Angiodysplasia medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nikita Singh, M.B.B.S.[2]
Overview
Treatment is not required for incidentally found, asymptomatic, non-bleeding lesions. However, it is considered for non-bleeding angiodysplasia with symptoms of occult or overt GI bleed. The invasiveness of therapy depends on the clinical severity of anemia, hemodynamic stability, and recurrence of symptoms. Although endoscopic techniques are the first choice, hormonal therapy, thalidomide, and octreotide are the pharmacological options that have been tried for patients with significant co-morbidities who cannot undergo invasive procedures.
Medical Therapy
- Pharmacological options like hormonal therapy, thalidomide, and octreotide have been tried in patients with significant co-morbidities who cannot undergo invasive procedures.
- Studies have shown hormonal therapy with ethinylestradiol and norethisterone vs placebo have no difference in outcomes.[1] However, a few case series have shown positive results regarding the efficacy of hormonal therapy in chronic renal failure patients.[2]
- Thalidomide inhibits angiogenesis by inhibiting vascular endothelial growth factor (VEGF)- and basic fibroblast growth factor (bFGF)-induced angiogenesis.[3] It has been reported to be effective in the management of chronic bleeding from angiodysplasia as well as reduction in the number and size of lesions.[4][5][6][7]
- Long-acting octreotide has been used to treat chronic bleeding due to angiodysplasia in elderly patients.[8]
Endoscopic Therapy
- Endoscopic techniques are the therapy of choice for angiodysplasia.
- Argon plasma coagulation (APC): Most widely used endoscopic method for the treatment of angiodysplasia that uses high frequency electric current and ionised argon gas.[9] It is a safe and effective method of treating gastrointestinal vascular lesions.[10]
- Electrocoagulation: This technique of using thermal energy to coagulate the lesions is no longer recommended due to risk of severe complications including bowel perforation.[11]
- Photocoagulation: Uses Nd:YAG (neodymium:yttrium-aluminium-garnet) and argon laser for photoablation of the lesions. This technique is mainly used for gastric antral vascular ectasia. Disadvantages include risk of perforation, uneconomical, and requirement of specialist expertise.[12][13]
- Endoscopic clips: Endoclips can be used to obliterate the feeder vessels in large colonic lesions to achieve mechanical hemostasis. Subsequent cauterization with APC is helpful to prevent re-bleeding.[14]
- Endoscopic ligation: Endoscopic band ligation is a safe and effective method to achieve hemostasis in acute non-variceal upper GI bleeding. Long-term efficacy is currently not known.[15][16][17]
Transcatheter Angiography and Intervention (TAI)
- This method is used for patients who fail endoscopic therapy or who are not good surgical candidates. This method can also be used to localize the site of active bleeding prior to surgery.
- Embolization is now preferred over local vasoconstrictive therapy with vasopressin infusion due to high risk of ischemia.[18]
- Superselective catheterization and subsequent transcatheter embolization with gelatine sponges and microcoils is currently the most effective means to control actively bleeding angiodysplastic lesions.[19]
References
- ↑ Junquera F, Feu F, Papo M, Videla S, Armengol JR, Bordas JM; et al. (2001). "A multicenter, randomized, clinical trial of hormonal therapy in the prevention of rebleeding from gastrointestinal angiodysplasia". Gastroenterology. 121 (5): 1073–9. doi:10.1053/gast.2001.28650. PMID 11677198.
- ↑ Bronner MH, Pate MB, Cunningham JT, Marsh WH (1986). "Estrogen-progesterone therapy for bleeding gastrointestinal telangiectasias in chronic renal failure. An uncontrolled trial". Ann Intern Med. 105 (3): 371–4. doi:10.7326/0003-4819-105-3-371. PMID 3488703.
- ↑ Chen HM, Ge ZZ, Liu WZ, Lu H, Xu CH, Fang JY; et al. (2009). "[The mechanisms of thalidomide in treatment of angiodysplasia due to hypoxia]". Zhonghua Nei Ke Za Zhi. 48 (4): 295–8. PMID 19576118.
- ↑ Heidt J, Langers AM, van der Meer FJ, Brouwer RE (2006). "Thalidomide as treatment for digestive tract angiodysplasias". Neth J Med. 64 (11): 425–8. PMID 17179574.
- ↑ Almadi M, Ghali PM, Constantin A, Galipeau J, Szilagyi A (2009). "Recurrent obscure gastrointestinal bleeding: dilemmas and success with pharmacological therapies. Case series and review". Can J Gastroenterol. 23 (9): 625–31. doi:10.1155/2009/862816. PMC 2776553. PMID 19816627.
