Diagnosis and therapeutic strategies for small bowel vascular lesions

Abstract

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.

Keywords: Angiodysplasia; Angioectasia; Argon plasm coagulation; Arteriovenous malformation; Deep enteroscopy; Dieulafoy’s lesion; Obscure gastrointestinal bleeding; Video capsule endoscopy.

Figure 1

Representative images of angioectasia. A: Video capsule endoscopy confirmed multifocal jejunal angioectasias in patients with chronic anemia; B: Double balloon endoscopy identified an angioectasia classified into Yano-Yamamoto classification Type 1b; C: Argon plasm coagulation cauterization was successfully performed.

Figure 2

Representative images of Dieulafoy’s lesion. A: Video capsule endoscopy confirmed active bleeding from unknown origin in patient with ongoing overt obscure gastrointestinal bleeding; B: Arterial bleeding occurred from a jejunal punctuate lesion classified into Yano-Yamamoto classification Type 2a; C: Successful hemostasis was achieved by combination of argon plasm coagulation cauterization and endoclips.

Figure 3

Representative images of arteriovenous malformation. A: Video capsule endoscopy confirmed active bleeding from jejunum in young patient with ongoing overt obscure gastrointestinal bleeding; B: Double balloon endoscopy identified pulsating subepithelial tumor classified into Yano-Yamamoto classification Type 4; C: Subsequent to endoscopic tattooing, surgical resection was performed; D: Pathological examination revealed a vascular malformation in the submucosa.

Figure 4

Diagnostic algorithm for small bowel vascular lesions. Note: ¹Computed tomography (CT) scan is especially recommended for patients with ongoing overt obscure gastrointestinal bleeding (OGIB). CT enterography can be replaced to multiphase CT or radionuclide scanning, considering patients general condition; ²Repeated video capsule endoscopy is recommended if the disease presentation changes from occult to overt or if a rapid decrease in the serum hemoglobin level is confirmed. Urgent deep enteroscopy may be useful to reveal the bleeding source in patients with recurrent overt OGIB; ³Surgical intervention with intra-operative endoscopy will be conducted when superselective transcatheter embolization was failed. Meanwhile subsequent endoscopic examination is recommended to reveal bleeding origin, even if hemodynamic instability was relieved. OGIB: Obscure gastrointestinal bleeding; CTE: Computed tomography enteroscopy; VCE: Video capsule endoscopy; DE: Deep enteroscopy; IOE: Intra-operative endoscopy; CT: Computed tomography.

Figure 5

Therapeutic algorithm for small bowel vascular lesions. Note: ¹Pharmacological treatment is recommended for patients whom endoscopy is contraindicated. Meanwhile conservative approach with iron supplementation remains an option for patients with mild anemia; ²Subsequent pharmacological treatment after successful endoscopic treatment may be useful as an adjunct therapy, especially for patients with a high risk of re-bleeding; ³Arteriovenous malformation usually requires surgical resection because of their relatively large size and tendency to re-bleed. AE: Angioectasia; DL: Dieulafoy’s lesion; AVM: Arteriovenous malformation; APC: Argon plasm coagulation; OCT-LAR: Long-acting release octreotide.