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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 5  |  Page : 809-812
Gastrointestinal Angiodysplasia in Chronic Renal Failure


Department of Internal Medicine, Charles Nicolle Hospital, Tunis, Tunisia

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   Abstract 

Gastrointestinal (GI) hemorrhage is a frequent and sometimes life-threatening complication of end-stage renal failure. Angiodysplasia (AD), vascular malformation, is the most common cause of recurrent lower-intestinal hemorrhage in patients with renal failure. We report four chronic hemodialysis patients with AD. All patients presented with severe anemia requiring transfusion. GI hemorrhage ceased spontaneously in three cases and after treatment with argon plasma coagulation in another. Diagnosis of AD is usually challenging, since its cause is still unknown, and its clinical presentation is variable. Lesions are multiple in 40-75% of cases, often located in the stomach and duodenum but can affect the colon and the jejunum. Diagnosis is improved by endoscopy which has a much higher sensitivity compared to angiography. Capsular endoscopy may reveal the hemorrhage site in the small intestine when regular endoscopy fails, and therapeutic intervention usually include argon plasma coagulation.

How to cite this article:
Kaaroud H, Fatma L B, Beji S, Boubaker K, Hedri H, Hamida F B, El Younsi F, Abdallah T B, Maiz H B, Kheder A. Gastrointestinal Angiodysplasia in Chronic Renal Failure. Saudi J Kidney Dis Transpl 2008;19:809-12

How to cite this URL:
Kaaroud H, Fatma L B, Beji S, Boubaker K, Hedri H, Hamida F B, El Younsi F, Abdallah T B, Maiz H B, Kheder A. Gastrointestinal Angiodysplasia in Chronic Renal Failure. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2014 Apr 25];19:809-12. Available from: http://www.sjkdt.org/text.asp?2008/19/5/809/42467

   Introduction Top


Gastrointestinal (GI) hemorrhage is a fre­quent and sometimes life-threatening compli­cation of end-stage renal failure. [1],[2] The most important causes of hemorrhage are vascular malformations, peptic ulcers, erosive gastritis and esophagitis, colonic and rectal ulcers and diverticular disease. [1]

Angiodysplasia (AD), vascular malformation, is the most common vascular abnormality of the gastrointestinal tract and probably the most common cause of recurrent lower-intestinal hemorrhage in patients with renal failure. [3]

The diagnosis of AD is often difficult and the treatment is frequently frustrating. [4],[5]

We report the clinical characteristics of the AD in four hemodialysis (HD) patients.


   Case Reports Top


Case 1

A 68-year-old female had been on chronic hemodialysis for six years with hemoglobin was stable around 11 g/dL with administration of human recombinant erythropoietin, when he developed severe melena that decreased he­moglobin to 5 g/dL. Colonoscopy revealed mul­tiple AD in the ascending colon, and labeled red blood cell scintigraphy demonstrated he­morrhage from these lesions. However, later the melena resolved, and the patient stabilized. Repeated colonoscopy revealed no AD, there­fore, the patient received no specific treatment for it.

Case 2

A 68–year-old female with end-stage renal failure secondary to diabetic nephropathy de­veloped GI hemorrhage, and hemoglobin dec­reased to 5.8 g/dL that required intensive blood transfusions. Colonoscopy revealed mul­tiple AD in the cecum with active hemorrhage. However, hemorrhage ceased spontaneously during the follow-up period, and the patient required no specific treatment.

Case 3

A 59–year-old female with end-stage renal failure associated with myeloid leukemia and monoclonal gammopathy. She presented no signs of gastrointestinal hemorrhage, but she developed severe anemia. Upper GI endoscopy revealed duodenal ulcer. Colonoscopy revealed AD in the cecum and ascending colon. Unfor­tunately, the patient died of cardiac arrythemia.

Case 4

A 40-year-old female, who had been on chro­nic hemodialysis for six years for undeter­mined nephropathy, developed GI hemorrhage with melena. She developed severe anemia, and hemoglobin decreased to 4 g/dL that required multiple blood transfusions. Colonos­copy revealed several tiny AD lesions with active hemorrhage in the ascending colon. The patient was successfully treated with argon plasma coagulation that ceased hemorrhage immediately and her hemoglobin levels im­proved and stabilized.


