Br. J. Surg. Vol. 66 (1979) 315-316
Angiodysplasia as a cause of colonic bleeding in the elderly H. B O G O K O W S K Y , S . S L U T Z K I AND H. A L O N * SUMMARY
Angiodysplasia is being recognized as a major causal factor of colonic haemorrhage in the elderly. Superior mesenteric arteriography in an 86-year-old lady with recurrent haemorrhage revealed the lesion. Coiifirmation of the diagnosis was made possible by the injection of contrast material into the blood vessels of the removed intestine and subsequent histological examination. ANGIODYSPLASIA in the right colon has, in recent times, become recognized as one of the most important causal factors of haemorrhage from the large bowel in the elderly. These vascular malformations of the digestive system are difficult to detect either by endoscopy or by barium meal examination. Selective arteriography of the superior mesenteric artery is the most valuable diagnostic tool. Case report An 86-year-old woman, known to be suffering from aortic stenosis and mild heart failure, was admitted with rectal bleeding in October 1975. Endoscopy and barium meal examinations failed to reveal the source of the bleeding. After blood transfusion the bleeding abated.
Fig. 2. Radiograph of the excised specimen showing the arteries, which are injected with radio-opaque material. The arrow shows the area of angiodysplasia from which histological sections were taken.
Fig. 3. Showing dilated vascular lakes in the submucosa, which are characterislic of angiodysplasia. ( x 80). Fig. 1 . Superior mesenteric arteriography showing early venous phase, with leak of contrast material into the lumen of the ascending colon (arrow).
* Department of Surgery, Asaf Harofe Government Hospital, Zerifin, and the Sackler School of Medicine, Tel-Aviv University, Israel.
316
H. Bogokowsky et al.
In February 1977 the patient was readmitted with severe rectal bleeding, and at this time a polyp was found in the sigmoid colon. It was suspected that this was the cause of the bleeding and a sigmoid colectomy was performed. Two months later the patient was again admitted with recurrent rectal bleeding. At this time selective arteriography of the superior mesenteric artery revealed a leak of contrast material into the lumen of the ascending colon (Fig. 1). The bleeding persisted and a right hemicolectomy was performed. Her postoperative course was uneventful and she was reviewed in the follow-up clinic. At her last visit in July 1978 the patient, now in her eighty-ninth year, was free of any further rectal bleeding. The diagnosis of angiodysplasia was confirmed by injection of barium diluted with Gastrografin into the blood vessels of the resected colon (Fig. 2). Arteriovenous malformations were demonstrated, and microscopic examination showed clusters of dilated blood vessels, which took the form of contrast-filled lakes in the submucosa (Fig. 3).
Discussion It has recently become apparent that angiodysplasias or vascular ectasias are responsible for colonic bleeding as frequently as diverticulosis in the elderly (Cooperman and Kelly, 1972; Margulis and Castelman, 1974; Crichlow et al., 1975; Moore et al., 1976; Boley et al., 1977; Hagihara et al., 1977; Marx et al., 1977; Welch et al., 1978). Margulis et al. in 1960 first demonstrated by arteriography the extravasation of contrast material into the intestinal lumen during active bleeding. Baum et al. (1972) initially described the pathological features of this disease, which have been further elucidated by Boley et al. (1977). The lesions are arteriovenous fistulas or aneurysms that penetrate the muscularis mucosa and are seen as submucosal vascular lakes. The aetiology of these lesions is not certain but several theories exist. Heyde (1958) found a statistical association of aortic stenosis and gastrointestinal bleeding and Williams (1961) surveyed 1443 cases of gastrointestinal bleeding at the Massachusetts General Hospital and found that there was a 25.5 per cent relationship with aortic stenosis. However, Marx et al. (1977) discounted this relationship. Baum et al. (1975) attributed these vascular malformations to a submucosal leak occurring during periods of hypotension. Boley et al. (1977) have suggested that the lesions may be caused by long term, low grade obstruction of the submucosal venules, especially where they pierce the muscular layers of the bowel. This results in retrograde dilatation of these venules, and when there is finally loss of the function of the precapillary sphincters, small arteriovenous fistulas are produced. Diagnosis is made by selective arteriography. During active bleeding there may be extravasation of contrast medium into the lumen of the bowel. This, however, occurs only if the bleeding is brisk. Pathognomonic signs are the accumulation of contrast material in vascular tufts during the capillary phase. The venous phase shows early filling of large veins, indicating arteriovenous fistulas. The arterial phase is normal.
