Definitive therapy of colonic angioectasia by submucosal coagulation

Abstract

Background and study aims Colonic angioectasia are the most common vascular lesions in the gastrointestinal tract and are among the most common causes for chronic or recurrent lower gastrointestinal bleeding. Endoscopic treatment involves a variety of techniques, all of which focus on destruction of the mucosal abnormality. However, recurrent bleeding after endoscopic treatment is common, with more than one treatment frequently necessary. We report a technique for definitive treatment of colonic angioectasia by targeting the feeding submucosal vessel.

Patients and methods Analogous to endoscopic mucosal resection, a submucosal injection is made beneath the target lesion which is then removed by electrocautery snare resection of the mucosal lesion. The exposed feeding vessel is then destroyed by application of coagulation current. The resection defect is closed by clips.

Results Six patients with a total of 14 colonic angioectasia were treated over the study period. All lesions were destroyed without adverse events.

Conclusion Elevation, hot snare resection and coagulation (ESC) of the visible vessel for treating colonic angioectasia appears safe and effective. Larger prospective comparative studies are required to assess its specific role.

• References

• 1 Foutch PG. Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993; 88: 807-818
• 2 Foutch PG, Rex DK, Lieberman DA. Prevalence and natural history of colonic angiodysplasia among healthy asymptomatic people. Am J Gastroenterol 1995; 90: 564-567
• 3 Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management. Aliment Pharmacol Therap 2014; 39: 15-34
• 4 Boley SJ, Sammartano R, Adams A. et al. On the nature and etiology of vascular ectasias of the colon. Degenerative lesions of aging. Gastroenterol 1977; 72: 650-660
• 5 Steger AC, Galland RB, Hemingway A. et al. Gastrointestinal haemorrhage from a second source in patients with colonic angiodysplasia. B J Surgery 1987; 74: 726-727
• 6 Pasha SF, Shergill A. et al. ASGE Standards of Practice Committee. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014; 79: 875-885
• 7 Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterol 1988; 95: 1569-1574
• 8 Olmos JA, Marcolongo M, Pogorelsky V. et al. Long-term outcome of argon plasma ablation therapy for bleeding in 100 consecutive patients with colonic angiodysplasia. Dis Colon Rectum 2006; 49: 1507-1516
• 9 Jackson CS, Gerson LB. Management of gastrointestinal angiodysplastic lesions (GIADs): a systematic review and meta-analysis. Am J Gastroenterol 2014; 109: 474-483 ; quiz 84
• 10 Jensen DM, Machicado GA. Colonoscopy for diagnosis and treatment of severe lower gastrointestinal bleeding. Routine outcomes and cost analysis. Gastrointest Endosc Clin North Am 1997; 7: 477-498
• 11 Moss A, Bourke MJ, Metz AJ. A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyps of the colon. The Am J Gastroenterol 2010; 105: 2375-2382
• 12 Moss A, Williams SJ, Hourigan LF. et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015; 64: 57-65
• 13 Croffie J, Somogyi L. et al. Technology Assessment Committee. Sclerosing agents for use in GI endoscopy. Gastrointest Endosc 2007; 66: 1-6
• 14 Soehendra N, Grimm H, Stenzel M. Injection of nonvariceal bleeding lesions of the upper gastrointestinal tract. Endoscopy 1985; 17: 129-132
• 15 Igawa A, Oka S, Tanaka S. et al. Major predictors and management of small-bowel angioectasia. BMC Gastroenterol 2015; 15: 108
• 16 Lee JG, Lieberman DA. Complications related to endoscopic hemostasis techniques. Gastrointest Endosc Clin North Am 1996; 6: 305-321
• 17 Fisher DA, Maple JT. et al. ASGE Standards of Practice Committee. Complications of colonoscopy. Gastrointest Endosc 2011; 74: 745-752
• 18 Fahrtash-Bahin F, Holt BA, Jayasekeran V. et al. Snare tip soft coagulation achieves effective and safe endoscopic hemostasis during wide-field endoscopic resection of large colonic lesions (with videos). Gastrointest Endosc 2013; 78: 158-163 e1
• 19 Pohl H, Grimm IS, Moyer MT. et al. Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Gastroenterology 2019; DOI: 10.1053/j.gastro.2019.03.019.