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Angiodysplasia of Colon

Joint Hospital Grand Round. Angiodysplasia of Colon. Yeung Kwan Lok Department of Surgery TKOH. Angiodysplasia of Colon. Introduction Diagnosis Management Controversial issue Conclusion. Introduction Diagnosis Management Controversial issue Conclusion. Introduction.

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Angiodysplasia of Colon

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  1. Joint Hospital Grand Round Angiodysplasia of Colon Yeung Kwan Lok Department of Surgery TKOH

  2. Angiodysplasia of Colon • Introduction • Diagnosis • Management • Controversial issue • Conclusion

  3. Introduction • Diagnosis • Management • Controversial issue • Conclusion

  4. Introduction • Acquired submucosal arteriovenous malformation • LGIB in elderly

  5. Introduction Bleeding after trauma • 0.5 -1 cm • Bright red, flat / slightly raised, covered by thin epithelium • 70-90% right colon • Majority – 2 or 3 lesions Angiodysplasia

  6. How common it is? • Exact incidence difficult to ascertain (0.2%-6.2%) Richter JM et al. Dig Dis Sci. 1984; 29:481-485 Heer M et al. Hepatogastroenterology. 1987; 34:127-131 Hochter WJ et al. Endoscopy. 1985;17:182-185 • 0.8% incidental • HA hospitals - 167 cases (1/1/2000-31/3/2006)

  7. Aetiology • Unknown • Degenerative disease Boley SJ et al. Severe lower intestinal bleeding: diagnosis and treatment. Clin Gastroenterol. 1981; 10:65-91

  8. Epidemiology • > 60 years old • F=M, no racial difference • Increase incidence with several medical conditions (a) CRF Zuckerman GR et al. Ann Intern Med. 1985; 102:588-592 Navab F et al. Am J Gastroenterol. 1989;84:1297-1300

  9. Epidemiology (b) Cirrhosis Naveau S et al.Dig Ds Sci 1991; 36: 1774-1781 (c) Aortic stenosis (d) von Willebrand's disease (e) pulmonary disease No study demonstrate the relationship • unrelated to inherited arteriovenous malformations (hereditary hemorrhagic telangiectasia)

  10. Presentation • Asymptomatic • GIB (1) Major bleed (2) Recurrent minor bleed (3) Positive FOB

  11. Introduction • Diagnosis • Management • Controversial issue • Conclusion

  12. Diagnosis 1. Angiogram - Extravasation (6-20%) - 3 signs correspond to development Boley SJ et al. Radiology. 1977; 125:615-621. (a) Densely opacified, dilated, tortuous, slow emptying intramural vein – 90% (b) Vascular tuft in arterial phase – 70-80% (c) Early filling vein within 45s. – 60-70%

  13. Diagnosis - Timing is important Delay >6 hrs. between time of presentation and angiogram – 28% fail to identify the source Browder W et al. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg. 1986; 204:530-536

  14. Diagnosis 2. Colonoscopy – pathognomonic Richter JM et al. Angiodysplasia: clinical presentation and colonoscopic diagnosis. Dig Dis Sci. 1984; 29:481-485 • Preoperative or intraoperative • Hidden behind mucosal fold in right colon 80-90 % - colonoscopy or angiogram

  15. Diagnosis 3. Radionuclide scan 4. Helical CT scan

  16. Introduction • Diagnosis • Management • Controversial issue • Conclusion

  17. Management • Amount of bleeding, extent and site of lesions • Asymptomatic • Massive hemorrhage - Resuscitation - Investigation - Surgical resection

  18. Management • Slow or intermittent 1. Surgical resection – rebleeding 15-25% 2. Endoscopic coagulation therapy (a) laser – argon preferable than Nd: YAG (b) electrocoagulation 10-30% rebleeding 7% perforation – usu. Nd: YAG laser

  19. Hot biopsy coagulation angiodysplasia Coagulated mucosa Angiodysplasia grasped and pulled up during electrocoagulation

  20. Management 3. Pharmacological (a) oestrogen-progesterone restore continuity of endothelium, shorten bleeding time, stasis in mesenteric microcirculation van Cutsem E et al. Lancet. 1990; 1: 953-955 (b) ß blocker (c) Somatostatin ↓splanchnic and portal blood flow Bowers et al. British Journal of Haematology 2000; 108: 524-527 Blich et al. Scandinavian Journal of Gastroenterology 2003; 38(7): 801-803 4. Angiographic

  21. Introduction • Diagnosis • Management • Controversial issue • Conclusion

  22. Controversial issue 1. Hormonal therapy

  23. Controversial issue 2. Management on incidental angiodysplasia

  24. Introduction • Diagnosis • Management • Controversial issue • Conclusion

  25. Conclusion • Angiodysplasia - common cause of LGIB of elderly • Diagnosis – difficult, combination techniques • Treatment – individualized • Controversial - systemic hormonal therapy - incidental angiodysplasia

  26. Conclusion • Prognosis • 90 % self limiting • Mortality related to severity of bleeding, age, co-morbidity

  27. The End

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