Introduction
Digestive angiodysplasias are vascular malformations whose pathogenesis is poorly
known. They are a rare cause of upper and lower occult or externalized digestive hemorrhages.
Most of them are of acquired origin, most often affecting the right colon and the
cecum, but can sit on the entire digestive tract.
On the other hand, radiation rectitis is a frequent complication, of variable severity,
occurring a few months after the radiation of the pelvic-perineal organs has stopped,
but which can manifest itself several years later.
Argon plasma coagulation (APC) is the technique of choice in the treatment of digestive
vascular abnormalities, improving the quality of life of patients and reducing the
need for repeated transfusions.[1]
[2]
The objective of our study is to evaluate the value of Argon Plasma Coagulation in
the treatment of gastrointestinal vascular abnormalities.
Instruments
The equipment required to perform the APC includes:
-
-The Argon bottle: Argon can be easily ionized at high electrical frequency and is then transformed
into a stable plasma of a pale yellow color.
-
-The electric scalpel with APC program.
-
-The pedal: connected to the unit and allowing the control of the electric arc.
-
-The APC probe: this is a teflon catheter in which a tungsten electrical guide is inserted. This
electrode is connected at its distal end with a ceramic inserted in the catheter lumen.
Some catheters are perforated laterally at their distal end their diameters are 1.5 mm,
2.3 mm, and 3.2 mm. The standard length is 220 cm, up to 300 cm for use in enteroscopy.
-
-The endoscope: The endoscopes used for the treatment of gastroduodenal and colonic lesions were
video endoscopes. The lesions of the small bowels that were not accessible of oesogastroduodenal
fibroscopy or colonoscopy were treated by high or low enteroscopy, depending on the
case.
Deep coagulation by APC is directly dependent on the power and time of coagulation,
so a perforation is possible. The ideal distance between the APC probe and the tissue
is 3 to 5 mm. The contact time should be in periods of 0.5 to 2 seconds (0.5 seconds
for the colon).
The average power used is 70 to 90 W for a recommended argon flow rate of 0.8 to 1.2
liters per minute.
Flow rate (power //flux):
Patients:
198 patients who have benefited from treatment with Argon Plasma Coagulation (APC)
for vascular anomalies of the digestive tract, divided into 2 groups:
Positive diagnosis was established by endoscopic examinations (Fibroscopy, enteroscopy,
colonoscopy) or by endoscopic videocapsule.
All patients included in the study had a pre-anesthetic consultation. They were given
a complete clinical examination and a biological assessment, mainly the hemostasis
assessment.
They were informed about the course of the examination and all gave their consent
for the procedure. The operation was performed on patients fasting, under sedation
or general anesthesia in dorsal or lateral decubitus position.
All patients who were going to benefit from a colonoscopy or low enteroscopy were
given a preparation per 4 liters of polyethylene glycol.
A clinical and biological control in 15 days to one month was systematic in order
to stratify the patients requiring a second APC session.
Inclusion Criteria
For Group A:
For Group B:
-
-Age >18 years.
-
-Any patient presenting an externalized (upper/lower) or occult digestive hemorrhage,
with the presence of angiodysplasia lesions during the endoscopic assessment of the
digestive tract (esogastroduodenal fibroscopy, colonoscopy, enteroscopy, videocapsule).
Data Collection
The data collection was done on the medical records of the patients, who are hospitalized
either 24 hours before the procedure, or on the same day (day hospital), on the other
hand the technical part relating to the endoscopic procedure was filled in by the
operator explaining the different steps of the endoscopic procedure.
The data that have been exploited are:
-
*
Demographic data
: -Age
-
-Sex
-
-Surgical history (Gastrectomy, operated gastric ulcer, lung cancer, prostate cancer,
esophageal cancer, cervical cancer, rectal cancer, anal cancer, colon cancer, system
disease, kidney failure, cirrhosis).
-
-Indication: Anemic syndrome, rectorragy, melena, hematemesis, epigastralgia.
-
*
Endoscopic data
: -Number of lesions.
-
-Site of injury (Oesophagus, fundus, antrum, bulb, duodenum, jejunum, ileum, gastric
stump, oeso-jejunal or gastro-jejunal anastomosis, afferent or efferent loop, cecum,
colon, rectum).
-
-Presence or not of active bleeding
-
-Use of complementary endoscopic hemostasis (Clip) or not.
-
*
Number of APC sessions
-
*
Prescription of an adjuvant medical treatment
(Corticotherapy or 5- aminosalicylated enemas) or not.
