Video Endoscopic Sequence 1 of 17.

Multiple Gastric Angiodysplasias

This 91-year old lady had medical history of multiple hospitalizations, her family reported that she had at least 20 hospitalizations at another hospital (public) due to upper gastrointestinal bleeding, patient is refered to our endoscopic unit for evaluation and therapeutic treatment.

Angiodysplasia is ectasia of intestinal submucosal veins and overlying mucosal capillaries. Lesions occur most often in the stomach, followed by the duodenum. Most lesions are less than 10mm in size, and multiple lesions are frequent. Concomitant lesions in the colon occur in 1/3 of cases. Anatomic clustering of acquired or sporatic angiodysplasia is a well described observation.

For more endoscopic details download the video clips by clicking on the endoscopic images, wait to be downloaded complete then press Alt and Enter; thus you can observe the video in full screen.

All endoscopic images shown in this Atlas contain
video clips.

Video Endoscopic Sequence 2 of 17.

Endoscopic View of Multiple Gastric Angiodysplasias

The endoscopic image as well as the video clip show multiple angiodysplasias.

Gastric angiodysplasia is associated with several systemic diseases, most notably hereditary hemorrhagic telangiectasia (HHT), or Rendu-Osler-Weber syndrome.

The first approach to therapy should be to replace and maintain iron. Endoscopic control of bleeding lesions (sclerotherapy, contact probes, and lasers) is well described but the recurrent bleeding rate is high.

Video Endoscopic Sequence 3 of 17.

Image of Multiple Gastric Angiodysplasias

This is a large submucosal vassel that seem to be ulcerated

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.

Video Endoscopic Sequence 4 of 17.

Mallory-Weiss tears occurring during endoscopy

Due to the age of the patient the anestesiologist administered little amount of sedatives so the endoscopic procedure was suspended for a moment because patient iniciates with nausea and vomiting causing this image

Mallory-Weiss tears occurring during the course of upper gastrointestinal endoscopy are apparently rare, Iatrogenic Mallory-Weiss tears are rare and generally have a benign course. They tend to occur mostly in patients who have experienced excessive retching or struggling during endoscopy. Mallory-Weiss tears complicating endoscopy occur especially in elderly, female patients with hiatal hernias.

Video Endoscopic Sequence 5 of 17.

Mallory-Weiss tears occurring during endoscopy

Video Endoscopic Sequence 6 of 17.

Multiple Gastric Angiodysplasias

The argon plasma therapy is initiated

Vascular anomalies associated with congenital or systemic diseases, such as blue rubber bleb nevus syndrome, Klippel-Trenaunay-Weber syndrome, Ehlers-Danlos syndrome, the CREST variant of scleroderma, and hereditary hemorrhagic telangiectasia (Osler-Weber -Rendu syndrome).

Acquired and sporadic lesions, such as angiodysplasias, gastric antral vascular ectasia, radiation-induced vascular ectasias, and Dieulafoy's lesions.

Angiodysplasias are by far the most common vascular anomalies encountered in the gastrointestinal tract. This topic review will cover the pathogenesis and clinical issues arising from these lesions. One of the most common complications associated with angiodysplasias is bleeding, which is often occult.

Video Endoscopic Sequence 7 of 17.

Argon plasma coagulation or APC is a medical endoscopic procedure used primarily to control bleeding from certain lesions in the gastrointestinal tract,

PATHOGENESIS — Angiodysplasias are composed of ectatic, dilated, thin-walled vessels that are lined by endothelium alone or by only small amounts of smooth muscle. Their anatomy has been best demonstrated by studies in which casts of the vessels were made by injecting a silicone material. These studies demonstrated that the most prominent feature in angiodysplasias are dilated tortuous submucosal veins. Small arteriovenous communications are present due to incompetence of the precapillary sphincter. Enlarged arteries are also present in bigger angiodysplasias and may be associated with arteriovenous fistulas, which explains why bleeding can be brisk in some patients.

Video Endoscopic Sequence 8 of 17.

Histologic examination demonstrates dilated vessels in the mucosa and submucosa, sometimes covered only by a single layer of surface. These features are shared by angiodysplasias in the colon and stomach.