If the lesion is detected, a right hemicolectomy is performed, since the natural history of these lesions is one of recurrent bleeding. Welch et al. (1978) report that in 12 per cent of patients who underwent only a segmental colectomy, rebleeding occurred. Boley et al. (1977) note that rebleeding is rare after right hemicolectomy. The identification of the lesions by the pathologist may be difficult unless the ‘coral head’ appearance of advanced angiodysplasia is seen (Boley et al., 1977). In order to localize the lesions, the vessels of the excised intestine were first injected with a mixture of barium in Gastrografin. The specimen was then X-rayed, revealing the area of angiodysplasia. In this way it was possible to localize the lesion and take accurate specimens for histological examination. Angiodysplasia is not known to be a major cause of colonic bleeding in the elderly. In these patients the use of arteriography and the performance of a right hemicolectomy will greatly improve the prognosis.
References s., ATHANASOULIS c. A., WALTMAN A. c. (1972) Paper presented at the 58th Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago 111. (Abstr. 181.) B A U M S., ATHANASOULIS C. A., WALTMAN A. C. et al. (1975) Angiodysplasia of the right colon as a cause of chronic gastrointestinal bleeding. Gustruenterubgy 68, 682. BOLEY s. J., SAMMARTANO s., ADAMS A. et a]. (1977) On the nature and etiology of vascular ectasias of the colon: degenerative lesions of aging. Gastroenterology 12, 650-660. COOPERMAN A. M. and KELLY K. A. (1972) Arteriovenous malformations of the intestine. An uncommon cause of gastrointestinal bleeding. Arch. Surg. 104, 284-287. CHRICHLOW R. w., MOSENTHAL w. T., SPEIGEL P. K . et al. (1975) Arteriovenous malformations of the bowel. An obscure cause of bleeding. Am. J . Sirrg. 129, 440-443. HAGIHARA P. F., CHUANG v. P. and GRIFFEN w. 0. (1977) Arteriovenous malformations of the colon. Am. J . Surg. 113, 681-686. HEYDE E. c. (1958) Gastrointestinal bleeding in aortic stenosis. N . Engl. J. Med. 259, 196. MARGULIS A. 8. and CASTELMAN B. (1974) Case records Of the Massachusetts General Hospital (Case 36, 1974). N . Engl. J. Med. 291, 569-571. MARGULIS A. R., HEINBECKER P. and BERNARD H. R. (1960) Operative mesenteric arteriography in the search for the site of bleeding in unexplained gastrointestinal hemorrhage. Surgery 48, 534-539. MARX F. w., GRAY R. K., DUNCAN A. M. et al. (1977) Angiodysplasia as a source of intestinal bleeding. Am. J . Surg. 134, 125-130. MOORE J. D., THOMPSON N. w., APPLEMAN H. D. et al. (1976) Arteriovenous malformations of the gastrointestinal tract. Arch. Surg. 111, 381-388. WELCH c. E., ATHANASOULIS c. A. and GADABINI M. D. (1978) Hemorrhage from the large bowel with special reference to angiodysplasia and diverticular disease. World J. Surg. 2, 73-83. WILLIAMS R. c. (1961) Aortic stenosis and unexplained gastrointestinal bleeding. Arch. Intern. Med. 108, 859-864. BAUM
Paper accepted 10 November 1978.
