Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points

Abstract

Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient’s quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.

Keywords: Angiodysplasias, Angioectasias, Vascular malformations, Epidemiology, Pathogenesis, Endoscopic treatment, Somatostatin analogues

Core tip: Gastrointestinal angiodysplasias (GIADs) are the most frequent vascular malformations. They cause 10% of all gastrointestinal bleeding and 50% of small bowel bleeding cases. In most patients, they manifest with frequent bleeding episodes, requiring expensive treatments and disturbing patient’s quality of life. In this review, we summarize the main aspects related to epidemiology, risk factors and pathophysiology of GIADs. The diagnostic challenge of causality and the efficiency of different treatment modalities available are critically discussed. A novel classification of GIADs based on endoscopic characteristics is proposed and future research directions that may improve diagnostic and therapeutic results will be highlighted.