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Vascular ectasia as an example of chronic bleeding from the gastrointestinal tract
Vascular ectasia, or angio dysplasia, is one of the common causes of both profuse and minor prolonged bleeding from the lower parts of the gastrointestinal tract. Most of them are associated with age-related degenerative changes in the vascular wall in the elderly. In other age groups, vascular wall disorders can be congenital. Two-thirds of patients with small intestinal angio dysplasia are older than 70 years. Angio-dysplastic lesions are usually multiple, less than 5 mm in diameter and localized in the cecum and in the right part of the transverse colon (Fig. 9-6). There is some correlation with aortic stenosis. The diagnosis of vascular ectasia is made according to the results of colonoscopy and angiography (ectasia is detected even in the absence of bleeding). Thus, the presence of angiodysplasia in patients with repeated bleeding in the absence of other sources of blood loss is the basis for initiating therapy.
The pathogenesis of angiodysplasia is not fully understood. There is a theory that angio-dysplastic changes are associated with periodic obstruction of the veins of the submucosal layer of the intestine at the points of passage through the muscle fibers, which leads to their expansion and change in the vascular wall. Sometimes dilatation of the entire arterio-capillary-venous complex may occur with impaired arteriovenosis
Typical angio-dyslastic changes in the colon mucosa
The predominant localization of angio-dysplastic changes in the cecum and the right part of the ileum is associated with a higher intraluminal pressure in this part of the intestine.
In approximately 5% of patients, despite an intensive examination (radiological, endoscopic, angiographic), it is not possible to identify the source of bleeding. The source of blood loss in such patients, apparently, are vascular ectasia. Unfortunately, most of these changes are so small that they cannot be detected by angiographic and endoscopic examinations.
If angio-dysplastic changes are detected, it is advisable to carry out their cauterization under endoscopic control. In the case of multiple bowel lesions, or the impossibility of endoscopic ablation (cauterization), a resection of the affected intestine is performed. With a combination of vascular ectasia with chronic renal failure and with a corresponding increase in bleeding time due to platelet dysfunction, it is advisable to carry out estrogen progesterone therapy. This therapy is also effective in the absence of manifestations of renal failure. Treatment with a combination of estrogen and progesterone can be carried out for patients with angio dysplasia even in the absence of a definitive diagnosis. In case of impossibility of surgical treatment of bleeding (localization, severe concomitant pathology not found), supportive blood transfusions are carried out.
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Vascular ectasia as an example of chronic bleeding from the gastrointestinal tract
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