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Challenges in Diagnosing and Managing Dieulafoy’s Lesions: A Case Report Highlighting the Importance of Clinical Suspicion and Multidisciplinary Approach in Obscure Gastrointestinal Bleeding

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Open Journal of Gastroenterology 2024年第3期14卷 80-86页

作者： Feruza Abraamyan Neeladri Misra Kenneth Tran Khalid Mahmood Benjamin Coombs Shilpa Lingala Sutter Roseville Medical Center Roseville USA

Upper gastrointestinal bleeding remains a significant cause of hospital admissions. Even though the incidence of peptic ulcer disease and gastritis is decreasing, the incidence rates in neoplasm, Dieulafoy’s lesions, angiodysplasia, and esophagitis are trending up, which necessities physicians to be aware of those pathologies and their specifics. Here, we represent a case of a 62-year-old male on dual antiplatelet therapy who was transferred to our hospital due to severe melena with suspicion of upper gastrointestinal bleeding. Due to hemodynamic instability, the patient was intubated and started on vasopressors. However, several repeated EGDs and CTs of the abdomen with GI bleeding protocol did not reveal the location of active bleeding to stop it. At the same time, clinically, the patient was hemodynamically unstable with continued melena. On the last EGD, a small area of concern resembling gastric varix was clipped for identification purposes, and the patient underwent a selective angiogram with further diagnosis of Dieulafoy’s lesion, which was successfully embolized. Our case demonstrates that Dieulafoy’s lesions can present as severe life-threatening hemorrhage, hard to diagnose with traditional methods such as EGD or CTs, in which case it is recommended to proceed with an angiogram sooner rather than later for further diagnosis and treatment if needed.

关键词： Upper Gastrointestinal Bleeding Dieulafoy’s Lesion angiodysplasia Melena Hematochezia EGD Angiogram Embolization

angiodysplasia Presenting with Multiple Polypoid Lesions: An Unusual Cause of Small Bowel Obstruction

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Case Reports in Clinical Medicine 2014年第11期3卷 592-595页

作者： Yoshiharu Takenaka Takahiro Sasaki Nobuyoshi Miyajima Takehito Otsubo Department of Gastroenterological Surgery St. Marianna University School of Medicine Toyoko Hospital Kanagawa Japan

angiodysplasia (AD), a morphologic vascular abnormality, is a common cause of gastrointestinal bleeding. We present a rare case of polypoid AD lesions. Three years after treatment for adhesive bowel obstruction, a 57-year-old man was admitted with recurrent abdominal distension, anorexia, and lower extremity edema. Computed tomography showed his dilated proximal and collapsed distal small bowel loops had disparate calibers. The transition point demonstrated mucosal enhancement and mesenteric lymphadenopathy. We observed small intestinal wall outpouching with strong mucosal enhancement and polypoid lesions dotting the dilated intestine. Intraoperative findings revealed a hard but elastic intraluminal nodule causing small bowel obstruction and the outpouching’s occurrence on the ileum’s antimesenteric border. We performed partial resection of the small intestine involving the nodule and Meckel’s diverticulum. Macroscopically, the nodule, diverticulum, and intestinal mucosa had polypoid lesions. Histopathologically, these lesions had foci within dilated thin- or thick-walled vascular channels in the submucosa, without specific histological abnormalities. These features led to a diagnosis of AD.

关键词： angiodysplasia Polipoid Lesions Small Bowel Obstruction Meckel’s Diverticulum

Role of octreotide in small bowel bleeding

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World Journal of Clinical Cases 2022年第26期10卷 9192-9206页

作者： Anwar Khedr Esraa Elaraby Mahmoud Noura Attallah Mikael Mir Sydney Boike Ibtisam Rauf Abbas B Jama Hisham Mushtaq Salim Surani Syed A Khan Department of Internal Medicine BronxCare Health SystemBronxNY 10457United States Department of Medicine University of SharjahSharjah 27272United Arab Emirates Critical Care Medicine Mayo Clinic Health SystemMankatoMN 56001United States Department of Medicine University of MinnesotaMinneapolisMN 55455United States Department of Medicine St.George School of MedicineGrenadaWest Indies Department of Medicine Texas A&M University Health Science CenterBryanTX 77807United States

