Successful Management of Colonic Angiodysplasia With Endoscopic Mucosal Resection and Argon Plasma Coagulation

Introduction

Angiodysplasia is a localized dilatation of abnormal, tortuous veins that lack an internal elastic lamina within the mucosa or submucosa [1]. Boley et al explained the pathogenesis of angiodysplasia by describing this phenomenon as vascular ectasia [1]. Angiodysplasia is a particularly common cause of chronic and recurrent lower gastrointestinal bleeding [2]. A retrospective cohort study in Japan [3] showed that, among adult patients hospitalized for acute hematochezia, angiodysplasia was the cause of bleeding in 1.3%. The prevalence of asymptomatic colonic angiodysplasia is estimated to range from 0.8% to 6.2% [4], with a particularly high prevalence in older adults [5]. Endoscopic hemostasis is not always performed because 40% to 90% of hemorrhages from colonic angiodysplasia cease spontaneously [6,7]. However, the above-mentioned Japanese cohort study [3] confirmed that patients with angiodysplasia required more blood transfusions relative to those without angiodysplasia. Endoscopic treatment of colonic angiodysplasia is not regarded as a well-documented consensus due to wide variation in treatment strategies [8]. Colonic angiodysplasia is more common in older patients and is usually managed with argon plasma coagulation (APC). Although APC is most commonly used as a first-line treatment for bleeding angiodysplasia, its efficacy remains unclear because there is a lack of prospective studies comparing clinical outcomes, including post-treatment rebleeding rates [9]. This report describes a 73-year-old woman with colonic angiodysplasia that was successfully managed with endoscopic mucosal resection (EMR) and APC for 2 lesions that caused lower gastrointestinal bleeding. Although reports of mucosal resection for colonic angiodysplasia are limited, Geyl et al [10] successfully treated polypoid angiodysplasia using EMR.

Case Report

A 73-year-old woman with diabetes mellitus and atrial fibrillation was referred to our hospital for management of anemia. Blood tests performed by a local physician had revealed hypochromic microcytic anemia, with a hemoglobin level of 7.9 g/dL. The physician had performed esophagogastroduodenoscopy and abdominal ultrasonography, which did not reveal the cause of anemia. The patient had been diagnosed with iron-deficiency anemia and prescribed ferrous sulfate. Because a subsequent fecal occult blood test result was positive, the patient underwent colonoscopy at our hospital. An angiodysplasia measuring 10 mm was identified in the cecum. The cecal lesion developed spontaneous hemorrhage during examination, which then stopped without intervention (Figure 1A, 1B). The presence of spontaneous hemorrhage suggested recurrent and chronic lower gastrointestinal bleeding; therefore, the angiodysplasia was regarded as the primary cause of anemia. Another angiodysplasia measuring 30 mm was detected in the ascending colon (Figure 1C). The 2 lesions in the right colon were treated endoscopically during the same session.

The angiodysplasia in the cecum was treated with EMR. A saline solution was injected into the submucosa at the center of the lesion to create a steep mucosal elevation. A snare was placed around the margins of the angiodysplasia to resect all vessels exposed on the mucosal surface. Although immediate bleeding occurred after EMR, the mucosal defect was closed with 5 clips (Figure 2A–2D). The angiodysplasia in the ascending colon was then ablated with APC as completely as possible (Figure 3A, 3B). The snaring approach could not be used for this angiodysplasia because the lesion’s size made it difficult to completely resect. Six months after treatment, endoscopic follow-up was performed. The cecal lesion showed clear scarring, whereas angiodysplasia had recurred on the mucosa in the ascending colon (Figure 4A, 4B). APC was performed again for the recurrent lesion, and good scarring was confirmed 2 months later. After the second APC treatment, ferrous sulfate was discontinued. At follow-up 3 months after treatment completion, the patient’s hemoglobin level had improved to 13.3 g/dL.

