Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points

Table 1 Risk factors for gastrointestinal angiodysplasias

Risk factors for gastrointestinal angiodysplasias
1 Age > 60 yr
2 Chronic obstructive pulmonary disease
3 Aortic stenosis (Heyde´s disease)
4 Low-flow left ventricular assist devices
5 Von Willebrand disease
6 Venous thromboembolism
7 Ischemic heart disease
8 Liver cirrhosis
9 Drugs1: Anti-platelet
Anti-coagulant
Anti-thrombotic

¹Related with bleeding induction.

Table 2 Stratification of small bowel angiodysplasias based on endoscopic characteristics by video capsule endoscopy or device-assisted enteroscopy, clinical manifestations, bleeding causality and hemorrhagic recurrence probability (García-Compeán D et al)

Type	Endoscopic characteristics	Bleeding causality	Clinical manifestations	Bleeding recurrence probability
Type 1	Punctuated or patchy lesions with non-pulsatile active bleeding	Certain	Overt bleeding; high frequency of hemodynamic instability	Very high, without hemostatic treatment
Type 2	Non-actively bleeding lesion; stigmata of hemorrhage (ulcer, adherent clot, digested blood debris)	High	Frequently overt bleeding; lower frequency of hemodynamic instability than Type 1 lesions	Highly likely
Type 3	Bright red spots; typical images	Moderate or mild	Overt or occult bleeding; low or null frequency of hemodynamic instability Iron deficiency anemia	Moderate rate; frequently IDA is dependent on iron supplements or blood transfusion
Type 4	Pale red spots	Low or null	Generally occult bleeding Chronic IDA; extra digestive cause of bleeding should be ruled out	When other sources of bleeding have been excluded, re-bleeding is low

IDA: Iron deficient anemia.

Table 3 Prospective and controlled trials evaluating the efficacy of hormonal therapy, somatostatin analogues and thalidomide in patients with recurrent bleeding due to gastrointestinal angiodysplasias confirmed by endoscopy

Author (yr)	Design	n	Treatment	Follow–up (mo)	Results
Hormonal therapy
Van Cutsem et al[98], 1990	DB, Cr Ov, Rx vs P,	10	Oral Ethinyloestradiol and norethisterone for 6 mo	6	Significant reduction of transfusion requirement in Rx patients vs controls (P < 0.003). Non-significant side effects in treated patients
Barkin and Ross[99],1998	Cohort	25	Oral Mestranol and norethynodrel or norethinidrone	18 (1-52)	None patients rebled during Rx. Side effects in 44% of patients
Junquera et al[100], 2001	R, DB, Rx vs P	Rx = 33 P = 35	Oral Norethisterone and ethinylstradiol for 1-2 yr	12 (12-36)	Bleeding recurrence: Rx = 39% vs P = 46%; P = NS
Somatostatin analogues
Nardone et al[106], 1999	Cohort	17	SC Octreotide 100 µg/8 h for 6 mo	12	Rates of complete, partial and non-response were 59%, 23% and 18% respectively; non-significant side effects
Junquera et al[107], 2007	Cohort, Rx vs P	Rx = 32 P = 38	SC Octreotide 50 µg/12 h for 12-24 mo	13 (12-36)	Bleeding recurrence: Rx = 23% vs P = 48% (P = 0.04); major adverse effects: Rx = 3.1% vs P = 2.6%
Scaglione et al[111], 2007	Cohort	13	IM Lanreotide 10 mg/mo for 12 mo	33 (12-60)	Rates of complete, partial and non-response were 70% and 23% respectively; non-significant side effects were observed
Molina et al[111], 2009	Cohort	11	IM Lanreotide 20 mg/mo	15 (5-48)	Patients with serious comorbidities; treatment reduced transfusion requirements and bleeding related hospitalizations
Bon et al[113], 2012	Cohort	15	IM Lanreotide 20 mg/mo for 12 mo	14 (10-36)	Rx significantly reduced bleeding recurrences, transfusion requirements and increased serum Hb levels; side effect were rare
Holleran et al[108], 2016	Cohort	24	IM Lanreotide 20 mg/mo for 3 mo	8 (3-17)	Rates of complete, partial and non-response were 70%, 20% and 10% respectively; adverse events: 30%
Thalidomide
Ge et al[121], 2011	Cohorts Rx vs C	R = 28 C: 27	Oral thalidomide 100 mg/day for 4 mo; oral iron 400 mg/day for 4 mo	39 (8-52)	Rate of response; Rx = 71.4 vs 3.7%; non-significant side effects
Garrido et al[119], 2012	Cohort	12	Oral 200 mg/day for 4 mo	4	Increase of serum Hb levels; severe side effects requiring Rx discontinuation in 17%

R: Randomized; DB: Double blind; Cr Ov: cross over; Rx: Treatment; P: Placebo; C: Controls; IM: Intramuscular; SC: Subcutaneous; NS: Non-significant.