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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2003  |  Volume : 14  |  Issue : 1  |  Page : 57-60
Asymptomatic Gastric Angiodysplasia in Chronic Hemodialysis Patients: Case Reports


Department of Nephrology, University Hospital, Sfax, Tunisia

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   Abstract 

Gastrointestinal (GI) angiodysplasia is a vascular lesion. It is a common cause of GI bleeding in chronic renal failure (CRF). We report three adult chronic hemodialysis patients with asymptomatic angiodysplasia. Over a period of four years, the hemoglobin level was stable and none of our patients received iron supplementation or erythropoietin (EPO) therapy. Incidence of angiodysplasia may be underestimated in the CRF patients. Further studies may be needed.

Keywords: Angiodysplasia, Hemodialysis, Chronic renal failure, Digestive tract.

How to cite this article:
Charfeddine K, Kammoun K, Kharrat M, Yaich S, Mkawar K, Jarraya F, Bahloul H, Hachicha J. Asymptomatic Gastric Angiodysplasia in Chronic Hemodialysis Patients: Case Reports. Saudi J Kidney Dis Transpl 2003;14:57-60

How to cite this URL:
Charfeddine K, Kammoun K, Kharrat M, Yaich S, Mkawar K, Jarraya F, Bahloul H, Hachicha J. Asymptomatic Gastric Angiodysplasia in Chronic Hemodialysis Patients: Case Reports. Saudi J Kidney Dis Transpl [serial online] 2003 [cited 2020 Dec 4];14:57-60. Available from: https://www.sjkdt.org/text.asp?2003/14/1/57/33088

   Introduction Top


Upper gastrointestinal disorders, especially angiodysplasia that manifests as telangiectasia, are recognised with increased frequency in chronic renal failure. [1],[2]

Since the first report about the association of this condition with chronic renal failure in 1981, [3] many studies have confirmed this association and indicated that telangiectasia was a common cause of the initial and recurrent upper gastro­intestinal (GI) bleeding in hemodialysis patients.

We report three cases of chronic hemodialysis patients who had angiodysplasia but never presented with gastrointestinal hemorrhage. The clinical characteristics of our three patients are summarised below.


   Case descriptions Top


Case 1:

A 65-year-old man has been on chronic hemodialysis for four years at the time of this report. He had polycystic kidney disease in the native kidneys. He never had signs of GI hemorrhage or acute anemia. Gastric angiodysplasia was discovered on endoscopy for dyspeptic symptoms.

For at least four years of follow-up after gastric endoscopy, hemoglobin and serum iron level remained stable without iron suppleme­nation or erythropoietin (EPO) therapy.

Case 2:

A 34-year-old man, with end stage renal failure (ESRF) of undetermined aetiology was maintained well on chronic hemo­dialysis. He was found to have gastric angio­dysplasia on endoscopic examination performed for dyspepsia (?). There was no history of GI bleeding. The surveillance of the hema­tologic parameters showed stable levels of hemoglobin and serum iron during the follow-up period.

Case 3:

A 43-year-old man was on chronic hemodialysis for ESRF secondary to chronic interstitial nephropathy. Angiodysplasia was discovered on gastric endoscopy. During four years of follow-up, he never presented with either GI symptoms of bleeding or needed any transfusion, iron supplementation and EPO.

In all these cases, endoscopy was syste­matically performed, and showed only inflammatory gastropathy. The angiodysplasia was diagnosed histologically, [Figure 1] and [Figure 2] In the third case, endoscopy was repeated after the histological results, and showed the typical findings of angiodysplasia.


   Discussion Top


Angiodysplasia is a vascular lesion of the GI tract that is frequently localised in the right colon, the stomach and the duodenum. [2],[4],[5],[6] Multiple locations of angiodysplasia are frequently observed. [4],[7]

In a retrospective study, angiodysplasia caused 24% of the initial hemorrhage in CRF and 53% of the recurrent GI bleeding. [8] Other studies found that these lesions were an infrequent cause of GI bleeding. [9],[10] Our patients never presented any clinical or biological symptoms of GI hemorrhage during follow-up for four years. Angiodysplasia was fortuitously discovered in our cases due to random screening upper GI endoscopy, while it was diagnosed in the context of GI bleeding in almost all the studies in the literature. The incidence of angiodysplasia may be underestimated in CRF patients in the literature and there may be a need for prospective studies performing systematic screening endoscopy.

The prevalence of angiodysplasia increases with age regardless of renal function. [5],[11],[12],[13] The average age of patients with angiodysplasia in chronic CRF varies from 62 to 73 years, while the age of patients with renal failure and and angiodysplasia are younger [5],[14],[15] The age of our patients was compatible with that reported in the literature.

The diagnosis of angiodysplasia is made by endoscopy [3],[4],[5],[8],[16],[17] It manifests as telangiectasia with a flat or slightly raised lesion and fernlike margins The endoscopic diagnosis of angiodysplasia needs an advanced instrument and experienced physician.

Histopathology can help the diagnosis in atypical cases. In our three cases, the angio­dysplasia was confirmed histologically. In one case, endoscopy was repeated, and it showed later typical findings of angiodysplasia.

