A Risk Assessment of Factors for the Presence of Angiodysplasias During Endoscopy and Factors Contributing to Symptomatic Bleeding and Rebleeds

Abstract

Background: Few studies have assessed factors associated with angiodysplasias during endoscopy or factors associated with symptomatic disease.

Aims: To evaluate risk factors for the presence of and contribution to symptomatic disease in patients with angiodysplasias.

Methods: We performed a systematic MEDLINE, EMBASE and Cochrane Library search according to the PRISMA guidelines for studies assessing risk factors involved in angiodysplasias detected during endoscopy and factors that lead to anemia or overt bleeding. Study quality was assessed with the Newcastle-Ottawa scale. A risk assessment was performed by selecting risk factors identified by two independent studies and/or by a large effect size.

Results: Twenty-three studies involving 92,634 participants were included. The overall quality of the evidence was moderate. Risk factors for the diagnosis of angiodysplasias during endoscopy confirmed by at least two studies were increasing age (OR 1.09 per year, 95% CI 1.04-1.1), chronic kidney disease (OR 4.5, 95% CI 1.9-10.5) and cardiovascular disease (2.9, 95% CI 1.4-6.2). The risk of rebleeds was higher in the presence of multiple lesions (OR 4.2, 95% CI 1.1-16.2 and 3.8, 95% CI 1.3-11.3 and 8.6, 95% CI 1.4-52.6), liver cirrhosis (OR 4.0, 95% 1.1-15.0) and prothrombin time < 30% (OR 4.2, 95% 1.1-15.4) with a moderate effect size. Multiple comorbidities were associated with an increased in-hospital mortality (OR 2.29, 95% CI 1.2-4.3).

Conclusions: This systematic review identified age, chronic kidney disease and cardiovascular disease as the most important risk factors for the diagnosis of angiodysplasias during endoscopy. Multiple lesions increase the risk of recurrent bleeding.

Keywords: Angiodysplasia/angioectasia; Disease severity; Gastrointestinal bleeding; Prognosis; Risk factors; Systematic review.

Fig. 1

Angiodysplasia in the colon. Legend: the differential diagnosis of angiodysplasias consists of other vascular malformations. They are caused by different mechanisms than angiodysplasias, leading to different treatment strategies. Portal hypertensive gastropathy can only develop in the presence of increased portal pressure. Histological (submucosal) biopsies show dilation and congested, tortuous submucosal venules [7]. This also differentiates from gastric antral vascular ectasias where biopsies show the presence of fibrin thrombi in dilated capillaries and fibromuscular proliferation in the lamina propria. As the name suggests, these two vascular diseases are limited to stomach involvement. Radiation-induced telangiectasias are caused by the toxicity of radiotherapy. The found telangiectasias are often multiple, and involvement is delimited to the area that received radiation [8]. Eosinophilic infiltrates, epithelial atypia, fibrosis and capillary telangectasia can be found in histological specimens. As last, a dieulafoy lesion is a submucosal artery that erodes the overlying epithelium and is of prominent caliber due to abnormal branching without the presence of an ulcer. These lesions might not be seen during endoscopy in case they are not actively bleeding [9]. The congenital inherited diseases hereditary hemorrhagic teleangectasia, blue rubber bleb nevus syndrome and Klippel–Trénaunay syndrome can present with angiodysplastic features during endoscopy; however, these disorders often become symptomatic at a young age, and the vascular malformations are present in multiple organs [10]

Fig. 2

Flow diagram of the search results