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; Dieulafoy’s lesion; Arteriovenous malformation; Obscure gastrointestinal bleeding; Video capsule endoscopy; Deep enteroscopy; Argon plasm coagulation

Core tip: Angiodysplasia includes a variety of synonymous disease concepts such as angioectasia, Dieulafoy’s lesion and arteriovenous malformation. Although these lesions are the most common causes of small bowel bleeding, optimal management strategies have not been established. We propose that these lesions should be addressed separately when determining diagnostic and therapeutic plans because of their clinical heterogeneity. In this review, we focused on differences in their epidemiology, pathology and clinical presentation and discussed the currently available diagnostic and therapeutic options that may be used to control small bowel bleeding, which consequently improve patient quality of life.