Gastrointestinal bleeding accounts for a drastic negative impact on the quality of the patients’lives as it requires multiple diagnostic and therapeutic interventions to identify the source of the bleeding.Small bowel bleeding is the least common cause of gastrointestinal bleeding.However,it is responsible for the majority of complaints from patients with persisting or recurring bleeding where the primary source of bleeding cannot be identified despite investigation.A somatostatin analog known as octreotide is among the medical treatment modalities currently used to manage small bowel bleeding.This medication helps control symptoms of gastrointestinal bleeding by augmenting platelet aggregation,decreasing splanchnic blood flow,and antagonizing angiogenesis.In this review article,we will highlight the clinical efficacy of octreotide in small bowel bleeding and its subsequent effect on morbidity and mortality.

关键词： Octreotide Small bowel Hemorrhage angiodysplasia Vascular malformations Hereditary hemorrhagic telangiectasia

Secondary angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease: Results from the nationwide inpatient sample

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World Journal of Gastrointestinal Endoscopy 2019年第10期11卷 504-514页

作者： Tooba Tariq Patrick Karabon Furqan B Irfan Sachin Goyal Matthew Masaru Mayeda Austin Parsons Stephanie Judd Murray Ehrinpreis Department of Internal Medicine Western Michigan University Homer Stryker M.D.School of MedicineKalamazooMI 49008United States Oakland University William Beaumont School of Medicine Oakland UniversityDetroitMI 48309United States College of Osteopathic Medicine Michigan State UniversityEast LansingMI 48824United States 不详 Department of Internal Medicine Division of GastroenterologyJohn D Dingell VA Medical CenterDetroitMI 48201United States

BACKGROUND Chronic kidney disease is associated with angiodysplasia of gastrointestinal tract leading to increased risk of gastrointestinal bleeding.AIM To determine the nationwide prevalence,trends,predictors and resource utilization of angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease hospitalizations.METHODS The Nationwide Inpatient Sample database from 2009 to 2014,was utilized to conduct a retrospective study on patients with angiodysplasia associatedgastrointestinal bleeding and end-stage renal disease.Hospitalizations with endstage renal disease were included in the Nationwide Inpatient Sample database and a subset of hospitalizations with end-stage renal disease and angiodysplasiaassociated gastrointestinal bleeding were identified with International Classification of Diseases,9th revision,Clinical Modification codes for both endstage renal disease(585.6)and angiodysplasia(569.85,537.83).RESULTS The prevalence of angiodysplasia-associated gastrointestinal bleeding was 0.45%(n=24709)among all end-stage renal disease patients(n=5505252)that were hospitalized.Multivariate analysis indicated that the following were significant factors associated with higher odds of angiodysplasia associated-gastrointestinal bleeding in end-stage renal disease patients:an increasing trend from 2009-2014(Pangiodysplasia associated-gastrointestinal bleeding in end-stage renal disease patients.In comparison with urban teaching hospitals,rural and urban nonteaching hospitals were associated with decreased odds of angiodysplasia associated-gastrointestinal hemorrhage.CONCLUSION angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease patients showed an increasing trend from 2009-2014.Advanced age,African American race,overall high comorbidities,hypertension and

关键词： angiodysplasia Renal Gastrointestinal Hemorrhage

Assessment of serum angiogenic factors as a diagnostic aid for small bowel angiodysplasia in patients with obscure gastrointestinal bleeding and anaemia

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World Journal of Gastrointestinal Pathophysiology 2017年第3期8卷 127-132页

作者： Grainne Holleran Mary Hussey Sinead Smith Deirdre McNamara Department of Clinical Medicine Trinity Centre for Health SciencesTallaght Hospital24 DublinIreland

