Colonoscopic and Clinical Features of Colonic Angiodysplasia: A Study in 54 Patients : Surgical Laparoscopy Endoscopy & Percutaneous Techniques

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Colonoscopic and Clinical Features of Colonic Angiodysplasia: A Study in 54 Patients

Zhang, Chenchen MSc; Wang, Yanan MD; Zhang, Dongdong MSc; Li, Shuai MD

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Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 33(2):p 115-120, April 2023. | DOI: 10.1097/SLE.0000000000001159
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Abstract

Colonic angiodysplasia refers to a non-neoplastic lower gastrointestinal (GI) vascular malformation, which is different from hemangioma.1 According to the Moore et al2 classification, this condition is defined as solitary type, which can occur as a solitary vascular disorder of the colon or a manifestation of systemic disease or syndrome in the digestive tract. Colonic angiodysplasia most often occurs in people aged over 60 years, and its incidence increases with age.3 Previous research has defined the incidence of colonic angiodysplasia between 0.6% and 6.2%.4–6 Nevertheless, the incidence is probably an underestimate as a majority of the patients are asymptomatic, and many endoscopists may lack adequate awareness of the disease.7 It is reported that mucosal ischemia and vascular degeneration could play critical roles in the development process, and most cases are associated with a history of chronic disorders, such as liver cirrhosis, renal failure, type 2 diabetes mellitus (T2DM), and hypertension.8 However, the exact etiology of colonic angiodysplasia remains unclear.

Generally, asymptomatic patients require no further treatment; however, colonic angiodysplasia is probably the most common cause of recurrent lower GI bleeding in elderly patients, in whom complex endoscopic or surgical procedures are required.9 At present, the diagnosis of colonic angiodysplasia in patients with lower GI bleeding remains difficult and the optimal modality remains controversial. Colonoscopy is the primary method of diagnosis, with a positivity rate of >90.0%.10 Argon plasma coagulation (APC) therapy is acknowledged as an effective endoscopic treatment.11,12 Other endoscopic treatments (laser, sclerotherapy, norepinephrine injection, etc.) and estrogen-progesterone therapies can also achieve a certain efficacy for a small amount of bleeding. Interventional and surgical treatments are often required in patients with large bleeding volumes and accurate lesion positioning.13

Previous studies have shown the clinical characteristics, GI distribution, and risk factors of colonic angiodysplasia.1,3–5,10 However, it has not yet been claimed the risk factors for active bleeding in patients with colonic angiodysplasia and the differences between patients with lower GI bleeding caused by colonic angiodysplasia and those by other diseases. Identification of these issues may raise awareness of endoscopists regarding this disease and help clinicians establish an appropriate approach for patients based on their individual characteristics.

MATERIALS AND METHODS

Study Population

We performed a retrospective study at the Second Hospital, Cheeloo College of Medicine, Shandong University between September 2013 and April 2022. Patients older than 18 years, and in whom evidence of angiodysplasia was displayed during the colonoscopy were enrolled in the study. The typical endoscopic characteristics of colonic angiodysplasia were as follows: single or multiple, sporadic or diffuse, spotty or patchy, red arachnid lesions, flat or slightly raised, radiating outwards, dilatation of mucosal capillaries, and the diameter ranging from ~5 mm to 12 mm (Fig. 1). The lesions may locate in different segments of the colorectum with active bleeding or not. Exclusion criteria were: patients diagnosed with hereditary hemorrhagic angiodysplasia,14 incomplete clinical data, incomplete examination of the entire colon, and poor bowel preparation before colonoscopy. The flowchart of the study population is shown in Figure 2.

F1
FIGURE 1:
Typical appearances of colonic angiodysplasia under colonoscopy. A and B, Isolated flat lesions and bright dendroid vessels. A, white light imaging; B, narrow band imaging. C, Isolated flat lesion, arachnid vessels, and narrow-band imaging. D and E, Diffuse flat lesions, dendritic dilatation, and white light imaging. F, Diffuse slightly raised lesions (radiation proctitis with angiodysplasia), patchy dilatation, and white light imaging. G, Isolated slightly raised lesions, patchy dilatation, and white light imaging. H, Isolated flat lesions, spotty dilatation, and white light imaging.
F2
FIGURE 2:
The flowchart of the study population.