The pathogenesis of angiodysplasias is not well understood.

Video Endoscopic Sequence 9 of 17.

Multiple Gastric Angiodysplasias

A pulsaltile vassel is observed

CLINICAL MANIFESTATIONS — Angiodysplasias can remain clinically silent or cause bleeding. Patients who bleed typically present with occult blood loss and are more likely than other patients with gastrointestinal bleeding to have had prior admissions for gastrointestinal bleeding. However, marked acute bleeding, causing orthostasis or hypotension, can occur.

Video Endoscopic Sequence 10 of 17.

Image and video clip of Multiple Gastric Angiodysplasias

Control of bleeding was achieved by argon plasma therapy in the vessel.

Video Endoscopic Sequence 11 of 17.

CLASSIFICATION — The terms "angiodysplasias," "arteriovenous malformations," and "vascular ectasias" have been used synonymously. Angiodysplasias are usually distinguished from telangiectasias, which, although anatomically similar, are usually referred to in the context of systemic or hereditary diseases.

Since most vascular abnormalities are detected during endoscopy, a taxonomy based upon endoscopi appearance has been proposed. The classification system recognizes the location, size, and number of angiodysplasias.

Video Endoscopic Sequence 12 of 17.

Multiple Gastric Angiodysplasias

Most angiodysplasias are detected in patients older than 60 , although presentation in patients in their 30s has been described . They may be asymptomatic or cause occult or overt gastrointestinal bleeding.

Video Endoscopic Sequence 13 of 17.

Multiple Gastric Angiodysplasias

More than one angiodysplasia is present in approximately 40 to 60 percent of patients] . These lesions tend to be clustered within intestinal segments, suggesting that the local environment predisposes to their development. However, synchronous lesions exist elsewhere in the gastrointestinal tract in approximately 20 percent of patients.

Video Endoscopic Sequence 14 of 17.

Endoscopy of Multiple Gastric Angiodysplasias

There are more small lesions.

CONDITIONS WITH INCREASED PREVALENCE — The prevalence of angiodysplasias is increased in older populations, those with gastrointestinal bleeding, and those with certain predisposing conditions such as end-stage renal disease.

End-stage renal disease — Angiodysplasia is the second most common cause of gastrointestinal bleeding in elderly patients with end-stage renal disease. These lesions account for about 20 and 30 percent of upper and lower gastrointestinal bleeds, respectively, and approximately one-half of recurrent upper gastrointestinal bleeds. They can occur anywhere along the gastrointestinal tract and are usually multiple.

Video Endoscopic Sequence 15 of 17.

Multiple Gastric Angiodysplasias

Vascular lesions of the gastrointestinal tract are clinically highly relevant, and are a common cause of gastrointestinal bleeding. Among these lesions, gastrointestinal angiodysplasia is frequently encountered, whereas Dieulafoy lesion and gastric antral vascular ectasia (GAVE) are less common. An understanding of the other described lesions is important, despite their rarity, because they are frequently misdiagnosed and mistreated. For example, historically most rectal hemangiomas were misdiagnosed and mistreated as internal hemorrhoids.

Video Endoscopic Sequence 16 of 17.

Multiple Gastric Angiodysplasias

Again endoscopy therapy with argon plasma coagulation

Video Endoscopic Sequence 1 of 3.

Gastric Angiodysplastic lesions and argon plasma coagulation treatment.

Gastric Angiodysplastic lesions may be encountered at any location, but they tend to occur primarily within the corpus. The tree images and video display ablative therapy with argon plasma coagulation APC.

Video Endoscopic Sequence 2 of 3.

Gastric Angiodysplastic lesions with argon plasma coagulation treatment.
Argon plasma coagulation (APC) is a method ofcauterizing the vascular abnormality using a non-contact probe.

Video Endoscopic Sequence 3 of 3.

Gastric Angiodysplastic lesions with argon plasma coagulation treatment.

Argon Plasma Coagulation has been used for more than 10 years in open surgery, laparoscopy and Thoracoscopy, especially for hemostasis of large surface bleeding. It conducts monopolar electrosurgical current to tissue via an ionized argon gas stream (argon plasma).