Clin Endosc.  2016 Jan;49(1):91-96. 10.5946/ce.2016.49.1.91.

Multiple Polypoid Angiodysplasia with Obscure Overt Bleeding

• Lee J
• Hwang SW
• Kim J
• Kang J
• Kang GH
• Park KJ
• Im JP
• Kim JS

• KMID: 2166556
• DOI: http://doi.org/10.5946/ce.2016.49.1.91

Abstract

Angiodysplasia (AD) is increasingly being recognized as a major cause of gastrointestinal bleeding. Morphologically flat lesions are common types of AD, whereas the polypoid types are rare. We report a case of multiple polypoid AD in the small bowel causing severe anemia and requiring surgical treatment. A 60-year-old male patient visited our hospital with dyspnea and hematochezia. He had a history of myocardial infarction and was taking both aspirin and clopidogrel. Capsule endoscopy, enteroscopy, computed tomography, and angiography revealed multifocal vascular lesions with a polypoid shape in the jejunum. Surgical resection was performed because endoscopic treatment was considered impossible with the number and the location of lesions. The risk of recurrent bleeding related to the use of antiplatelet agents also contributed to the decision to perform surgery. AD was histologically diagnosed from the surgical specimen. He resumed taking both aspirin and clopidogrel after surgery. He fully recovered and has been doing well during the several months of follow-up.

Keyword

Angiodysplasia; Gastrointestinal hemorrhage; Capsule endoscopy

MeSH Terms

Anemia
Angiodysplasia*
Angiography
Aspirin
Capsule Endoscopy
Dyspnea
Follow-Up Studies
Gastrointestinal Hemorrhage
Hemorrhage*
Humans
Jejunum
Male
Middle Aged
Myocardial Infarction
Platelet Aggregation Inhibitors
Aspirin
Platelet Aggregation Inhibitors

Figure

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  Fig. 1. (A-D) Capsule endoscopy image showing active bleeding from the proximal jejunum, the exact mucosal lesions could not be detected (arrows).

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  Fig. 2. (A-D) Computed tomography angiography scan showing multifocal small enhancing nodular lesions in the jejunum (arrows).

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  Fig. 3. Single-balloon enterocopy image show multiple, variabl-sized, bluish vascular lesions with a polypoid shape between the proximal (A) and distal (B) jejunum.

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  Fig. 4. Small-bowel resection was performed, and the length of the resected bowel was 120 cm. The resected specimen includes 16 polypoid submucosal hematomas, with the largest being 1.5×1.3×0.8 cm in size.

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  Fig. 5. (A) The lesion consisting of ectatic vasculature and organizing thrombi (H&E stain, ×200). (B) Elastin staining confirming that the dilated and tortuous vasculature is composed of arteries and veins with direct communication (elastin stain, ×200).

Reference

1. Dray X, Camus M, Coelho J, Ozenne V, Pocard M, Marteau P. Treatment of gastrointestinal angiodysplasia and unmet needs. Dig Liver Dis. 2011; 43:515–522.

2. Lecleire S, Iwanicki-Caron I, Di-Fiore A, et al. Yield and impact of emergency capsule enteroscopy in severe obscure-overt gastrointestinal bleeding. Endoscopy. 2012; 44:337–342.

3. Regula J, Wronska E, Pachlewski J. Vascular lesions of the gastrointestinal tract. Best Pract Res Clin Gastroenterol. 2008; 22:313–328.

4. Sharma R, Gorbien MJ. Angiodysplasia and lower gastrointestinal tract bleeding in elderly patients. Arch Intern Med. 1995; 155:807–812.

5. Rodriguez-Jurado R, Morales SS. Polypoid arteriovenous malformation in the jejunum of a child that mimics intussusception. J Pediatr Surg. 2010; 45:E9–E12.

6. Dodda G, Trotman BW. Gastrointestinal angiodysplasia. J Assoc Acad Minor Phys. 1997; 8:16–19.

7. Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia: pathogenesis, diagnosis and management. Aliment Pharmacol Ther. 2014; 39:15–34.

8. Rizvi AZ, Kaufman JA, Smith P, Silen ML. Solitary arteriovenous malformation of the small intestine. J Am Coll Surg. 2005; 200:808–809.

9. Richardson JD. Vascular lesions of the intestines. Am J Surg. 1991; 161:284–293.

10. Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg. 1982; 69:412–422.

11. Burrows PE, Mulliken JB, Fellows KE, Strand RD. Childhood hemangiomas and vascular malformations: angiographic differentiation. AJR Am J Roentgenol. 1983; 141:483–488.

12. Foutch PG, Rex DK, Lieberman DA. Prevalence and natural history of colonic angiodysplasia among healthy asymptomatic people. Am J Gastroenterol. 1995; 90:564–567.

13. Funaki B. Endovascular intervention for the treatment of acute arterial gastrointestinal hemorrhage. Gastroenterol Clin North Am. 2002; 31:701–713.

14. Czymek R, Kempf A, Roblick UJ, et al. Surgical treatment concepts for acute lower gastrointestinal bleeding. J Gastrointest Surg. 2008; 12:2212–2220.

15. Shim KN, Song EM, Jeen YT, et al. Long-term outcomes of NSAID-induced small intestinal injury assessed by capsule endoscopy in Korea: a nationwide multicenter retrospective study. Gut Liver. 2015; 9:727–733.