This study was performed in accordance with the principles of the Declaration of Helsinki. All information was anonymized to protect patient privacy. Therefore, the requirement for obtaining informed consent was exempted. This exemption and the research approach were granted by the Ethics Committee of the Second Hospital, Cheeloo College of Medicine, Shandong University (Ethical approval number: KYLL-2022LW064).

Data Collection and Study Definitions

Data on the clinical and coloscopic features of the study population, including age, sex, chief complaints, history of chronic diseases, smoking, alcohol consumption, disease progression, and related treatments, were collected by reviewing the medical records and electronic databases. Liver cirrhosis, hyperlipidemia, arteriosclerosis, and T2DM were diagnosed using laboratory tests or/and imaging examinations (multislice spiral computed tomography, ultrasound, magnetic resonance imaging, and computed tomography angiography), while also based on previous diagnostic records. Hypertension was defined as systolic/diastolic blood pressure ≥130/85 mm Hg or receiving treatment for the disease.

Isolated lesions could be calculated and labeled according to their location in the colon. The right colon includes the cecum, ascending colon, and transverse colon, whereas the left colon includes descending colon, sigmoid, and rectum. The total colon comprises both the left colon and right colon. The typical appearances of colonic angiodysplasia were divided into bright dendroid lesions, arachnid lesions, patchy dilatation, and spotty dilatation lesions according to the distribution and arrangement of microvessels under colonoscopy. Active bleeding was defined as hematochezia or positive fecal occult blood test. The clinical and colonoscopic features of colonic angiodysplasia patients with active bleeding were analyzed and compared with those of patients without bleeding. A single lesion means 1 isolated lesion in the colon. Multiple lesions were defined as more than 1 isolated lesion or diffuse lesions in the colon. Comparisons were also conducted between patients with active bleeding caused by colonic angiodysplasia and those by other diseases. Rectal angiodysplasia may develop as a complication of radiotherapy, followed by chronic radiation proctitis. Patients underwent radiotherapy at a public tertiary hospital. Antiplatelet drugs included aspirin and clopidogrel.

Colonoscope Examination

Colonoscopies were completed with a standard colonoscope (CF H260AI or CF-HQ290I; Olympus) by experienced endoscopists who had experience performing more than 500 colonoscopies. The endoscopists aimed for a withdrawal time of ≥6 minutes according to the current quality indicators for colonoscopy. Air insufflation was used in all procedures. The detailed colonoscopy procedure was explained to each participant before the scheduled colonoscopy appointment. Polyethylene glycol (Klean-PrepR, Helsinn Birex Pharmaceuticals Ltd.) was used as the standardized bowel preparation. Before the procedure, all patients received a sedation regimen comprising midazolam 2.5 mg and meperidine 25 mg, and further doses were administered according to the needs of the participants. Bowel preparation was reported according to the Boston bowel preparation scale, and a preparation scale score ≥6 was considered good. The cecal intubation rates were also retrieved and summed.

Statistical Analyses

Data were statistically analyzed using SPSS (version 28.0; IBM). The measurement data were expressed as the mean ± SD; categorical data were expressed as numbers and percentages, and comparisons between the groups were performed using χ2, Fisher exact test, and unpaired t tests. Statistical significance was set at P <0.05.

RESULTS

Clinical Manifestations

Fifty-four eligible patients (32 men and 22 women) were included in this study; 55.55% of the participants were aged over 60 years; the mean age was 61.20 ± 11.90 years (ages ranging from 32 to 80 years). In total, 10 of the 54 patients (18.52%) experienced lower digestive bleeding caused by colonic angiodysplasia, of 3 whom patients were diagnosed with radiation proctitis. Twenty-four patients (44.44%) presented with no symptoms. Abdominal pain or distension was a common complaint but could be attributed to other colonic lesions. Details of the clinical manifestations are presented in Table 1.

TABLE 1 - Clinical Features of Patients With Colonic Angiodysplasia
Variables Patients with colonic angiodysplasia, (N = 54); n (%)
Sex
 Men 32 (59.26)
 Women 22 (40.74)
Age (y)
 <40 4 (7.41)
 40-60 20 (37.04)
 >60 30 (55.55)
Chief complaints
 Asymptomatic 24 (44.44)
 Active bleeding* 10 (18.52)
 Changed bowel habits 2 (3.71)
 Abdominal pain or distension 18 (33.33)
*Active bleeding means hematochezia or positive fecal occult blood test caused by colonic angiodysplasia.

