What is the primary treatment for Angiodysplasia (Angiodysplasia syndrome)?

Primary Treatment for Angiodysplasia Syndrome

The primary treatment for angiodysplasia syndrome is endoscopic therapy with argon plasma coagulation (APC), which resolves bleeding in approximately 85% of patients with colonic angiodysplasia. 1

Diagnosis and Localization

• Angiodysplasia lesions are recognized at colonoscopy by their characteristic appearance as red, fern-like flat lesions consisting of ectatic blood vessels that radiate from a central feeding vessel, typically 2-10 mm in diameter, sometimes with a pale mucosal halo around the lesion 2
• Most angiodysplasia lesions (54-62%) are detected in the cecum and ascending colon, followed by the sigmoid colon (18%) and rectum (14%) 2, 3
• When the colon is examined completely, the sensitivity of colonoscopy for detecting angiodysplasia exceeds 80% 2
• Angiography remains the gold standard for diagnosis of angiodysplasia with 100% specificity but lower sensitivity (30-47%) 2
• Video capsule endoscopy should be performed as soon as possible in patients with ongoing bleeding after negative upper and lower endoscopy, as diagnostic yield decreases with each day of delay 2

Endoscopic Treatment Options

Argon Plasma Coagulation (First-Line)

• Argon plasma coagulation, a non-contact method of electrocoagulation, is the preferred first-line treatment for bleeding colonic angiodysplasia 2
• Long-term outcomes show that APC resolves overt bleeding and stabilizes hemoglobin levels without transfusions or iron therapy in 85% of patients 1
• The probability of remaining free of rebleeding at one and two year follow-up is 98% and 90%, respectively 1
• Complication rates with APC are low (approximately 1.7%) 1

Contact Thermal Methods

• Conventional endoscopic treatment can also be performed with contact thermal probes 2
• For large angiodysplasia, cauterization should proceed from the outer margin toward the center to obliterate feeder vessels 2
• Technical parameters for heater probe treatment include:
  • Large probe size for active bleeding
  • Power setting of 10-15 joules
  • Light pressure application
  • Endpoint is when bleeding stops 2

Other Endoscopic Options

• Injection therapy with sclerosing agents (such as ethanolamine) has been described but is not widely employed 2
• Consider injection with 1:10,000 adrenaline prior to endoscopic coagulation in cases of active bleeding 2

Special Considerations

• Extra care must be taken when treating lesions in the cecum to avoid perforation 2
• The use of narcotic medication for sedation may decrease the sensitivity of colonoscopy for detecting angiodysplasia by transiently decreasing mucosal blood flow 2
• Administration of intravenous naloxone can enhance the appearance of angiodysplasia during colonoscopy in patients who have received meperidine for sedation, though this may result in patient discomfort 2

Alternative Treatments for Refractory Cases

Angiographic Interventions

• For patients with severe unremitting bleeding, angiography can be both diagnostic and therapeutic 2
• Hemostasis can be achieved by intra-arterial infusion of vasopressin or arterial embolization 2
• Intra-arterial vasopressin infusion controls hemorrhage in up to 91% of patients with lower GI bleeding from angiodysplasia, though bleeding recurs in up to 50% after cessation 2
• Terlipressin (a longer-acting synthetic vasopressin analogue) has been used successfully as a single bolus intra-arterial injection 2

Surgical Management

• Surgical treatment may be considered for patients with refractory bleeding not controlled by endoscopic or angiographic methods 4
• Surgery has shown a frequency of rebleeding less than half that of medical and endoscopic treatment groups in some studies, though this difference did not reach statistical significance (p=0.15) 4

Management of Chronic Iron Deficiency Anemia

• In patients with angiodysplasia presenting with chronic iron deficiency anemia, iron supplementation should be continued for three months after correction of anemia to replenish iron stores 2
• For patients with transfusion-dependent iron deficiency anemia and suspected small bowel angiodysplasia, enteroscopy may be helpful to detect and treat lesions 2
• Video capsule endoscopy should be considered in selected cases of unexplained mild chronic iron-deficiency anemia 2

Follow-up Recommendations

• After successful treatment, monitor hemoglobin concentration and red cell indices at regular intervals (suggested every three months for one year and then after a further year) 2
• Provide additional oral iron if hemoglobin or MCV falls below normal 2
• Consider repeat investigations (endoscopy, colonoscopy, and/or capsule endoscopy) in patients with recurrent bleeding 2