Angiodysplasia🎥 {Free Video}
Angiodysplasia
Introduction
Angiodysplasia (AD) is an acquired, degenerative vascular malformation consisting of dilated, thin-walled veins, venules and capillaries in the mucosa and submucosa. Lesions are most common in the caecum and ascending colon but can occur anywhere from stomach to rectum.
Epidemiology & Risk Factors
- Peak presentation ≥ 60 years; prevalence rises with age.
- Associated conditions: chronic kidney disease, aortic stenosis (Heyde syndrome), von Willebrand disease and radiation enteropathy.
Pathophysiology
- Repetitive muscular contraction and increased wall tension in the right colon cause intermittent venous obstruction and arteriovenous shunting.
- Progressive dilatation produces tortuous vessels that are fragile and prone to rupture, leading to occult or overt bleeding.
Clinical Presentation
| Symptoms | Signs |
|---|---|
| Intermittent painless fresh or dark rectal bleeding; melaena if proximal. | Pallor, conjunctival pallor. |
| Fatigue, exertional dyspnoea due to iron-deficiency anaemia (IDA). | Tachycardia, orthostatic hypotension in acute bleed. |
| Syncope in brisk haemorrhage. | Koilonychia, glossitis, angular stomatitis in chronic IDA. |
Investigations
| Modality | Role / Findings |
|---|---|
| Full blood count & ferritin | Microcytic IDA. |
| Bidirectional endoscopy (oesophago-gastroduodenoscopy + colonoscopy) | First-line to locate and treat lesions; characteristic flat, red “fern-like” or “cherry-red” patches. |
| Capsule endoscopy / balloon-assisted enteroscopy | Detects small-bowel lesions when OGD/colonoscopy negative. |
| CT angiography | Identifies active bleeding ≥ 0.3 mL min⁻¹; guides embolisation. |
| Radionuclide labelled-RBC scan | Highly sensitive for intermittent bleeding but poor spatial resolution. |
Complications
- Chronic iron-deficiency anaemia requiring repeated transfusion.
- Haemodynamic shock from massive lower-GI haemorrhage.
- Post-interventional complications: perforation, peritonitis (rare).
Management
Initial approach
- Resuscitate with IV fluids / blood products as for any GI bleed.
- Correct coagulopathy (vitamin K, platelet or PCC) and stop anticoagulants where possible.
Definitive therapy
| Strategy | Indication / Notes |
|---|---|
| Endoscopic thermal coagulation (argon plasma coagulation, bipolar electrocoagulation) | First-line for accessible lesions. Repeatable with low complication rate. |
| Endoscopic mechanical therapy (clips, band ligation) | Alternative when thermal therapy contraindicated. |
| Angiographic embolisation | Active bleeding unresponsive or inaccessible to endoscopy; uses coils / particles. |
| Intra-arterial vasopressin infusion | Temporary measure if embolisation not feasible. |
| Surgical segmental resection | Last resort for refractory, localised disease or uncontrolled haemorrhage. |
Adjunct pharmacological options (for multifocal or recurrent bleeding)
- Tranexamic acid 1 g tds orally or 10 mg kg⁻¹ IV for short courses.
- Long-acting somatostatin analogues (octreotide LAR 20 mg IM monthly) reduce re-bleed rates.
- Thalidomide 50–100 mg nocte under specialist supervision (teratogenic).
- Iron replacement – oral ferrous sulphate or IV ferric carboxymaltose for persistent IDA.
Cancer-rule-out pathway
- NICE 2-week-wait referral for unexplained IDA or visible lower-GI bleeding in adults ≥ 60 years to exclude colorectal carcinoma; may run concurrently with AD work-up.
Follow-up
-
Check Hb and ferritin 6–8 weeks after therapy, then every 3–6 months.
-
Repeat endoscopy if recurrent bleeding or Hb falls > 20 g L⁻¹.
-
Optimise cardiovascular and renal comorbidities.
FAQ from our users
What causes angiodysplasia?
- The exact cause is unclear but it is associated with ageing, intermittent bowel contraction, and increased pressure in the veins.
Is angiodysplasia related to cancer?
No
What is capsule endoscopy?
swallows a tiny camera, which allows clinicians to image the small intestine.
What is argon plasma coagulation?
A procedure which uses ionised gas to coagulate blood in the GI tract & thus stop bleeding.
What are the associations of angiodysplasia?
- Von Willebrand disease
- End stage renal disease (ERSD)
- Heyde syndrome
- Aortic stenosis
- Acquired von Willebrand disease
- Angiodysplasia
- Left ventricular assist devices
Common pitfalls in a clinical setting
Common pitfalls in a clinical setting
- Any GI bleeding in elderly patients needs to be treated with very high suspicion of malignancy within the GI tract.