Colonoscopic Findings

Some patients with colonic angiodysplasia also presented with other lesions, including polyps (n = 34), colitis and proctitis (n = 10), melanosis coli (n = 2), and colonic diverticulum (n = 9). Thirty-two patients were characterized by single and isolated lesions, 10 patients suffered from more than 1 isolated lesion, and 12 patients had diffuse lesions. As shown in Figure 3, 35 lesions of the 52 isolated lesions were located in the right colon and 17 lesions in the left colon. In contrast, diffuse lesions were more likely to be located in the total colon (P = 0.000). The main appearance of isolated lesions was patchy dilated lesion (32.69%) and flat (69.23%), and diffuse lesions were most commonly bright dendroid lesions (41.67%), but not statistically significant. Only 4 isolated lesions were linked to active GI bleeding, but 6 patients with diffuse lesions experienced active bleeding (7.69% vs 50.0%, P = 0.002). The relevant results are presented in Table 2.

F3
FIGURE 3:
The distribution of 52 isolated lesions in 42 patients, with 35 lesions in the right colon and 17 lesions in the left colon.
TABLE 2 - Colonoscopic Features of Isolated and Diffuse Lesions of Colonic Angiodysplasia
Variables Isolated lesion (N = 52); n (%) Diffuse lesions (N = 12); n (%) P
Location 0.000
 Left colon 17 (32.69) 3 (25.0)
 Right colon 35 (67.31) 0
 Total colon 0 9 (75.0)
Typical appearances 0.747
 Bright dendroid 14 (26.92) 5 (41.67)
 Arachnid 16 (30.77) 2 (16.67)
 Patchy dilatation 17 (32.69) 4 (33.33)
 Spotty dilatation 5 (9.62) 1 (8.33)
Flat or slightly raised 0.206
 Slightly raised 16 (30.77) 6 (50.0)
 Flat 36 (69.23) 6 (50.0)
Active bleeding* 0.002
 Yes 4 (7.69) 6 (50.0)
 No 48 (92.31) 6 (50.0)
Bold values indicates significant P value.
*Active bleeding means hematochezia or positive fecal occult blood test.

Comparison of Clinical And Colonoscopic Features Between Colonic Angiodysplasia Patients With and Without Lower GI Bleeding

In total, 10 patients with colonic angiodysplasia suffered from active lower GI bleeding and were enrolled in the bleeding group (Table 3). Forty-four patients without active GI bleeding were enrolled in the no-bleeding group. The average ages in the bleeding and no-bleeding groups were 64.30 ± 9.48 and 60.50 ± 12.37 years, respectively, with no statistically significant difference (P = 0.367). The proportion of men was higher in the no-bleeding group than in the bleeding group (P = 0.037). There were no significant differences in smoking or alcohol consumption between the groups. As to comorbid chronic diseases, the prevalence of T2DM in the bleeding group was higher than that in the no-bleeding group (P = 0.035), and no differences were seen among the prevalence of liver cirrhosis, hyperlipidemia, arteriosclerosis, or hypertension. Furthermore, all 3 patients who underwent radiotherapy were in the bleeding group (P < 0.001) and 2 patients received APC therapy for active rectal bleeding (Fig. 4). Antiplatelet drugs were used more often in the bleeding group than in the no-bleeding group (P = 0.012). Lesions located in the right colon might harbor a lower risk of bleeding (P = 0.119). Most patients with multiple lesions belonged to the bleeding group (P = 0.037).