- ↑ Kamalaporn P, Saravanan R, Cirocco M, May G, Kortan P, Kandel G; et al. (2009). "Thalidomide for the treatment of chronic gastrointestinal bleeding from angiodysplasias: a case series". Eur J Gastroenterol Hepatol. 21 (12): 1347–50. doi:10.1097/MEG.0b013e32832c9346. PMID 19730385.
- ↑ Bauditz J, Lochs H, Voderholzer W (2006). "Macroscopic appearance of intestinal angiodysplasias under antiangiogenic treatment with thalidomide". Endoscopy. 38 (10): 1036–9. doi:10.1055/s-2006-944829. PMID 17058171.
- ↑ Orsi P, Guatti-Zuliani C, Okolicsanyi L (2001). "Long-acting octreotide is effective in controlling rebleeding angiodysplasia of the gastrointestinal tract". Dig Liver Dis. 33 (4): 330–4. doi:10.1016/s1590-8658(01)80087-6. PMID 11432511.
- ↑ Vargo JJ (2004). "Clinical applications of the argon plasma coagulator". Gastrointest Endosc. 59 (1): 81–8. doi:10.1016/s0016-5107(03)02296-x. PMID 14722558.
- ↑ Suzuki N, Arebi N, Saunders BP (2006). "A novel method of treating colonic angiodysplasia". Gastrointest Endosc. 64 (3): 424–7. doi:10.1016/j.gie.2006.04.032. PMID 16923494.
- ↑ Asge Technology Committee. Conway JD, Adler DG, Diehl DL, Farraye FA, Kantsevoy SV; et al. (2009). "Endoscopic hemostatic devices". Gastrointest Endosc. 69 (6): 987–96. doi:10.1016/j.gie.2008.12.251. PMID 19410037.
- ↑ Selinger RR, McDonald GB, Hockenbery DM, Steinbach G, Kimmey MB (2006). "Efficacy of neodymium:YAG laser therapy for gastric antral vascular ectasia (GAVE) following hematopoietic cell transplant". Bone Marrow Transplant. 37 (2): 191–7. doi:10.1038/sj.bmt.1705212. PMID 16284614.
- ↑ Gostout CJ, Bowyer BA, Ahlquist DA, Viggiano TR, Balm RK (1988). "Mucosal vascular malformations of the gastrointestinal tract: clinical observations and results of endoscopic neodymium: yttrium-aluminum-garnet laser therapy". Mayo Clin Proc. 63 (10): 993–1003. doi:10.1016/s0025-6196(12)64914-3. PMID 3262793.
- ↑ Pishvaian AC, Lewis JH (2006). "Use of endoclips to obliterate a colonic arteriovenous malformation before cauterization". Gastrointest Endosc. 63 (6): 865–6. doi:10.1016/j.gie.2005.10.020. PMID 16650560.
- ↑ Ertekin C, Taviloglu K, Barbaros U, Guloglu R, Dolay K (2002). "Endoscopic band ligation: alternative treatment method in nonvariceal upper gastrointestinal hemorrhage". J Laparoendosc Adv Surg Tech A. 12 (1): 41–5. doi:10.1089/109264202753486911. PMID 11905861.
- ↑ Matsui S, Kamisako T, Kudo M, Inoue R (2002). "Endoscopic band ligation for control of nonvariceal upper GI hemorrhage: comparison with bipolar electrocoagulation". Gastrointest Endosc. 55 (2): 214–8. doi:10.1067/mge.2002.121337. PMID 11818925.
- ↑ Junquera F, Brullet E, Campo R, Calvet X, Puig-Diví V, Vergara M (2003). "Usefulness of endoscopic band ligation for bleeding small bowel vascular lesions". Gastrointest Endosc. 58 (2): 274–9. doi:10.1067/mge.2003.357. PMID 12872104.
- ↑ Funaki B (2002). "Endovascular intervention for the treatment of acute arterial gastrointestinal hemorrhage". Gastroenterol Clin North Am. 31 (3): 701–13. doi:10.1016/s0889-8553(02)00025-0. PMID 12481726.
- ↑ Walker TG (2009). "Acute gastrointestinal hemorrhage". Tech Vasc Interv Radiol. 12 (2): 80–91. doi:10.1053/j.tvir.2009.08.002. PMID 19853226.