Discussion

In the present case, 2 angiodysplasias were treated with EMR and APC, respectively. Angiodysplasia recurrence was observed after APC, whereas no recurrence was detected after treatment comprising EMR combined with clipping. Colonic angiodysplasia, the most common vascular abnormality in the gastrointestinal tract, can cause lower gastrointestinal bleeding [2]. The most common etiology of lower gastrointestinal bleeding is diverticular bleeding, which causes 30% to 50% of all cases. Its frequency differs by age group, such that angiodysplasia is more prevalent in older adults [11]. Gastrointestinal bleeding due to colonic angiodysplasia is identified in approximately 3% to 15% of patients [12]. Colonic angiodysplasia is often found incidentally during colonoscopy performed for colorectal cancer screening or evaluation of anemia. In patients without a history of gastrointestinal bleeding or anemia, incidental vascular dysplasia does not require treatment. Multiple endoscopic modalities for the treatment of colonic angiodysplasia have been described [6]. APC is the most widely available endoscopic treatment; in 1 report, it was selected for 32.6% of patients [3]. APC is particularly effective for controlling superficial mucosal bleeding, and the maximum achievable coagulation depth under appropriate control is 3 to 4 mm [13]. Although APC is easy to handle, its accuracy is not fully established due to insufficient clinical data [14]. A disadvantage of APC is the relatively high rate of post-treatment rebleeding, which occurs in 10% to 34% of cases [15,16]. Consequently, repeated endoscopic procedures may be required.

Colonic angiodysplasia is most commonly found in the cecum or ascending colon, comprising 54% to 89% of all cases [14]. However, the right colon carries the highest risk of perforation after coagulation therapy. Because the perforation rate associated with APC is reportedly around 1% [15], procedures in the right colon are more challenging.

Angiodysplasia does not require deep ablation because bleeding originates from the colonic mucosa [6]. APC is suitable for mucosal ablation and thus is commonly used for the treatment of colonic angiodysplasia. However, standardization of the ablation depth during endoscopic treatment is difficult, and the depth cannot be reliably predicted. Ablation depth depends on the angle of the argon beam; therefore, APC accuracy depends on the endoscopist’s skill level.

In the present case, EMR was selected as treatment for angiodysplasia. Geyl et al reported that EMR can achieve curative resection, even for localized colonic angiodysplasia, although the risk of rebleeding remains high [10]. EMR is a fundamental endoscopic technique generally available to endoscopists who can perform polypectomy, given that it is part of standard endoscopic training [14]. The perforation rate of EMR in the right colon is reportedly 0.05% to 0.17% [17], indicating that EMR is a safe treatment for colonic angiodysplasia within the usual size limit of approximately 20 mm. A limitation of EMR is delayed post-polypectomy bleeding. Clip closure of mucosal defects after resection is a well-established technique that constitutes an additional safety measure to prevent delayed perforation and post-treatment bleeding [18]. In a study evaluating the cold snare technique for angiodysplasia, Arimoto et al [19] reported that delayed post-polypectomy bleeding occurred in 0% of cases when prophylactic clipping was performed. Thus, in cases of colonic angiodysplasia treated with EMR, additional clipping may be effective.

Our patient experienced angiodysplasia recurrence after treatment with APC alone. The lesion in her ascending colon may have had larger submucosal feeding vessels than expected. In a retrospective subgroup analysis of patients receiving oral antithrombotic therapy, Ismail et al [20] found that combined treatment with APC and clipping was associated with a lower risk of post-treatment rebleeding relative to APC alone. Based on this finding, recurrence in the present case might have been avoided if APC had been combined with clipping.

Hemorrhage from colonic angiodysplasia has been associated with advanced age, cardiovascular disease, and anticoagulant use [21]. Although a Japanese nationwide cohort study of angiodysplasia [3] did not identify clear risk factors for post-treatment rebleeding, the additional use of clipping in combination with APC or EMR may help prevent rebleeding in patients who exhibit risk factors for angiodysplasia-related hemorrhage. Even in flat lesions of colonic angiodysplasia, EMR may be an effective option for reducing rebleeding rates. Accordingly, EMR has the potential to serve as a standard treatment option for colonic angiodysplasia – similar to APC – depending on availability and clinical outcomes.

Conclusions

EMR has the potential to be comparable to APC as a standard treatment option for colonic angiodysplasia. The additional use of clipping in combination with APC or EMR may help prevent rebleeding, particularly in patients with risk factors for angiodysplasia-induced hemorrhage.