Angiodysplasia as a cause of colonic bleeding in the elderly H. B O G O K O W S K Y , S . S L U T Z K I AND H. A L O N * SUMMARY
Angiodysplasia is being recognized as a major causal factor of colonic haemorrhage in the elderly. Superior mesenteric arteriography in an 86-year-old lady with recurrent haemorrhage revealed the lesion. Coiifirmation of the diagnosis was made possible by the injection of contrast material into the blood vessels of the removed intestine and subsequent histological examination. ANGIODYSPLASIA in the right colon has, in recent times, become recognized as one of the most important causal factors of haemorrhage from the large bowel in the elderly. These vascular malformations of the digestive system are difficult to detect either by endoscopy or by barium meal examination. Selective arteriography of the superior mesenteric artery is the most valuable diagnostic tool. Case report An 86-year-old woman, known to be suffering from aortic stenosis and mild heart failure, was admitted with rectal bleeding in October 1975. Endoscopy and barium meal examinations failed to reveal the source of the bleeding. After blood transfusion the bleeding abated.
Fig. 2. Radiograph of the excised specimen showing the arteries, which are injected with radio-opaque material. The arrow shows the area of angiodysplasia from which histological sections were taken.
Fig. 3. Showing dilated vascular lakes in the submucosa, which are characterislic of angiodysplasia. ( x 80). Fig. 1 . Superior mesenteric arteriography showing early venous phase, with leak of contrast material into the lumen of the ascending colon (arrow).
* Department of Surgery, Asaf Harofe Government Hospital, Zerifin, and the Sackler School of Medicine, Tel-Aviv University, Israel.
316
H. Bogokowsky et al.
In February 1977 the patient was readmitted with severe rectal bleeding, and at this time a polyp was found in the sigmoid colon. It was suspected that this was the cause of the bleeding and a sigmoid colectomy was performed. Two months later the patient was again admitted with recurrent rectal bleeding. At this time selective arteriography of the superior mesenteric artery revealed a leak of contrast material into the lumen of the ascending colon (Fig. 1). The bleeding persisted and a right hemicolectomy was performed. Her postoperative course was uneventful and she was reviewed in the follow-up clinic. At her last visit in July 1978 the patient, now in her eighty-ninth year, was free of any further rectal bleeding. The diagnosis of angiodysplasia was confirmed by injection of barium diluted with Gastrografin into the blood vessels of the resected colon (Fig. 2). Arteriovenous malformations were demonstrated, and microscopic examination showed clusters of dilated blood vessels, which took the form of contrast-filled lakes in the submucosa (Fig. 3).
Discussion It has recently become apparent that angiodysplasias or vascular ectasias are responsible for colonic bleeding as frequently as diverticulosis in the elderly (Cooperman and Kelly, 1972; Margulis and Castelman, 1974; Crichlow et al., 1975; Moore et al., 1976; Boley et al., 1977; Hagihara et al., 1977; Marx et al., 1977; Welch et al., 1978). Margulis et al. in 1960 first demonstrated by arteriography the extravasation of contrast material into the intestinal lumen during active bleeding. Baum et al. (1972) initially described the pathological features of this disease, which have been further elucidated by Boley et al. (1977). The lesions are arteriovenous fistulas or aneurysms that penetrate the muscularis mucosa and are seen as submucosal vascular lakes. The aetiology of these lesions is not certain but several theories exist. Heyde (1958) found a statistical association of aortic stenosis and gastrointestinal bleeding and Williams (1961) surveyed 1443 cases of gastrointestinal bleeding at the Massachusetts General Hospital and found that there was a 25.5 per cent relationship with aortic stenosis. However, Marx et al. (1977) discounted this relationship. Baum et al. (1975) attributed these vascular malformations to a submucosal leak occurring during periods of hypotension. Boley et al. (1977) have suggested that the lesions may be caused by long term, low grade obstruction of the submucosal venules, especially where they pierce the muscular layers of the bowel. This results in retrograde dilatation of these venules, and when there is finally loss of the function of the precapillary sphincters, small arteriovenous fistulas are produced. Diagnosis is made by selective arteriography. During active bleeding there may be extravasation of contrast medium into the lumen of the bowel. This, however, occurs only if the bleeding is brisk. Pathognomonic signs are the accumulation of contrast material in vascular tufts during the capillary phase. The venous phase shows early filling of large veins, indicating arteriovenous fistulas. The arterial phase is normal.
