What's The Cause Of Low Blood Pressure – Angiodysplasia, also known as angioectasia or arteriovenous malformation, refers to blood vessels that are tortuous (twisted) and swollen in the mucosal and submucosa layers of the gastrointestinal (GI) tract. It is the most common etiology of small bowel bleeding in individuals over 60 years of age. The GI tract segment is divided into four layers: mucosa (epithelium, lamina propria, and muscularis mucosa), submucosa, muscularis propria (inner circular muscle layer, intermuscular space, and outer longitudinal muscle layer), and serosa. . With angiodysplasia, vessels found directly adjacent to the lumen, or opening, of the GI tract can become fragile and can rupture leading to blood loss. It is the most common vascular malformation in the GI tract and occurs most frequently in the colon. It can also affect the large intestine, small intestine, or stomach.

Although the exact mechanism of angiodysplasia is unknown, it is thought that the muscularis propria, or the thick muscle layer of the GI tract, may increase contractility, thereby obstructing the submucosal veins. This vein drains the mucosal and submucosa layers as it passes through the muscularis propria. Over time, the obstruction can cause the submucosal veins to dilate, or dilate, and become tortuous, along with all the venules and capillaries that then drain them.

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Age-related deterioration of small blood vessels and cardiovascular and pulmonary disease are also risk factors. This condition can cause hypoperfusion of vessels, further causing abnormal lesions and ischemic necrosis. Heyde syndrome refers to the triad of aortic stenosis (a condition that occurs when the heart valve that controls the aorta narrows and narrows), acquired coagulopathy, and anemia due to bleeding from intestinal angiodysplasia. Heyde syndrome is thought to be caused by changes in blood clotting factors, such as Von Willebrand factor (VWF). Additionally, when VWF is absent or deficient, it can cause Von Willebrand disease (VWD), a blood disorder in which blood does not clot properly, and can cause bleeding from upper and lower GI angiodysplasia lesions.

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Individuals with angiodysplasia may be asymptomatic or have mild to moderate lower GI bleeding without abdominal pain. Occult bleeding is defined as gastrointestinal bleeding that cannot be seen by the person or doctor, but a stool sample is positive for blood. If angiodysplasia bleeds, the appearance can vary based on the source and location of the bleeding. For example, slow bleeding from the stomach or small intestine may appear as melena, which refers to dark, sticky stools. If the bleeding is from the colon, it may appear as bright red blood. If there is excessive bleeding, or slow occult bleeding over a longer period of time, a person can show symptoms of iron deficiency anemia. These include excessive fatigue, shortness of breath, or heart murmurs. The prevalence of angiodysplasia increases with age and mainly occurs in individuals over 60 years of age. If there is aortic stenosis associated with angiodysplasia, cardiac examination may show a systolic ejection murmur. In cases of acute and heavy bleeding from abnormal vessels, orthostasis and hypotension may occur.

Angiodysplasia is usually diagnosed based on incidental findings during a colonoscopy for a colorectal cancer screening exam, or when evaluating a patient for anemia related to acute or chronic blood loss. For this diagnosis, a medical history is usually obtained, assessing the presence of weakness, dizziness, or hematemesis (ie, blood present in vomit). A physical exam is also usually performed to assess the individual’s vitals to ensure they are hemodynamically stable. Various laboratory tests, including a complete blood count, liver function tests, coagulation studies, and kidney function tests may be ordered to evaluate anemia and diagnose medical conditions associated with rectal bleeding (eg, end-stage renal disease or congenital or acquired disorders. freezing). Upper endoscopy, a nonsurgical procedure in which a flexible tube with a light and camera is inserted through the mouth to visualize the GI tract, may also be performed to visualize angiodysplasia. Because angiodysplasia can occur further along the GI tract, upper endoscopy may not visualize the lesion; in this case, capsule endoscopy can be used. During this procedure a pill-sized capsule is swallowed and as it moves through the digestive tract, it takes an image. Other diagnostic methods include radionuclide scanning images (that is, an imaging technique that uses small doses of radioactive chemicals), CT mesenteric angiography, and magnetic resonance angiography (that is, a procedure that uses dyes and x-rays to see how blood flows through the arteries).

Incidental angiodysplasias found during routine examination do not require treatment in the absence of a history of GI bleeding or unexplained iron deficiency anemia. However, if symptomatic, management often includes hemodynamic resuscitation, restoring proper tissue perfusion, monitoring of complete blood counts, and blood transfusion, if necessary. To manage the source of bleeding, argon plasma coagulation (APC) ablation is the most commonly used intervention. APC is a medical endoscopic procedure used to control bleeding from certain lesions in the GI tract. Other interventions include electrocoagulation, which is a procedure that uses heat from an electric current to destroy abnormal tissue, as well as endoscopic clips and band ligation, both of which are mechanical methods used to treat angiodysplasia. Injection sclerotherapy, which involves injecting a sclerosant (that is, a drug that causes the vessels to shrink) to eliminate angiodysplasia, can be used as well. If the cause of the bleeding is due to Heyde’s syndrome, aortic valve replacement can offer a long-term solution to the bleeding.

Angiodysplasia can be cured by surgical resection of the part of the GI tract where angiodysplasia is present, or with other treatment options including APC, electrocoagulation, ligation and sclerotherapy. However, if there are no adverse symptoms of angiodysplasia, it is most likely not necessary to treat or cure it. In fact, most bleeding angiodysplasias will stop spontaneously. Overall, a conservative approach is recommended especially for those who are hemodynamically stable.

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Angiodysplasia is a swollen and tortuous blood vessel found in the mucosal and submucosa walls of the GI tract. The most common are angiodysplasias of the colon, followed by the small intestine, and the stomach. It is not clear what the cause is, however, it may be due to increased contraction of the muscles that line the GI tract. Diagnosis relies on a thorough medical history and physical examination, as well as laboratory, endoscopy and imaging studies. Treatment is not always indicated, especially if the bleeding stops on its own. If there is heavy bleeding, the goal is to restore the lost blood and stop the bleeding. This can be done through APC ablation, electrocoagulation, endoscopic clips, or sclerotherapy. If angiodysplasia persists despite conservative management, surgery may be indicated and curative.

Chong, J., Tagle, M., Barkin, J. S., & Reiner, D. K. (1994). Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology. The American Journal of Gastroenterology, 89(12), 2143–2146.

Ertekin, C., Taviloglu, K., Barbaros, U., Guloglu, R., & Dolay, K. (2002). Endoscopic band ligation: an alternative treatment method in non-variceal upper gastrointestinal bleeding. Journal of laparoendoscopic & advanced surgical techniques. Part A, 12(1), 41–45. DOI: 10.1089/109264202753486911

Hussein, A., Gamarra, R. (2019, May 8). Angiodysplasia of the colon. In Medscape. Retrieved January 10, 2022, from https://emedicine.medscape.com/article/170719-overview

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Poralla T. (1998). Angiodysplasia in kidney patients: how to diagnose and how to treat? Nephrology, dialysis, transplantation : official publication of the European Society of Dialysis and Transplantation – European Renal Society, 13(9), 2188–2191. DOI: 10.1093/ndt/13.9.2188

Sami, S. S., Al-Araji, S. A., & Ragunath, K. (2014). Review article: gastrointestinal angiodysplasia – pathogenesis, diagnosis and management. Food pharmacology & therapeutics, 39(1), 15–34. DOI: 10.1111/apt.12527

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