Although the pathogenesis of angio­dysplasia is still unknown, several theories suggested a vascular degenerative process accelerated by the hypoxygenation of the intestinal mucosa secondary to atherosclerotic peripheral vascular disease. [3],[4],[5],[6],[12]


   Conclusion Top


Angiodysplasia is commonly reported as a cause of GI bleeding in chronic renal failure. Its real prevalence is still unknown. We report three cases of patients on chronic hemodialysis with angiodysplasia, who never had clinically detectable GI haemorrhage and who were accidentally discovered. Our cases raise some questions: Is angiodysplasia more frequent in CRF patients than what is reported in the literature, since it could remain asymptomatic, or is it as frequent as in the general population? Could the difference in frequency be explained only by the high bleeding tendency observed on these patients?


   Acknowledgements Top


We thank the staff of the department of gastroenterology of the University Hospital, Sfax, Tunisia, for their co-operation in performing this study and also Faiza Mtar and Nabila Frikha for typing the manuscript.

 
   References Top

1.Margolis DM, Saylor JL, Geisse G, et al. Upper gastrointestinal disease in chronic renal failure. A prospective evaluation. Arch Intern Med 1978;138:1214 -7.  Back to cited text no. 1    
2.Feydy P, Aazib L, Driguez E, Ghannoun Z, Brasseu J, Coevoet B. Treatment with laser Nd YAG of digestive angiodysplasia in dialysed patients with chronic kidney failure. Gastroenterol Clin Biol 1993; 17:772-3.  Back to cited text no. 2    
3.Cunningham JT. Gastric telangi-ectasia in chronic hemodia-lysis patients: a report of six cases. Gastroenterol 1993;81:1131-3.  Back to cited text no. 3    
4.Dave PB, Romeu J, Antonelli A, Eiser AR. Gastrointestinal telangi-ectasia. A source of bleeding in patients receiving hemodialysis. Arch Intern Med 1984;144:1781-3.  Back to cited text no. 4    
5.Clouse RE, Costigan DJ, Mills BA, Zuckerman GR. Angio-dysplasia as a cause of upper gastrointestinal bleeding. Arch Intern Med 1985; 145:458-61.  Back to cited text no. 5  [PUBMED]  
6.Barbier JP, Berger M. Angio-dysplasies digestives. In editions techniques encycl Med Chi (Frances-Paris). Gastroenterol 1991; 9006:B10.  Back to cited text no. 6    
7.Bronner MH, Pate MB, Cunningham JT, Marsh WH. Estrogen-progesterone therapy for bleeding gastrointestinal telangiectasias in chronic renal failure. Ann Intern Med 1986;105:371-4.  Back to cited text no. 7  [PUBMED]  
8.Zuckerman GR, Cornette GL, Clouse RE, Harter HR. Upper gastrointestinal bleeding in patients with chronic renal failure. Ann Intern Med 1985;102:588-92.  Back to cited text no. 8  [PUBMED]  
9.Blackstone MO. Angiodysplasia and gastro­intestinal bleeding in chronic renal failure. Ann Intern Med 1985;103(5):805.  Back to cited text no. 9    
10.Milito G, Taccone-Gallucci M, Brancaleone C, et al. The gastro-intestinal tract in uremic patients on long-term hemodialysis. Kidney Int Suppl 1985;17:S157-60.  Back to cited text no. 10  [PUBMED]  
11.Chalasani N, Costonis G, Wilcox CM. Upper gastrointestinal bleeding in patients with chronic renal failure: role of vascular ectasia. Ann J Gastro Nephrol 1996; 11:2329-32.  Back to cited text no. 11    
12.Doherty CC. Gastrointestinal bleed-ing in dialysis patients. Nephron 1993;63:132-6.  Back to cited text no. 12  [PUBMED]  
13.Repse S, Obrez I, Baretic-Kolar E, Ursic M, Kovic M. Angiodysplasia a cause of gastro­intestinal bleeding. Acta Chir Iugosl 1983; 30(1):55-69.  Back to cited text no. 13    
14.Cello JP, Grendell JH. Endoscopic laser treatment for gastrointestinal keep ectasias. Ann Intern Med 1986;104:352-4.  Back to cited text no. 14  [PUBMED]  
15.Flynn CT, Chandran PK. Renal failure and angiodysplasia of the colon. Ann Intern Med 1985; 103:154.  Back to cited text no. 15    
16.Harasawa H, Suzuki Y, Kobayashi M, et al. Gastric vascular ectasia in a chronic hemo­dialysis patient. Clin Nephrol 1995; 43:202-4.  Back to cited text no. 16  [PUBMED]  
17.Di Liberato L, Sirolli V, Lattanzio P, et al. Endoscopy as a tool for diagnosing and treating gastrointe-stinal angiodysplasia in haemo­dialysis patients. Int J Artif Organs 1999;22(7): 488-91.  Back to cited text no. 17    

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Correspondence Address:
K Charfeddine
Assistant Professor of Nephrology, Sfax University, P.O. Box 288, 3027 Sfax-Jadida
Tunisia
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PMID: 17657090

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    Abstract
    Introduction
    Case descriptions
    Discussion
    Conclusion
    Acknowledgements
    References
 

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