   Discussion Top


Prevalence of AD as a cause of hemorrhage in chronic renal failure ranges from 19–32% com­pared to 5% in individuals with normal renal function.

The cause of AD is still unknown, and it could be related to vascular degenerative pro­cess accelerated by hypoxygenation of the intestinal mucosa secondary to atherosclerotic peripheral vascular disease. [6],[7],[8] Microscopically AD consists of dilated thin-walled distorted vessels lined by endothelium and, infrequently, by a thin layer of smooth muscle. [3]

Clinical presentations of AD may include un­explained iron deficiency, anemia, hemocult positive stool, and melena. Hemorrhage is usually painless, ceases spontaneously in at least 90% of the cases, [3] and recurs in 25–47% of them. In our study, all patients developed severe anemia with evident GI hemorrhage in three cases.

Diagnosis of AD is usually difficult. Barium contrast studies are not useful to detect lesions and 99m Tc-labelled red blood cell scintigra­phy may reveal active hemorrhage but not the cause of it. [9]

Colonoscopy is an effective means of diag­nosis. Endoscopically, lesions appear flat or slightly raised above the mucosal surface, che­rry red in color, and 2–10 mm in size. [3] Lesions are multiple in 40-75% of cases, often located in the stomach and duodenum but can affect the colon and the jejunum. [1],[2],[10] All our patients revealed simultaneously multiple lesions.

False negative endoscopic examinations may occur in severely anemic or volume depleted patients, and false positive can occur by minor trauma during endoscopy.[11] Repeating endos­copic to improve the specificity is often nece­ssary.

Angiography may reveal an early sign of bleeding AD with prolonged opacification of a draining vein in 80 –90% of cases. However, diagnosis requires observation of extravasa­tions of contrast material to the gastrointestinal lumen which is observed in 20% or less of patients and requires a hemorrhage activity of at least one ml per minute. [12],[13] Based on small series, sensitivity of endoscopy is much higher compared to angiography 80% versus 20%. [14],[15] Accordingly, we did not perform angiography on any of our patients.

Capsular endoscopy offers a unique possibility to reveal the hemorrhage site in the small intestine when endoscopy fails. [3] That was the case in two of our patients. In addition, cap­sular endoscopy offers planning of appropriate therapeutic intervention such as our fourth patient. Few months later the patient died of pulmonary edema.

Some authors believe that when AD is found accidentally in patients who have never bled before, it should be left untreated but should avoid ingestion of non-steroid anti-inflamma­tory agents, which cause platelet dysfunction and increased risk of hemorrhage. [3]

In patients with active hemorrhage, endos­copic hemostatic therapy is generally the ini­tial form of treatment. Endoscopy treatment with argon plasma coagulation has been used successfully. [17] It was efficient in the fourth case of our study.

In patients with persistent or recurrent hemo­rrhage despite endoscopic therapy, surgical re­section should be considered. When surgery appears too risky or the AD is multiple in different parts of the gastrointestinal tract, hormonal therapy including conjugated estro­gens is used with successful application in two uncontrolled studies. [3],[17],[18],[19] However, side effects of estrogens including gynecomastia, fluid re­tention, vaginal hemorrhage, thrombosis and stroke should be considered carefully in the decision to treat, since controlled trials of the use of hormonal therapy in renal patients are lacking. Octreotide, a long-acting synthetic somatostatin analogue, is known to treat hemo­rrhage of esophageal varices, and it can be considered as well, but its efficacy to treat hemorrhage from AD has not been studied yet. [20]

We conclude that angiodysplasia is a frequent cause of hemorrhage in chronic renal failure, and its cause is still unknown. The diagnosis is based on endoscopy, and treatment can be im­proved by argon plasma coagulation. Hormo­nal therapy requires controlled studies.

