AKT · Gastroenterology/GI bleeding

Angiodysplasia

Acquired ectatic submucosal vascular malformations of the bowel wall (commonest in caecum/right colon)

Overview

Acquired degenerative vascular ectasias, most often in the caecum and right colon, that are a common cause of obscure/occult lower-GI bleeding and iron-deficiency anaemia in the elderly. Classically associated with aortic stenosis (Heyde syndrome — acquired type 2A von Willebrand disease) and with chronic kidney disease.

Recognise

Elderly patient with painless intermittent or occult GI bleeding → recurrent iron-deficiency anaemia, or fresh PR bleeding/melaena
Recurrent obscure GI bleeding with normal initial endoscopy (lesions easily missed; may be small-bowel)
Associations: aortic stenosis (Heyde), chronic kidney disease, von Willebrand disease/LVADs

Red flags

Haemodynamic compromise from acute bleeding → resuscitate as GI bleed
Transfusion-dependent recurrent bleeding → escalate beyond endoscopic therapy

Differentials & how to tell them apart

Diverticular bleedpainless, often brisk, typically left colon; diverticula on colonoscopy

Colorectal cancermass/stricture, change in bowel habit, weight loss

Haemorrhoidsbright-red outlet bleeding, perianal; benign on examination

Investigations

Colonoscopy (cherry-red, fern-like flat lesions, right colon); CT/mesenteric angiography for active bleeding; capsule endoscopy/device-assisted enteroscopy for small-bowel source; FBC (IDA); assess for aortic stenosis and acquired vWD if recurrent.

Management

Resuscitate + iron; endoscopic argon plasma coagulation; aortic valve replacement for Heyde syndrome

1Resuscitate, correct anaemia/coagulopathy, and localise the lesion (colonoscopy ± CT angiography/capsule endoscopy). Treat identified accessible lesions with endoscopic argon plasma coagulation.Gate: If bleeding recurs despite endoscopic therapy → tranexamic acid, then thalidomide/octreotide or angiographic embolisation; in Heyde syndrome (aortic stenosis + acquired von Willebrand disease) AORTIC VALVE REPLACEMENT stops the bleeding.
2Angiographic embolisation or, rarely, surgical resection for localised refractory bleeding; long-term iron support.

Resuscitation + iron/transfusion — correct anaemia and any coagulopathy

Endoscopic argon plasma coagulation — first-line for accessible identified lesions

Tranexamic acid — adjunct for ongoing/recurrent bleeding

Thalidomide / octreotide; angiographic embolisation — refractory recurrent bleeding

Aortic valve replacement — corrects Heyde-syndrome bleeding (restores von Willebrand multimers)

Key points

Recurrent obscure GI bleeding / iron-deficiency anaemia in an elderly patient — especially with an aortic-stenosis murmur (Heyde syndrome, acquired type 2A vWD) — = angiodysplasia → argon plasma coagulation; valve replacement cures the Heyde-related bleeding.

Monitor & prognosis

Haemoglobin/iron status; recurrence is common.

Often recurrent and multifocal; individual lesions treatable but new lesions appear.

Source: BSG; StatPearls