Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 14, 2019; 25(22): 2720-2733
Published online Jun 14, 2019. doi: 10.3748/wjg.v25.i22.2720
Diagnosis and therapeutic strategies for small bowel vascular lesions
Eiji Sakai, Ken Ohata, Atsushi Nakajima, Nobuyuki Matsuhashi
Eiji Sakai, Ken Ohata, Nobuyuki Matsuhashi, Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
Eiji Sakai, Atsushi Nakajima, Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
Author contributions: All the authors helped to perform the research; Sakai E drafted the article; Nakajima A participated in the study’s conception and design; Ohata K and Matsuhashi N approved the final manuscript.
Conflict-of-interest statement: None of the authors have any potential conflicts of interest to declare.
Open-Access: This article is an open-access article which was selected byan in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Atsushi Nakajima, MD, PhD, Professor, Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama 236-0004, Japan.
Telephone: +81-45-7872640 Fax: +81-45-7843546
Received: March 12, 2019
Peer-review started: March 13, 2019
First decision: April 11, 2019
Revised: April 21, 2019
Accepted: May 3, 2019
Article in press: May 3, 2019
Published online: June 14, 2019

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

Keywords: Angiodysplasia, Angioectasia, Dieulafoy’s lesion, Arteriovenous malformation, Obscure gastrointestinal bleeding, Video capsule endoscopy, Deep enteroscopy, Argon plasm coagulation

Core tip: Angiodysplasia includes a variety of synonymous disease concepts such as angioectasia, Dieulafoy’s lesion and arteriovenous malformation. Although these lesions are the most common causes of small bowel bleeding, optimal management strategies have not been established. We propose that these lesions should be addressed separately when determining diagnostic and therapeutic plans because of their clinical heterogeneity. In this review, we focused on differences in their epidemiology, pathology and clinical presentation and discussed the currently available diagnostic and therapeutic options that may be used to control small bowel bleeding, which consequently improve patient quality of life.