 
   References Top

1.Fabian G, Szigeti N, Kovacs T, Nagy J. An usual multiplex cause of severe gastro­ intestinal hemorrhage in a haemodialysed patient. Nephrol Dial Transplant 2000;15 (11):1869-71.  Back to cited text no. 1    
2.Charfeddine K, Kammoun K, Kharrat M, et al. Asymptomatic gastric angiodysplasia in chronic hemodialysis patients: Case reports. Saudi J Kidney Dis Transpl 2003; 14(1):57-60.  Back to cited text no. 2    
3.Poralla T. Angiodysplasia in the renal patient: How to diagnose and how to treat? Nephrol Dial Transplant 1998;13(9):2188-91.  Back to cited text no. 3    
4.Richardson JD, Lordon RE. Gastrointestinal hemorrhage caused by angiodysplasia: a different problem in patients with chronic renal failure receiving hemodialysis therapy. Am J Surg 1993;59(10):636-8.  Back to cited text no. 4    
5.Zuckerman JR, Cornette GL, Clouse RE, Harter HR. Upper gastrointestinal hemo­rrhage in patients with chronic renal failure. Ann Intern Med 1985;102(5):588-92.  Back to cited text no. 5    
6.Cunningham JT. Gastric telangiectasia in chronic hemodialysis patients: a report of six cases. Gastroenterol 1993;81:1131-3.  Back to cited text no. 6    
7.Barbier JP, Berger M. Angiodysplasies digestives. In editions techniques encycl Med Chir (France-Paris). Gastroenterol 1991,9006:B10.  Back to cited text no. 7    
8.Doherty CC. Gastrointestinal hemorrhage in dialysis patients. Nephron 1993;63(2): 132-6.  Back to cited text no. 8    
9.Brummer U, Capelli P, Laterza F, et al. Wireless capsule endoscopy in the diagnostic of small intestine angiodysplasia in chronic uremic patient. Minerva Urol Nephrol 2005;57(1):61-9.  Back to cited text no. 9    
10.Machicado GA, Jensen DM. Upper gastro­intestinal angiomata: diagnosis and treat­ment. Gastrointest Endosc Clin North Am 1991;1:241-62.  Back to cited text no. 10    
11.Foutch PG. Angiodysplasia of the intes­tinal tract. Am J Gastroenterol 1993;88(6): 807-18.  Back to cited text no. 11    
12.Boley SJ, Spryregen S, Sammartano RJ, Adams A, Kleinhaus S. The pathophysio­logic basis for the angiographic signs of vascular ectasias of the colon. Radiology 1997;125(3):615-21.  Back to cited text no. 12    
13.Richardson JD, May MH, Flint LM, et al. Hemorrhage vascular malformations of the intestine. Surgery 1978;84:430-6.  Back to cited text no. 13    
14.Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia: The role of urgent colonoscopy after purge. Gastroenterology 1988;95(6):1569-74.  Back to cited text no. 14    
15.Salem RR, Wood CB, Rees HC, Khesha­varzian A, Hemingway AP, Allison DJ. A comparison of colonoscopy and selective visceral angiography in the diagnosis of colonic angiodysplasia. Ann R Coll Surg Engl 1985;67(4):225-6.  Back to cited text no. 15    
16.Tomori K, Nakamoto H, Kotaki S, et al. Gastric angiodysplasia in patients under­going maintenance dialysis. Adv Perit Dial 2003;19:136-42.  Back to cited text no. 16  [PUBMED]  
17.Manzanera MJ, Gutierrez E, Dominguez­ Gil B, Garcia JA, Gonzalez E, Praga M. Digestive haemorrhage due to angio­dysplasia in dialysis patients: Treatment with conjugated estrogens. Nefrologia 2005;25(4):412-5.  Back to cited text no. 17    
18.Bronner MH, Pate MB, Cunningham JT, Marsh WH. Estrogen-progesterone therapy for hemorrhage gastrointestinal telangiec­tasias in chronic renal failure. Ann Intern Med 1986;105(3):371-4.  Back to cited text no. 18    
19.Sloand JA, Schiff MJ. Beneficial effect of low-dose transdermal estrogen on hemo­rrhage time and clinical hemorrhage in uremia. Am J Kidney Dis 1995;26(1):22-6.  Back to cited text no. 19    
20.Rivera M, Lucero J, Guerrero A, et al. Octreotide in the treatment of angio­dysplasia in patients with advanced chro­nic renal failure. Nephrologia 2005;25(3): 332-5.  Back to cited text no. 20    

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Correspondence Address:
H Kaaroud
Department of Internal Medicine A, Charles Nicolle Hospital, Boulevard 9 Avril 1938 1006 BS Tunis
Tunisia
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PMID: 18711303

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