Angiodysplasia of the Upper Gastrointestinal Tract

Pathophysiology
In contrast to colonic angiomas, which are believed to develop from chronic low-grade venous
obstruction associated with aging, the cause of upper gastrointestinal angiomas is unknown.
ESSENTIALS OF DIAGNOSIS

Chronic or acute recurrent episodes of bleeding.

Long history of bleeding requiring multiple transfusions prior to diagnosis.

Multiple nondiagnostic endoscopic procedures performed previously.

Iron deficiency anemia and occult-blood-positive stools.

Associated disordersrenal failure, von Willebrand's disease, aortic stenosis, cirrhosis,

pulmonary disease.

General Considerations
Other terms used synonymously with angioma include arteriovenous malformation,
telangiectasia, vascular ectasia, and angiodysplasia. Upper gastrointestinal angiomas account for
1.28.0% of patients with occult-blood-positive stool and iron deficiency anemia. Infrequently,
patients with upper gastrointestinal angiomas present with acute bleeding. Small bowel angiomas
are the most common cause of gastrointestinal bleeding of obscure origin. Upper gastrointestinal
angiomas may be suggestive of angiomas elsewhere in the gastrointestinal tract or may be part of
the Osler-Weber-Rendu syndrome or hereditary hemorrhagic telangiectasia.
Clinical Findings
Bleeding from upper gastrointestinal angiomas is usually low-grade and intermittent, causing
hemoccult-positive stools and iron deficiency anemia. Video endoscopy and enteroscopy are the
diagnostic procedures of choice for evaluating upper gastrointestinal and small bowel angiomas.
The classic angiographic features of intestinal angiomas include an early filling vein, a vascular
tuft, and a late-draining vein.
Differential Diagnosis
Because upper gastrointestinal angiomas infrequently cause acute gastrointestinal bleeding, it is
important to exclude other causes of upper gastrointestinal bleeding such as peptic ulcers,
Mallory-Weiss tears, or varices. Incidental angiomas rarely bleed, therefore, treatment is not
indicated.
Treatment
Hormonal therapy with combination estrogen and progesterone for bleeding angiomas has
yielded conflicting results. Endoscopic therapy with thermal coagulation is the treatment of
choice for bleeding upper gastrointestinal angiomas. Thermal coagulation may be performed
with contact probes at a low power setting, eg, multipolar electrocoagulation (1015 W 1second pulses) or heater probe (1020 J/pulse). Nd:YAG laser may be used at a low power
setting (40100 W 0.20.5 seconds). There is limited experience with injection therapy
for upper gastrointestinal angiomas.
The endoscopic end point for thermal coagulation of angiomas is mucosal whitening and
ablation of all visible angiomatous tissue. It is important to avoid excessive bowel distention,

high-power generator settings, firm probe pressure, and repeated coagulation to the same area to
minimize the risk of transmural injury and perforation. Surgical therapy such as intraoperative
enteroscopy is reserved for failures of endoscopic and medical therapy.
Prognosis
Over one-half of patients stop bleeding spontaneously without any therapy. For patients with
recurrent bleeding, endoscopic therapy can decrease the number of bleeding episodes as well as
the transfusion requirement.
Chalasani N, Cotsonis G, Wilcox CM: Upper gastrointestinal bleeding in patients with chronic
renal failure: role of vascular ectasia. Am J Gastroenterol 1996;91(11):2329.
Foutch PG: Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993;88:807.
Lewis BS et al: Does hormonal therapy have any benefit for bleeding angiodysplasia? J Clin
Gastroenterol 1992;15(2):99.
Machicado GA, Jensen DM: Upper gastrointestinal angiomata. Diagnosis and treatment. In:
Severe Nonvariceal Upper Gastrointestinal Hemorrhage. Jensen DM (editor). Gastrointest
Endosc Clin North Am 1991;1:241.
Van Cutsem E, Rutgeerts P, Vantrappen G: Treatment of bleeding gastrointestinal vascular
malformations with oestrogen-progesterone. Lancet 1990;335:953.