If the lesion is detected, a right hemicolectomy is performed, since the natural history of these lesions is one of recurrent bleeding. Welch et al. (1978) report that in 12 per cent of patients who underwent only a segmental colectomy, rebleeding occurred. Boley et al. (1977) note that rebleeding is rare after right hemicolectomy. The identification of the lesions by the pathologist may be difficult unless the ‘coral head’ appearance of advanced angiodysplasia is seen (Boley et al., 1977). In order to localize the lesions, the vessels of the excised intestine were first injected with a mixture of barium in Gastrografin. The specimen was then X-rayed, revealing the area of angiodysplasia. In this way it was possible to localize the lesion and take accurate specimens for histological examination. Angiodysplasia is not known to be a major cause of colonic bleeding in the elderly. In these patients the use of arteriography and the performance of a right hemicolectomy will greatly improve the prognosis.
References s., ATHANASOULIS c. A., WALTMAN A. c. (1972) Paper presented at the 58th Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago 111. (Abstr. 181.) B A U M S., ATHANASOULIS C. A., WALTMAN A. C. et al. (1975) Angiodysplasia of the right colon as a cause of chronic gastrointestinal bleeding. Gustruenterubgy 68, 682. BOLEY s. J., SAMMARTANO s., ADAMS A. et a]. (1977) On the nature and etiology of vascular ectasias of the colon: degenerative lesions of aging. Gastroenterology 12, 650-660. COOPERMAN A. M. and KELLY K. A. (1972) Arteriovenous malformations of the intestine. An uncommon cause of gastrointestinal bleeding. Arch. Surg. 104, 284-287. CHRICHLOW R. w., MOSENTHAL w. T., SPEIGEL P. K . et al. (1975) Arteriovenous malformations of the bowel. An obscure cause of bleeding. Am. J . Sirrg. 129, 440-443. HAGIHARA P. F., CHUANG v. P. and GRIFFEN w. 0. (1977) Arteriovenous malformations of the colon. Am. J . Surg. 113, 681-686. HEYDE E. c. (1958) Gastrointestinal bleeding in aortic stenosis. N . Engl. J. Med. 259, 196. MARGULIS A. 8. and CASTELMAN B. (1974) Case records Of the Massachusetts General Hospital (Case 36, 1974). N . Engl. J. Med. 291, 569-571. MARGULIS A. R., HEINBECKER P. and BERNARD H. R. (1960) Operative mesenteric arteriography in the search for the site of bleeding in unexplained gastrointestinal hemorrhage. Surgery 48, 534-539. MARX F. w., GRAY R. K., DUNCAN A. M. et al. (1977) Angiodysplasia as a source of intestinal bleeding. Am. J . Surg. 134, 125-130. MOORE J. D., THOMPSON N. w., APPLEMAN H. D. et al. (1976) Arteriovenous malformations of the gastrointestinal tract. Arch. Surg. 111, 381-388. WELCH c. E., ATHANASOULIS c. A. and GADABINI M. D. (1978) Hemorrhage from the large bowel with special reference to angiodysplasia and diverticular disease. World J. Surg. 2, 73-83. WILLIAMS R. c. (1961) Aortic stenosis and unexplained gastrointestinal bleeding. Arch. Intern. Med. 108, 859-864. BAUM
Paper accepted 10 November 1978.
