Colonic angiodysplasia

Clinical Presentation

In November, 2018, 32 year old man presented with repeated episodes of severe anemia with history of malena stool and blood transfusions of six month duration. Complete blood results showed severe hypochromic microcytic anemia with hemoglobin level 4.6 g%. Imaging studies revealed right 5th bi-fid rib on chest X-ray and mild splenomegaly on ultrasound examination. Urea, creatinine and electrolytes results were within normal range. The patient received a blood transfusion of four units of fresh whole blood.

• Upper GI Endoscopy – NAD
• Lower GI Endoscopy and Biopsy

  Total colonoscopy showed extensive dilated, tortuous vessels on thickened, narrowed lumen with reddish-purple mucosal abnormalities (which easily bled on touch) from the sigmoid-descending junction upward about 20 cm in length. Our provisional diagnosis was colonic varices or arterio-venous malformation in the descending colon and the biopsy showed angiodysplasia.

Colonoscopic pictures

Imaging Studies

We requested for NECT and CECT examination and reported as long segment (27 cm) contrast enhanced colonic wall thickening (unilateral wall thickness 2.3 cm) with mural calcifications, luminal narrowing, marked mesenteric infiltration and likely mesenteric varices in the descending colon. Marked luminal narrowing is noted in mid descending colon with residual patent luminal diameter about 0.7 cm. Serosal infiltrations, marked peri-colic fat stranding, nodular mesenteric infiltrations and increased mesenteric vascularity (especially tortuous venous drainage of smaller branches) were also noted. Radiologist’s impression was descending colon adeno-carcinoma and the differential diagnoses were colonic lymphoma and severe inflammatory bowel disease.

Inflammatory markers and Tumor marker

The inflammatory markers were: LDH level – 490 U/L (normal <243.0) and C reactive protein was 16.4 mg/L (normal <5.0). His coagulation profile was within normal limit. His carcino-embryonic antigen (CEA) level was 1.94 ng/ ml (normal value for non-smoker <5.0).

Differential Diagnoses

Our differential diagnoses were:
– Large angiodysplasia
– Colonic haemangioma
– Colonic Varices

Surgery

The laparotomy preformed showed a large, crowded patch of nodular vascular lesions with multiple dilated, tortuous small vessels along the serosal surface of the descending colon about 30 cm in length. There was a thickened peri-colonic fat patch surrounding the small, dilated and tortuous vessels in the meso-colon, lateral colonic wall and retro-peritoneal part of the descending colon. There was no significant peri-colonic lymph node enlargement and inferior mesenteric vessels appeared to be normal. We performed resection of affected segment of the descending colon. The histopathology report was the same as the endoscopic biopsy report: angiodysplasia.

Gross pictures

Histological pictures

Discussion

Angiodysplasia is the most common vascular abnormality of the gastrointestinal tract. After diverticulosis, it is the second leading cause of lower GI bleeding in patients older than 60 years. Angiodysplasia may account for approximately 6% of cases of lower GI bleeding. It may be seen incidentally at colonoscopy in as many as 0.8% of patients older than 50 years. The prevalence for upper GI lesion is approximately 1% – 2% . [1]

Colonic angiodysplasia in Japanese patients is predominantly located in the left colon, where as in Western patients it is mainly located in the right colon. Colonic lesions with a size of more than 5mm or larger were more common in Japanese patients. [1]

Most patients found to have angiodysplasia are over 60 years but most are older than 70 years. However, occurence in young people have been reported. [1]

Reference
1. Angiodysplasia of the colon – Medscape; by Hussein Al-Hamid, MD Fellow, Department of Gastroenterology, Providence Hospital. Updated on May 08, 2019.

Kyaw Zay Ya¹, Thet Aung Zaw Myint², Zaw Myint³

1. First Assistant Surgeon, No. (12/100) Military Hospital, Dawei.
2. Consultant Gastroenterologist, No. (12/100) Military Hospital, Dawei.
3. Senior Consultant Surgeon, Dawei General Hospital.