending colon. Seventy-seven percent of angiodysplasias are located in the cecum and ascending colon, 15% are located in the jejunum and ileum, and the remainder is distributed throughout the alimentary tract. These lesions typically are nonpalpable and small (< 5 mm).

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Colon Angiodysplasia

Angiodysplasia is the most common vascular lesion of the gastrointestinal tract, and this condition may be asymptomatic, or it may cause gastrointestinal (GI) bleeding.

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Therapy with Argon Plasma coagulator in Colonic Angiodysplasia.

Personally I prefer the combination of two therapeutic methods using injections of absolute alcohol and argon plasma coagulator, As in other cases here presented in this atlas.

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Colon Angiodysplasia and Multiple Myeloma

This is a 63 year-old male, previously admitted on 4 different occasions for massive lower gastrointestinal bleeding, needing multiple blood transfusions. He is referred to our unit for evaluation. Findings included multiple arterial malformations compatible with cecal Angiodysplasia. Sessions with argon plasma coagulation were initiated. 10 days after therapy patient presents with a new episode of massive lower gastrointestinal bleeding, again requiring multiple blood transfusions. New colonoscopy revealed ulcerated nodules in ascending colon not visualized on previous colonoscopy, raising clinical suspicion of a paraneoplasic syndrome. Chest, abdominal, and pelvic CT were normal. Alcaline phosphatase and serum creatinine levels were normal. During the night, a sudden jerk of the left arm produced a pathological fracture of the left humerus. Pictures below.

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Angiodysplasia is the most common vascular lesion of the gastrointestinal tract, and this condition may be asymptomatic, or it may cause gastrointestinal (GI) bleeding. The vessel walls are thin, with little or no smooth muscle, and the vessels are ectatic and thin.

Colonic angiodysplasia occurs in approximately 1% of the adult population and is one of the most common causes of massive lower GI bleeding in patients over the age of 65. The lesions seen here are typical cecal angiodysplasia. While angiodysplasia can be found anywhere along the colon, significant bleeding occurs most frequently from those lesions located in the cecum.

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Angiodysplasia is a degenerative lesion of previously
healthy blood vessels found most commonly in the cecum
and proximal ascending colon. Seventy-seven percent of
angiodysplasias are located in the cecum and ascending
colon, 15% are located in the jejunum and ileum, and the
remainder is distributed throughout the alimentary tract.
These lesions typically are nonpalpable and small (<5 mm).

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Ablative Therapy with Argon Plasma

Argon plasma coagulation (APC) has been adopted into general gastrointestinal practice as an effective and theoretically safer approach to cauterization. The advantage of APC is a decreased depth of penetration and a tendency for the ionized arc of electrical current to deflect away from coagulated tissue to surrounding areas making complications such as intestinal perforation rare.

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The exact mechanism of development of angiodysplasia is not known, but chronic venous obstruction may play a role. This hypothesis accounts for the high prevalence of these lesions in the right colon and is based on the Laplace law. The Laplace law relates wall tension to luminal size and transmural pressure difference in a cylinder, whereby the wall tension is equal to the pressure difference multiplied by the radius of the cylinder. In the case of the colon, wall tension refers to intramural tension, the pressure difference is that between the bowel lumen and the peritoneal cavity, and cylinder radius is the radius of the right colon. Wall tension is highest in bowel segments with the greatest diameter, such as the right colon.

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Ten days after the therapy with argon plasma, patient presents with a new episode of massive lower gastrointestinal bleeding, again requiring multiple blood transfusions.

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Colon Plasmacytoma

A new colonoscopy revealed ulcerated nodules in ascending colon not visualized on previous colonoscopy, raising clinical suspicion of a paraneoplasic syndrome.

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A submucous mass is detected in the ascending colon that could be compatible with lipoma or amiloide deposit due to the multiple myeloma.

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The cecum is displayed with ulcers due to a previous therapy with APC.

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This ulcer is consequence of the preious therapy with APC, 10 day ago.

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The ulcer was managed with hemoclip and infiltration of
absolute alcohol achieving the hemostasia.

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Left Humerus with pathologic fracture due to a multiple myeloma.

To enlarge the image in a new windows click on it.

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Radiographic survey demonstrates lytic lesions

The preferred initial radiographic examination for the staging and diagnosis of myeloma remains the skeletal survey. Patients suspected of having multiple myeloma based on bone marrow aspirate results or hypergammaglobulinemia should undergo a radiographic skeletal survey. Conventionally, this skeletal survey has consisted of a lateral radiograph of the skull, anteroposterior (AP) and lateral views of the spine, and AP views of the pelvis, ribs, femora, and humeri. Inclusion of these bones is important for both staging and diagnosis.

The finding of more than one lytic lesion in a patient with myeloma indicates stage III disease. Focused examinations of newly painful bones are of value in assessing for impending pathologic fracture.

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Radiograph of the left humerus. This image demonstrates a destructive lesion of the diaphysis. Pathologic fracture is seen.

In one third of patients, MM is diagnosed after a pathologic fracture occurs; as it did happens in our patient, such fractures commonly involve the axial skeleton.

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Lateral radiograph of the skull. This image demonstrates numerous lytic lesions, which are typical for the appearance of widespread myeloma.

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Multiple myeloma is the most common primary neoplasm of the skeletal system. The disease is a malignancy of plasma cells. Radiologically, multiple destructive lesions of the skeleton as well as severe demineralization characterize multiple myeloma. The etiology of the disease is the monoclonal proliferation of B cells, with a resultant increase of a single immunoglobulin and its fragments in the serum and urine. Electrophoretic analysis shows increased levels of immunoglobulins in the blood as well as light chains (Bence-Jones protein) in the urine.

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Multiple Myeloma.

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Multiple Myeloma.

Bone marrow biopsy demonstrating sheets of malignant plasma cells in multiple myeloma.

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Multiple Myeloma.

The presentation of multiple myeloma can range from asymptomatic to severely symptomatic with complications requiring emergent treatment. Systemic ailments include bleeding, infection and renal failure; local catastrophes include pathologic fractures and spinal cord compression. Although patients benefit from treatment (ie, longer life, less pain, fewer complications), currently no cure exists. Recent advances in therapy have helped to lessen the occurrence and severity of adverse effects of multiple myeloma.

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Colon Angiodysplasia

This is a 91 year-old female in a colonoscopy was found two asymptomatic angiodysplasias, near to the ileocecal valve, also in the sigmoid colon has some areas of diverticulitis.

Incidentally found lesions — Angiodysplasia that is detected during screening colonoscopy should not be treated.

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Multiple Colonic Angiodysplasias

A 70-year-old female, was referred to our endoscopic unit for a colonoscopy, in which several angiodysplasias and irregularity of the vascularization of the ascending colon and hepatic angle were observed. In posterior endoscopy, varices of the esophagus are found.

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Multiple angiodysplastic lesions of the colon

Associated diseases: Angiodysplasias have been reported with high frequency in patients with aortic stenosis, renal insufficiency, von Willebrand disease, cirrhosis and pulmonary disease.

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Multiple angiodysplastic lesions of the colon

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Multiple angiodysplastic lesions of the colon

Three angiodysplasias are displays

Angiodysplasia may present as an isolated lesion or as multiple vascular lesions.