Endoscopic treatment may be possible during diagnostic evaluation; the specific methods used depend upon the findings. Patients with severe, overt bleeding may require angiography. However, treatment of lesions suspected of causing bleeding may not always prevent recurrent bleeding. In addition, the suspected lesion may not be the cause or there may be additional sources of bleeding, particularly in patients with vascular ectasias.
Despite aggressive evaluation, the cause of occult or chronic recurrent gastrointestinal bleeding may not be identified. In some cases, such as small intestinal angiodysplasia, the cause of bleeding may be known, but the location may not be easily accessible to endoscopic intervention, multiple bleeding sites may exist, or bleeding may recur despite endoscopic therapy. Such patients usually require iron supplementation and may need periodic transfusion.
Hormonal therapy with estrogen (with or without progesterone) has been used to control obscure gastrointestinal bleeding in patients with hereditary hemorrhagic telangiectasias (Osler-Weber-Rendu syndrome), von Willebrand disease, and end-stage renal disease [1-4]. Among patients with bleeding from sporadic angiodysplasia, a benefit has been suggested in some small uncontrolled and crossover trials [5,6], although discordant data have been reported [7]. The most rigorous data come from a multicenter, placebo-controlled trial involving 72 noncirrhotic patients bleeding from documented angiodysplasia that showed no benefit from hormone therapy [8]. However, this study was performed prior to deployment of capsule endoscopy and deep enteroscopy; thus, the nature of the bleeding was not known.
Although the efficacy of hormonal therapy continues to be debated, there appears to be little or no role in patients with bleeding from documented angiodysplasia, except possibly those with hereditary hemorrhagic telangiectasias, von Willebrand disease, and end-stage renal disease.
Miscellaneous other treatments have been described in patients with obscure bleeding, including octreotide, thalidomide, erythropoietin, and replacement of von Willebrand's factor, but their efficacy is unclear [9-15].
References:
- McGee RR. Estrogen-progestogen therapy for gastrointestinal bleeding in hereditary hemorrhagic telangiectasia. South Med J 1979; 72:1503.
- Bronner MH, Pate MB, Cunningham JT, Marsh WH. Estrogen-progesterone therapy for bleeding gastrointestinal telangiectasias in chronic renal failure. An uncontrolled trial. Ann Intern Med 1986; 105:371.
- Lavabre-Bertrand, T, Navarro, M, Blanc, PO, et al. von Willebrand's disease, digestive angiodysplasia and estrogen-progesterone treatment (letter). Am J Hematol 1990; 85:1649.
- Liu YK, Kosfeld RE, Marcum SG. Treatment of uraemic bleeding with conjugated oestrogen. Lancet 1984; 2:887.
- Granieri R, Mazzulla JP, Yarborough GW. Estrogen-progesterone therapy for recurrent gastrointestinal bleeding secondary to gastrointestinal angiodysplasia. Am J Gastroenterol 1988; 83:556.
- Barkin JS, Ross BS. Medical therapy for chronic gastrointestinal bleeding of obscure origin. Am J Gastroenterol 1998; 93:1250.
- Lewis BS, Salomon P, Rivera-MacMurray S, et al. Does hormonal therapy have any benefit for bleeding angiodysplasia? J Clin Gastroenterol 1992; 15:99.
- Junquera F, Feu F, Papo M, et al. A multicenter, randomized, clinical trial of hormonal therapy in the prevention of rebleeding from gastrointestinal angiodysplasia. Gastroenterology 2001; 121:1073.
- Blich M, Fruchter O, Edelstein S, Edoute Y. Somatostatin therapy ameliorates chronic and refractory gastrointestinal bleeding caused by diffuse angiodysplasia in a patient on anticoagulation therapy. Scand J Gastroenterol 2003; 38:801.
- Bowers M, McNulty O, Mayne E. Octreotide in the treatment of gastrointestinal bleeding caused by angiodysplasia in two patients with von Willebrand's disease. Br J Haematol 2000; 108:524.
- Gonzalez D, Elizondo BJ, Haslag S, et al. Chronic subcutaneous octreotide decreases gastrointestinal blood loss in blue rubber-bleb nevus syndrome. J Pediatr Gastroenterol Nutr 2001; 33:183.
- Pérez-Encinas M, Rabuñal Martínez MJ, Bello López JL. Is thalidomide effective for the treatment of gastrointestinal bleeding in hereditary hemorrhagic telangiectasia? Haematologica 2002; 87:ELT34.
- Shurafa M, Kamboj G. Thalidomide for the treatment of bleeding angiodysplasias. Am J Gastroenterol 2003; 98:221.
- Zaharia-Czeizler V. Erythropoietin stops chronic diffuse transfusion-dependent gastrointestinal bleeding. Ann Intern Med 2001; 135:933.
- Morris ES, Hampton KK, Nesbitt IM, et al. The management of von Willebrand's disease-associated gastrointestinal angiodysplasia. Blood Coagul Fibrinolysis 2001; 12:143.