TABLE 3 - Comparison of Clinical and Colonoscopic Features Between Patients With and Without GI Bleeding
Variables Bleeding group (N = 10); n (%) No bleeding group (N = 44); n (%) P
Age (y); mean±SD 64.30±9.48 60.50±12.37 0.367
Sex (M) 3 (30.0) 29 (65.91) 0.037
Smoking 2 (20.0) 13 (29.55) 0.517
Alcohol consumption 1 (10.0) 11 (25.00) 0.286
Chronic disease history
 Liver cirrhosis 1 (10.0) 6 (13.64) 0.757
 Hyperlipidemia 0 3 (6.82) 0.396
 Arteriosclerosis 3 (30.0) 9 (20.45) 0.512
 T2DM 3 (30.0) 3 (6.82) 0.035
 Hypertension 2 (20.0) 4 (9.09) 0.322
Undergone radiotherapy 3 (30.0) 0 <0.001
Usage of antiplatelet drugs 3 (30.0) 2 (4.55) 0.012
Location 0.119
 Right colon 2 (20.0) 25 (56.82)
 Left colon 4 (40.0) 10 (22.73)
 Total colon 4 (40.0) 9 (20.45)
Number 0.037
 Single* 3 (30.0) 29 (65.91)
 Multiple 7 (70.0) 15 (34.09)
Bold values indicates significant P value.
*Single lesion means one isolated lesion in the colon.
Multiple lesions were defined as more than 1 isolated lesion or diffuse lesions in the colon.
GI indicates gastrointestinal; T2DM, type 2 diabetes mellitus.

F4
FIGURE 4:
The Argon plasma coagulation (APC) therapy for rectal angiodysplasia (caused by long-term radiotherapy) with active bleeding. A, Before APC therapy. B, During APC therapy, the APC probe could be seen. C, After APC therapy.

Characteristics of Patients With Active Lower GI Bleeding Caused by Colonic Angiodysplasia and Those by Other Diseases

Besides colonic angiodysplasia, many other diseases could induce lower GI bleeding, including colonic ulcers, colorectal cancers, diverticulum of the colon, ischemic bowel disease, small intestinal lesions, and hemorrhoids. This study retrospectively compared patients admitted at the same period with active lower GI bleeding caused by colonic angiodysplasia and those by other diseases. The average age of the patients was 64.30 ± 9.48 years in the colonic angiodysplasia group and 59.34 ± 17.57 years in the other diseases group, with no statistical significance between the groups. There were no significant sex or therapy method differences between the groups. The duration between bleeding and admission was longer in the colonic angiodysplasia group than in the other diseases group (182.50 ± 158.0 days vs 58.54 ± 202.32 days, P = 0.043). Although there were no significant differences in the systolic blood pressure, heart rate, or hemoglobin level at admission between the two groups, the shock index was higher in the colonic angiodysplasia group than in the other diseases group (0.61 ± 0.10 vs 0.69 ± 0.20, P = 0.045). The average hospital stay was longer in the colonic angiodysplasia group at 13.80 ± 11.55 days compared with 9.04 ± 4.74 days in the other diseases group (P = 0.228). The reasons for bleeding were identified by a 1-time colonoscopy in the majority of patients. Bleeding relapsed in 3 patients in the colonic angiodysplasia group, and the rate of bleeding recurrence was higher in the colonic angiodysplasia group than in the other disease groups (P < 0.001). The results of this analysis are presented in Table 4.

TABLE 4 - Characteristics of Patients With Active Lower GI Bleeding Caused by Colonic Angiodysplasia and Those by Other Diseases*
Variables Colonic angiodysplasia group (N = 10); n (%) Other diseases group (N = 71); n (%) P
Age (y); mean±SD 64.30±9.48 59.34±17.57 0.190
Sex (M) 3 (30.0) 39 (54.93) 0.140
The duration of bleeding to admission (d); mean±SD 182.50±158.0 58.54±202.32 0.043
Systolic pressure at admission (mm Hg); mean±SD 126.30±12.29 125.44±22.59 0.857
Heart rate at admission (per min); mean±SD 76.10±11.12 83.18±16.32 0.098
The level of hemoglobin at admission (g/L); mean±SD 90.90±37.26 107.24±29.25 0.211
Shock index at admission; mean±SD 0.61±0.10 0.69±0.20 0.045
Average hospital stay (d); mean±SD 13.80±11.55 9.04±4.74 0.228
Times of colonoscopy 0.430
 1 9 (90.0) 68 (95.77)
 2 or more 1 (10.0) 3 (4.23)
Recurrent bleeding <0.001
 Yes 3 (30.0) 2 (2.82)
 No 7 (70.0) 69 (97.18)
Therapy method 0.203
 Medicine 8 (80.0) 46 (64.80)
 Endoscopy therapy 2 (20.0) 5 (7.0)
 Interventional therapy 0 7 (9.90)
 Operation 0 13 (18.30)
Bold values indicates significant P value.
*Other diseases for active lower gastrointestinal bleeding included colonic ulcers, colorectal cancers, diverticulum of the colon, ischemic bowel disease, small intestinal lesions, and hemorrhoids.
Shock index was defined as heart rate divided by systolic blood pressure.
GI indicates gastrointestinal.

