Approach

Once the source of the bleeding is identified, treatment may follow. Diagnostic methods may be often combined with treatment. Referral to a gastrointestinal surgeon and gastroenterologist is recommended during or after stabilisation.

Supportive care

After assessment of the patient's haemodynamic status (vital signs), depending on the degree of blood loss, the patient may need protection and support of the airway through intubation. The patient's circulatory status is assessed with attention to the degree of blood loss, blood pressure, and pulse.

Supportive care includes giving intravenous fluids and blood transfusions as indicated, and should continue as needed in haemodynamically stable patients. The European Society of Gastrointestinal Endoscopy recommends red blood cell transfusion in haemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, with a haemoglobin threshold of ≤ 70 g/L (≤ 7 g/dL) prompting red blood cell transfusion.[38]​ In those with a history of cardiovascular disease, a haemoglobin threshold of ≤ 80 g/L (≤ 8 g/dL) should prompt red blood cell transfusion.[38]

Haemodynamically unstable

In patients with unstable angiodysplastic bleeding, guidelines recommend CT angiography as the initial test to assess the arterial anatomy and localise the bleeding point.[18]​​[35]​​[38]​​ This should be followed by mesenteric angiography with a view to embolisation to control the source of bleeding.[34][39]​​​ An upper gastrointestinal endoscopy may be performed next to rule out a source proximal to the distal duodenum.

Colonoscopy or surgery may be appropriate in the absence of angiography. During colonoscopy, electrocautery, photocoagulation, clips, or an adrenaline (epinephrine) injection may be indicated to treat the lesion. For patients with colonic angiodysplasias, careful treatment in the right colon is recommended, due to the thinner walls and higher risk for perforation. For patients with recurrent small bowel bleeding, endoscopic management via device-assisted enteroscopy can be considered depending on the patient’s clinical course and response to prior therapy.[8]​ Electrocautery uses heated probes to coagulate the bleeding lesions. Photocoagulation uses argon and Yag lasers and requires specific training. Argon photocoagulation appears to be safe and effective in patients with bleeding from colonic angiodysplasia.[62][63][64][Figure caption and citation for the preceding image starts]: Endoscopic (device-assisted enteroscopy) image of small bowel angiodysplasia after treatment with argon plasma coagulation​From the personal collection of Dr Elli, Milan, Italy; used with permission [Citation ends].com.bmj.content.model.Caption@22fce181[Figure caption and citation for the preceding image starts]: Endoscopic image of argon plasma coagulation of colonic angiodysplasiaPermission obtained from patient; GNU Free Documentation License [Citation ends].com.bmj.content.model.Caption@41059f01​​​​ Capsule endoscopy may also be indicated in a specific group where the above investigations have not yielded a source of bleeding. There may be a role for device-assisted enteroscopy after a positive capsule endoscopy to treat a small bowel bleeding lesion.

[Figure caption and citation for the preceding image starts]: ​Small bowel angiodysplasia seen during small bowel capsule endoscopy​From the personal collection of Dr Elli, Milan, Italy; used with permission [Citation ends].com.bmj.content.model.Caption@5aed98cb[Figure caption and citation for the preceding image starts]: ​Small bowel angiodysplasia seen during small bowel capsule endoscopy​From the personal collection of Dr Elli, Milan, Italy; used with permission [Citation ends].com.bmj.content.model.Caption@1f4e86c8

Only patients with a large, life-threatening haemorrhage with little relief from interventional endoscopy or embolisation are appropriate for surgery. At operation, the patient may undergo an on-table enteroscopy to localise the bleeding before a blind sub-total colectomy. Ideally, the bleed site should be identified before resection. Recurrent bleeding is still common after right hemicolectomy, as unidentified lesions may still be present. Aortic valve replacement should be considered in patients with Heyde’s syndrome, known small bowel angiodysplasia, and ongoing bleeding.[8]​ As surgery carries a high mortality, consider it only when all other options are exhausted. 

Haemodynamically stable

If the patient has a stable airway and vital signs, most bleeding episodes will stop spontaneously.

An elective colonoscopy is recommended to identify the source of bleeding. During the procedure, electrocautery, photocoagulation, clips, or an adrenaline injection may be indicated to treat the lesion.[34]

If the endoscopy is negative and the bleeding continues, based on local expertise, capsule endoscopy or CT angiography should be performed which may guide further intervention. If CT angiography confirms active bleeding, it should be followed by a mesenteric angiography with a view to embolisation to treat the bleeding.[39]​ Device-assisted enteroscopy can be used to treat bleeding lesions in the small bowel, seen on CT or capsule endoscopy.

If device-assisted enteroscopy or angiography is unavailable or unsuccessful and the patient is a surgical candidate, surgery can be considered. Surgery should not be used as a diagnostic tool to localise the site of bleeding in haemodynamically stable patients.[34]​ The exact procedure used will depend on the likely site(s) of the bleeding based on preoperative and intraoperative investigations.

If the patient is inappropriate for surgery, drug therapy is an option, but minimal research supports usage and results are mixed.[39] One systematic review and meta-analysis found that pharmacological treatment of any kind led to significantly reduced bleeding episodes and notable improvement in haemoglobin levels.[65]​ Somatostatin analogues (e.g., octreotide, lanreotide) and thalidomide have shown benefit in this setting. There is poor evidence for oestrogen derivatives.[39][66][67]​​ One multi-centre randomised controlled trial found that octreotide reduced transfusion requirements and the annual volume of endoscopic procedures in patients with angiodysplasia-related anaemia.[68]​ Long-term lanreotide therapy has shown to significantly improve anaemia and reduce hospitalisations, blood transfusions, and endoscopies in patients with angiodysplasias.[69][70]​ Systematic reviews suggest that somatostatin analogue therapy is safe and effective in patients with gastrointestinal angiodysplasia; octreotide therapy may be more effective than lanreotide therapy.[71][72]​ One retrospective study reported that somatostatin analogue therapy plus endoscopic therapy reduced bleeding episodes in patients with recurrent anaemia and small bowel angioectasia.[46]

Re-bleeding

If re-bleeding occurs, a repeat capsule endoscopy may be appropriate to localise site of bleeding before further intervention.[35]

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