AIM To assess the use of serum levels of angiopoietin-1(Ang1), Ang2 and tumor necrosis factor-α(TNFα) as predictive factors for small bowel angiodysplasia(SBA).METHODS Serum samples were collected from patients undergoing capsule endoscopy for any cause of obscure gastrointestinal bleeding(OGIB) or anaemia. Based on small bowel findings patients were divided into 3 groups:(1) SBA;(2) other bleeding causes; and(3) normal, according to diagnosis. Using ELISA technique we measured serum levels of Ang1, Ang2 and TNFα and compared mean and median levels between the groups based on small bowel diagnosis. Using receiver operator curve analysis we determined whether any of the factors were predictive of SBA.RESULTS Serum samples were collected from a total of 120 patients undergoing capsule endoscopy for OGIB or anaemia: 40 with SBA, 40 with other causes of small bowel bleeding, and 40 with normal small bowel findings. Mean and median serum levels were measured and compared between groups; patients with SBA had significantly higher median serum levels of Ang2(3759 pg/mL) compared to both other groups, with no significant differences in levels of Ang1 or TNFα based on diagnosis. There were no differences in Ang2 levels between the other bleeding causes(2261 pg/mL) and normal(2620pg/mL) groups. Using Receiver Operator Curve analysis, an Ang2 level of > 2600 pg/mL was found to be predictive of SBA, with an area under the curve of 0.7. Neither Ang1 or TNFα were useful as predictive markers.CONCLUSION Elevations in serum Ang2 are specific for SBA and not driven by other causes of bleeding and anaemia. Further work will determine whether Ang2 is useful as a diagnostic or prognostic marker for SBA.

关键词： angiodysplasia 小肠的流血囊内视镜检查法 Angiogenic 因素 Angiopoietin-2

Diagnosis and therapeutic strategies for small bowel vascular lesions

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World Journal of Gastroenterology 2019年第22期25卷 2720-2733页

作者： Eiji Sakai Ken Ohata Atsushi Nakajima Nobuyuki Matsuhashi Department of Gastroenterology NTT Medical Center TokyoTokyo 141-8625Japan Division of Gastroenterology and Hepatology Yokohama City University School of MedicineYokohama 236-0004Japan

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions;therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

关键词： angiodysplasia Angioectasia Dieulafoy's lesion Arteriovenous malformation Obscure gastrointestinal bleeding Video capsule endoscopy Deep enteroscopy Argon plasm coagulation

Aortic stenosis and Heyde’s syndrome:A comprehensive review

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World Journal of Clinical Cases 2021年第25期9卷 7319-7329页

作者： Dennisdhilak Lourdusamy Vamsee Krishna Mupparaju Navila Fahmida Sharif Uzoma N Ibebuogu Internal Medicine Methodist South HospitalMemphisTN 38116United States Internal Medicine University of Tennessee Health Science CenterMemphisTN 38103United States Cardiovascular Diseases University of Tennessee Health Science CenterMemphisTN 38163United States

Heyde’s syndrome is an under reported systemic disease of gastrointestinal and cardiac manifestation in older adults.It is characterized by a triad of aortic stenosis,angiodysplasia with bleeding and acquired von Willebrand syndrome.It is characterized by proteolysis of high molecular weight multimers of von Willebrand Factor and loss of platelet mediated homeostasis.Heyde’s syndrome is a treatable condition in most cases,especially in the current era of evolution in interventional cardiology and gastroenterology.There are currently no established guidelines in the management of this condition due to paucity of high quality studies,which warrant future trials.High index of suspicion and increasing the awareness of the syndrome among the general practitioners and sub-specialists will improve the diagnostic potential of Heyde’s syndrome.Future studies may change the management aspect of Heyde's syndrome and pave a path for drawing specific guidelines and algorithms.The aim of our review article is to summarize the basic pathophysiology,diagnostics and management of Heyde’s syndrome with a special attention to Transcatheter aortic valve replacement.

关键词： Heyde's syndrome Aortic stenosis angiodysplasia Transcatheter aortic valve replacement Gastrointestinal bleed Anti platelet

Thalidomide for refractory gastrointestinal bleeding from vascular malformations in patients with significant comorbidities

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World Journal of Clinical Cases 2020年第15期8卷 3218-3229页

作者： Alexis Mae Bayudan Chien-Huan Chen Department of Medicine Washington University School of MedicineSt.LouisMO 63108United States Division of Gastroenterology Department of Internal MedicineWashington University School of MedicineSt.LouisMO 63110United States

