History and exam
Key diagnostic factors
common
gastrointestinal bleeding
Patients usually display chronic, painless, low-grade, intermittent bleeding, with either fresh rectal bleeding in lower gastrointestinal disease or melaena in upper gastrointestinal disease.
There may be long periods of time between bleeding episodes, and episodes are usually self-limiting.
In rare cases, patients may present with massive haemorrhage (haematochezia or haematemesis).
Usually bright red stool, but may be maroon.
Other diagnostic factors
common
age >60 years
shortness of breath
Because bleeding may be low grade and chronic, patients may present with symptoms and signs of anaemia.
fatigue
Because bleeding may be low grade and chronic, patients may present with symptoms and signs of anaemia.
pallor
Because bleeding may be low grade and chronic, patients may present with symptoms and signs of anaemia.
uncommon
tachycardia
May occur if bleeding occurs at a faster pace and in larger amounts.
hypotension
May occur if bleeding occurs at a faster pace and in larger amounts.
Risk factors
weak
chronic renal failure/end-stage renal disease
In patients with chronic renal failure, angiodysplasia is responsible for 19% to 32% of lower gastrointestinal bleeding episodes, compared with 5% to 6% episodes in the general population.[4] Increased risk of bleeding may be attributed to uraemic platelet dysfunction, use of anticoagulants, or reduced production of erythropoietin.[4] An increased prevalence of angiodysplasia is observed in patients undergoing dialysis and is a common cause of gastrointestinal bleeding in this patient group.[13][14][15]
von Willebrand's disease
The incidence of angiodysplasia is higher in patients with von Willebrand's disease.[4][16][31][32]
Bleeding from gastrointestinal angiodysplasia is observed only in patients with either hereditary or acquired von Willebrand's disease; these patients lack high molecular weight multimers of von Willebrand's factor.[4][33] These multimer abnormalities have been shown to be associated with increased risk of bleeding from angiodysplasia.[4]
aortic stenosis
Heyde's syndrome is characterised by gastrointestinal bleeding from angiodysplasia in the presence of aortic stenosis.[19] It has predominantly been attributed to acquired von Willebrand's disease, but the absence of von Willebrand's disease does not rule out the diagnosis of Heyde's syndrome.[19]
One large epidemiological study found a significant association between aortic stenosis and gastrointestinal bleeding presumed due to intestinal angiodysplasia.[20] Prevalence of patients with both aortic stenosis and gastrointestinal bleeding was low, which may have precluded smaller studies finding a significant association.[20] Classically, angiodysplasia is located in the ascending colon, while that associated with Heyde's syndrome is predominantly located in the small intestine.[19] One meta-analysis reported cessation of bleeding after valve replacement.[21]
scleroderma
Gastrointestinal mucosal abnormalities, including gastric and/or small intestinal angiodysplasia and gastric and/or small intestinal telangiectasia, were reported in 52% of patients with systemic sclerosis in one study.[22]
cardiovascular disease
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