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Vascular GI Lesions

by Parswa Ansari, MD

Several distinct congenital or acquired syndromes involve abnormal mucosal or submucosal blood vessels in the GI tract. These vessels may cause recurrent bleeding, which is rarely massive. Diagnosis is by endoscopy and sometimes angiography. Treatment is endoscopic hemostasis; occasionally, angiographic embolization or surgical resection may be needed.

Vascular ectasias (angiodysplasias, arteriovenous malformations) are dilated, tortuous vessels that typically develop in the cecum and ascending colon. They occur mainly in people > 60 and are the most common cause of lower GI bleeding in that age group. They are thought to be degenerative and do not occur in association with other vascular abnormalities. Most patients have 2 or 3 lesions, which are typically 0.5 to 1.0 cm, bright red, flat or slightly raised, and covered by very thin epithelium. Vascular ectasias also occur in association with a number of systemic diseases (eg, renal failure, cirrhosis, CREST syndrome [calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias]—see Pathophysiology) and after radiation to the bowel.

Gastric antral vascular ectasia (watermelon stomach or GAVE) consists of large dilated veins running linearly along the stomach, creating a striped appearance suggestive of a watermelon. The condition occurs mainly in older women and is of unknown etiology.

Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome—see also Hereditary Hemorrhagic Telangiectasia) is an autosomal dominant disorder that causes multiple vascular lesions in various parts of the body, including the entire GI tract. GI bleeding rarely occurs before age 40.

Dieulafoy lesion is an abnormally large artery that penetrates the gut wall, occasionally eroding through the mucosa and causing massive bleeding. It occurs mainly in the proximal stomach.

Arteriovenous malformations and hemangiomas, both congenital disorders of blood vessels, can occur in the GI tract but are rare.

Symptoms and Signs

Vascular lesions are painless. Patients often present with heme-positive stools or modest amounts of bright red blood from the rectum. Bleeding is often intermittent, sometimes with long periods between episodes. Patients with upper GI lesions may present with melena. Major bleeding is unusual.

Diagnosis

  • Endoscopy

Vascular lesions are most commonly diagnosed endoscopically. If routine endoscopy is nondiagnostic, small-bowel endoscopy, capsule endoscopy, intraoperative endoscopy, or visceral angiography may be required. 99m Tc-labeled RBC scans are less specific but may help localize the lesion enough to facilitate endoscopy or angiography.

Treatment

  • Endoscopic coagulation

Endoscopic coagulation (with heater probe, laser, argon plasma, or bipolar electrocoagulation) is effective for many vascular lesions. Endoscopic clips may be applied to some lesions. Vascular ectasias often recur, although there is some evidence that oral estrogen-progesterone combinations may limit recurrence.

Mild recurrent bleeding can be treated simply with chronic iron therapy. More significant bleeding that is unresponsive to endoscopic measures may require angiographic embolization or surgical resection. However, rebleeding occurs in about 15 to 25% of surgically treated patients.

Key Points

  • A variety of inherited and acquired vascular abnormalities can cause mild to moderate GI bleeding (usually lower).

  • Preferred treatment is endoscopy with coagulation of lesions.

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