BACKGROUND Refractory gastrointestinal bleeding(GIB)secondary to gastrointestinal vascular malformations(GIVM)such as gastrointestinal angiodysplasia(GIAD)and gastric antral vascular ectasia(GAVE)remains challenging to treat when endoscopic therapy fails.Recently thalidomide has been suggested as a treatment option for refractory GIB.AIM To determine the outcome of patients treated with thalidomide for refractory GIB due to GIVM.METHODS IRB approved,single center,retrospective review of electronic medical records from January 2012 to November 2018.Patients age>18 years old,who had>3 episodes of GIB refractory to medical or endoscopic therapy,and who had been treated with thalidomide for at least 3 mo were included.The primary endpoint was recurrence of GIB 6 mo after initiation of thalidomide.RESULTS Fifteen patients were included in the study,all with significant cardiac,hepatic,or renal comorbidities.The cause of GIB was GIAD in 10 patients and GAVE in 5 patients.Two patients were lost to follow up.Of the 13 patients followed,38.5%(n=5)had no recurrent GIB or transfusion requirement after treatment with thalidomide.Furthermore,84.6%(n=11)of patients had a reduction in transfusion requirements and hospitalizations for GIB.Thalidomide was discontinued in 2 patients due to cost(n=1)and medication interaction(n=1).Reported adverse reactions included fatigue(n=3),neuropathy(n=2),dizziness(n=1),and constipation(n=1).Six patients died during follow up due to unknown cause(n=4)and sepsis(n=2).CONCLUSION Thalidomide appears to be an effective treatment for refractory GIB due to GIAD or GAVE in a Western population with significant comorbidities.

关键词： Vascular malformation Thalidomide Refractory gastrointestinal bleeding Gastric antral vascular ectasia angiodysplasia

Shared changes in angiogenic factors across gastrointestinal vascular conditions:A pilot study

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World Journal of Gastrointestinal Pharmacology and Therapeutics 2020年第3期11卷 40-47页

作者： Atiyekeogbebe R Douglas Grainne Holleran Sinead M Smith Deirdre McNamara TAGG Research Centre School of MedicineTrinity College DublinDublin D24Ireland

BACKGROUND Neovascularisation is common to a variety of gastrointestinal(GI)disorders with differing aetiologies and presentations;usually affecting adults above 60 years.Shared angiogenic factors modulated by disease specific elements could be a common denominator and represent novel diagnostic and therapeutic targets.As yet,assessment of angiogenic factors across several GI vascular disorders associated with recurrent bleeding and anaemia has not been reported.AIM To assess serum levels of angiogenic factors in several intestinal vascular disorders.METHODS A case control study was performed in Tallaght University Hospital in patients with endoscopically proven small bowel angiodysplasia(SBA),portal hypertensive gastropathy(PHG),gastric antral vascular ectasia(GAVE)and nonbleeding,non-anaemic controls.Using enzyme-linked immunosorbent assay,concentrations of Angiopoietin 1(Ang-1),Ang-2 and vascular endothelial growth factor(VEGF)were measured from 2 serum tubes of blood following informed consent.The relative expression of Ang-1 and Ang-2 and Ang-1/2 ratio was calculated and compared between groups.Statistical analysis was applied using a t-test,and a P value of<0.05 was considered significant.RESULTS To date 44 samples were tested:10 SBA,11 PHG,8 GAVE and 15 controls.Mean age 60(range 20-85)years and 20(45%)were males.Controls were significantly younger(49 years vs 66 years,P=0.0005).There was no difference in VEGF levels between the groups(P=0.6).SBA,PHG and GAVE Ang-1 levels were similar and were significantly lower than controls,(P=0.0002,95%CI:241 to 701).Ang-2 levels were statistically higher in PHG and GAVE groups compared to controls(P= 0.01, 95%CI: 77.8 to 668) and as a result, also had a lower Ang-1/2 ratioscompared to controls. While SBA Ang-2 levels were higher than controls, this didnot reach statistical significance. Neither age nor haemoglobin level, which wassimilar between disease groups, could explain the difference. In addition, themedian Ang-1/Ang-2 ratio for all patients was found to be sign

关键词： Gastric antral vascular ectasia Portal hypertensive gastropathy angiodysplasia Angiopoietins Angiogenic factors Recurrent bleeding