Saudi Journal of Kidney Diseases and Transplantation

BRIEF COMMUNICATION
Year
: 2016  |  Volume : 27  |  Issue : 4  |  Page : 748--751

Gastrointestinal bleeding due to angiodysplasia in patients on hemodialysis: A single-center study


Yassir Zajjari1, Mouna Tamzaourte2, Dina Montasser1, Kawtar Hassani1, Taoufiq Aatif1, Driss El Kabbaj1, Mohammed Benyahia1,  
1 Department of Nephrology-Dialysis, Military Hospital Mohammed V, Rabat, Morocco
2 Department of Gastroenterology, Military Hospital Mohammed V, Rabat, Morocco

Correspondence Address:
Yassir Zajjari
Department of Nephrology-Dialysis, Military Hospital Mohammed V, Rabat
Morocco

Abstract

Gastrointestinal (GI) bleeding due to angiodysplastic lesions is a common problem among patients receiving hemodialysis (HD). We studied 22 HD patients (5 females and 17 males) who had GI bleeding due to angiodysplasia; the mean age of whom was 54 ± 10 years. All patients had upper and lower GI endoscopy. The most common site for the lesion was the right colon in seven cases (31.8%), followed by stomach in 4 cases (18.1%). In eight (36.3%) patients, there were multiple lesions located in the stomach, duodenum, and the right colon. All patients were treated with coagulation; with argon plasma in 14 (63.6%) patients, bipolar coagulation in five (22.7%) patients, and hot clip in three (13.6%) patients. One patient who presented with persistent bleeding despite endoscopic therapy was well-benefited of a complementary treatment, thalidomide. Hemostasis was obtained in all patients after an average of 6.8 sessions of endoscopic coagulation procedure. We conclude that angiodysplasia is a frequent cause of hemorrhage in chronic renal failure that can be managed in most patients by argon plasma and bipolar coagulation.



How to cite this article:
Zajjari Y, Tamzaourte M, Montasser D, Hassani K, Aatif T, El Kabbaj D, Benyahia M. Gastrointestinal bleeding due to angiodysplasia in patients on hemodialysis: A single-center study.Saudi J Kidney Dis Transpl 2016;27:748-751


How to cite this URL:
Zajjari Y, Tamzaourte M, Montasser D, Hassani K, Aatif T, El Kabbaj D, Benyahia M. Gastrointestinal bleeding due to angiodysplasia in patients on hemodialysis: A single-center study. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2021 Dec 3 ];27:748-751
Available from: https://www.sjkdt.org/text.asp?2016/27/4/748/185237


Full Text

 Introduction



Gastrointestinal (GI) bleeding due to angiodysplastic lesions is a common problem in patients receiving chronic hemodialysis (HD). [1],[2],[3] Association of chronic renal failure with angiodysplasia was first reported in 1981. [4]

Angiodysplasias are intestinal vascular malformations, red, flat, or slightly elevated on the mucus lining with a diameter between two and 10 mm. Prevalence of angiodysplasia as a cause of hemorrhage in chronic renal failure ranges from 19% to 32% compared to 5% in individuals with normal renal function. [5],[6] Many studies have confirmed this association and indicated that telangiectasia is a common cause of initial and recurrent upper GI bleeding in HD patients.

We aimed in this study to present our experience in chronic renal failure patients on HD who had GI bleeding due to angiodysplasia.

 Patients and Methods



We retrospectively studied the clinical course of our chronic HD patients with GI bleeding due to angiodysplasia. We included all patients who were diagnosed with GI bleeding due to angiodysplasia by means of endoscopy at our department from January 2009 to December 2013 in the study.

All the patients had similar clinical presentation: GI bleeding as hematemesis and melena with severe anemia that, in all cases, had required repeated blood transfusions. These patients were followed up for 12 months.

The continuous variables were expressed as the mean and standard deviation and the categorical variables were expressed as relative frequency.

 Results



There were 22 HD patients [17 (77.3%)] males and five [22.7% (females)] with a mean age of 54 ± 10 years with a range of 40-66 years. Etiology of renal failure and duration of dialysis are shown in [Table 1].{Table 1}

Five patients were on antiplatelet agents for ischemic heart disease, and therapy was continued regardless of the severity of the pathology.

The clinical presentation, biochemical markers, and need of blood transfusions are shown in [Table 2].{Table 2}

[Table 3] shows the region in which the endoscopic alterations were found. The most common site for the lesion was the right colon in seven (31.8%) cases, followed by stomach in four (18.1%) cases. In eight (36.3%) patients, there were multiple lesions located in the stomach, duodenum, and the right colon. [Figure 1] and [Figure 2] show single angiodysplasia in duodenum and cecum.{Figure 1}{Figure 2}{Table 3}

All the patients received treatment with coagulation of the lesions; coagulation with argon plasma was used in 14 (63.6%) patients, coagulation with bipolar coagulation was used successfully in five (22.7%) patients, and with hot clip in three (13.6%) patients. One patient who presented with persistent bleeding despite endoscopic therapy was well-benefited from a complementary treatment with thalidomide.

Hemostasis was obtained in all patients after an average of 6.8 sessions of endoscopic coagulation procedure. One case of colonic perforation was encountered in our study, and it was successfully treated with surgery.

 Discussion



In the present study, we present our experience in HD patients who had GI bleeding due to angiodysplasia. Angiodysplastic lesions in the general population are usually detected in patients older than 60 years, while they may be detected at a younger age in patients with chronic kidney disease. [7],[8] In our study, the mean age was 54 ± 10 years.

Clinical presentation of angiodysplasia may include unexplained iron deficiency, anemia, hemoccult positive stool, and melena. Hemorrhage is usually painless, ceases spontaneously in at least 90% of the cases, and recurs in 25-47% of them. [9] In our study, 45.4% of the patients developed melena, 27.2% developed occult anemia (anemia without evident GI hemorrhage), 18.1% developed rectal bleeding, and 9.1% developed hematemesis and melena.

Colonoscopy is an effective means of diagnosis of angiodysplasia, which is frequently located in the right colon. Multiple locations of angiodysplasia are frequently observed; [5],[10],[11] the most frequent location was the right colon (31.8%), and multiple locations (stomach, duodenum, and the right colon) were observed in 36.3% of the patients in our study.

In patients with active hemorrhage, endoscopic coagulation therapy is generally the initial form of treatment. Argon plasma and bipolar coagulation were used successfully in the treatment of angiodysplasia with a low complication rate. [1],[12] Endoscopy treatment with argon plasma coagulation was successfully used in 63.6% of the patients, coagulation with bipolar coagulation in 22.7% of the patients, and hot clip in 13.6% of the patients in our study.

Thalidomide is an effective and safe treatment for patients with refractory bleeding from GI vascular malformations. Mechanisms of its action activity are related to a vascular endothelial growth factor. [13] One patient who presented with persistent bleeding despite endoscopic therapy was well-benefited from thalidomide 100 mg daily for four months.

 Conclusion



We conclude that our study demonstrated our experience with angiodysplasia as a frequent cause of hemorrhage in chronic renal failure patients. The most frequent location was in the right colon, and cure could be achieved by endoscopic argon plasma coagulation and bipolar coagulation.

Conflict of interest: None declared.

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