DISCUSSION

In this study, all patients with colonic angiodysplasia were enrolled according to the diagnostic criteria under colonoscopy.15 A total of 55.55% of the patients in our study were older than 60 years, and a further 37.04% ranged in age from 40 to 60 years, indicating that incidence increases with age. Isolated angiodysplasia lesions were more commonly located in the right colon in agreement with other research.16,17 We also found diffuse lesions mainly located in the total or left colon, which was not described in previous studies. Admitting further research is needed, and comorbid chronic diseases might account for these differences. In addition, the typical appearances of colonic angiodysplasia were displayed in this study (Fig. 1), including bright dendroid red vessels, sporadic arachnid lesions with central red points, spotty or patchy dilated vessels with distinct or fuzzy boundaries, and diffuse lesions with flexuous and gracile vessels. We described and exhibited the typical and vivid features of colonic angiodysplasia to raise awareness of this condition in endoscopists.

The incidence of colonic angiodysplasia is low in the general population, and half of the patients are asymptomatic (44.44% in this study). However, it should not be overlooked in patients with active lower GI bleeding. Asymptomatic patients should be carefully monitored during colonoscopy because of the potential bleeding risk. We found colonic angiodysplasia followed by active bleeding is more likely to occur in women patients and is mainly located in the left and total colon, indicating that endoscopists should perform careful observation of the entire intestine, especially for women patients. Previous research has claimed that angiodysplasia is associated with chronic renal failure, liver cirrhosis, aortic stenosis, and autoimmune disorders.18–22 In our study, many patients with colonic angiodysplasia had comorbid chronic diseases, such as liver cirrhosis, hyperlipidemia, arteriosclerosis, T2DM, and hypertension. The prevalence of T2DM was higher in the bleeding group than in the no-bleeding group. In addition, patients with a radiotherapy history, antiplatelet drug use, and multiple lesions were more likely to endure active bleeding. This fact should remind endoscopists to be aware of the risk factors. Nevertheless, the sample size was too small to draw clear conclusions, and more relevant research should be conducted to clarify these points.

Although colonic angiodysplasia is a rare disease, it is nevertheless a common cause of lower GI bleeding in older adults.23 This study provides the clinical data and colonoscopic findings of patients with active lower GI bleeding caused by colonic angiodysplasia and those by other diseases. Only 18.52% of the patients with colonic angiodysplasia experienced active GI bleeding in our study, however, they might be more prone to recurrent bleeding. Moreover, as the colonic angiodysplasia is composed of capillaries, the rate of bleeding is more slowly and more insidiously than clots from arterial hemorrhages. Hemorrhage due to colonic angiodysplasia had a statistically greater estimated duration from bleeding to admission than lower GI bleeding caused by other diseases. But among the remaining severity indicators, such as systolic blood pressure, heart rate, and hemoglobin level at admission, no significant differences were seen between the two groups. APC therapy has been acknowledged as an effective endoscopic treatment for patients with lower GI bleeding caused by colonic angiodysplasia.24 During the study, 2 patients received APC therapy for continued bleeding caused by colonic angiodysplasia, and both 2 operations were successful.

Our study had several limitations, which should be noted. The main limitation was the single-center design of the study, which limits the generalizability of our observations to other colonoscopy studies. Another limitation was the study’s potential selection bias given its observational and retrospective design. Some detailed data were not available from the medical records. In addition, our results relied on the inpatient information; however, the majority of patients with colonic angiodysplasia were asymptomatic and required no hospital treatment, and the results may represent a very small percentage of the patients. More clinical data on colonic angiodysplasia should be submitted in the future.

CONCLUSION

The study summarized the colonoscopic and clinical features of colonic angiodysplasia. Endoscopists should perform colonoscopy scrupulously and consider colonic angiodysplasia as a differential diagnosis in patients with lower GI bleeding, especially for older women and adults with chronic diseases, such as T2DM.

ACKNOWLEDGMENTS

The authors thank Editage (www.editage.cn) for English language editing.

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Keywords:

colonic angiodysplasia; gastrointestinal bleeding; colonoscopy; chronic disease

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