Statistical Analysis
We performed a two-step statistical analysis:
-
A descriptive analysis of our population including the different demographic, clinical and endoscopic variables:
-
An analytical study was then carried out:
The comparison of the quantitative variables with normal distribution was done by
the Student's test.
The comparison of quantitative variables with an unsymmetrical distribution was done
by the Man Whitney test.
The comparison of qualitative variables between two groups was done by the Chi-square
or Fisher test.
A value of p < 0.05 was considered statistically significant.
The statistical analysis was performed using SPSS version 24.0 software.
Our study has been approved by our hospital's ethics committee.
Results
The mean age of our patients was 64.95 ± 9.88 years [43 - 83] in group A, with a sex
ratio M/F of 0.82, while in group B the mean age was 65.19 ± 14.29 years [40 - 91]
with a clear male predominance in 72.5%. ([Table 1])
Table 1
Patient Demographics:
|
Characteristics
|
Group A (n = 107)
|
Group B (n = 91)
|
p
|
|
Age
|
64,95 ± 9,88
|
65,19 ± 14,29
|
0,89
|
|
Sex: -Men
-Woman
|
48(45,3%)
58(54,7%)
|
66(73,3%)
24(26,7%)
|
<0,0001
|
The majority of group A patients were followed for prostate cancer in 33.8% (n = 28),
followed by cervical cancer in 33.8% (n = 22), while 13.8% (n = 9) and 4.6% (n = 3)
had cancer of the rectum and bladder, respectively; and one patient had squamous cell
carcinoma of the anus.
On the other hand, 26.3% (n = 5) of patients in group B had chronic renal failure,
followed by cancer of the stomach in 15.8% (n = 3), and cancer of the esophagus in
10.5% (n = 2) ([Table 2]).
Table 2
Patient medical and surgical history
|
Background
|
Group A (n = 107)
|
Group B (n = 91)
|
p
|
|
Gastrectomy
|
|
3(15,8%)
|
|
|
Gastric ulcer operated
|
|
1(5,3%)
|
|
|
Lung cancer
|
|
1(5,3%)
|
|
|
Prostate cancer
|
28(43,1%)
|
|
|
|
Cancer of the esophagus
|
|
2(2,2%)
|
<0,0001
|
|
Cervical cancer
|
22(33,8%)
|
|
|
|
Rectal cancer
|
9(13,8)
|
|
|
|
Anal cancer
|
1(1,5%)
|
|
|
|
Colon cancer
|
|
1(1,1%)
|
|
|
System disease
|
|
2(2,2%)
|
|
|
Kidney failure
|
|
5(5,5%)
|
|
|
Cirrhosis
|
|
1(1,1%)
|
|
The clinical symptomatology was dominated in group A by rectorragies in 40.2% (n = 43),
an anemic syndrome in 3.7% (n = 4) and only one patient had melena of low abundance.
On the other hand, in group B, 46.8% (n = 49) of the patients had rectorragies, 35.8%
(n = 33) had iron deficiency anemia, 32.6% (n = 30) had melenas, two patients had
hematemesis and one patient had epigastralgia. ([Table 3]).
Table 3
Reason for patient hospitalization:
|
Clinical signs
|
Group A (n = 107)
|
Group B (n = 91)
|
p
|
|
Anemic Syndrome
|
4(3,7%)
|
33(35,8%)
|
|
|
Melena
|
1(2,2%)
|
30(32,6)
|
|
|
Rectragies
|
43(40,2)
|
49(46,8)
|
0,25
|
|
Hematemesis
|
|
2(2,2%)
|
|
|
Epigastralgies
|
|
1(1,1%)
|
|
The median number of APC sessions in both groups was 2.[1]
[2]
The median number of lesions in each patient was 2.[1]
[2]
[3]
The rectal injury was dominated in group A in 98.1% (n = 105), whereas in group B
the lesions were mainly located in the stomach in 58.3% (n = 55), followed by the
coecum in 30.9% (n = 25), the jejunum in 19.1% (n = 13) and the duodenum in 17.7%
(n = 16).
The presence of active bleeding was without significant difference between the two
groups: 10.7% in group A versus 11% in group B.
The use of adjuvant corticosteroid therapy or 5-ASA enema was only in group A in 4.7%
(n = 5).Use of hemostatic clip was only in group B in 3.3%(n = 3) ([Table 4]).
The endoscopic evolution was favorable in all our patients with a clear improvement
of rectal lesions and digestive angiodysplasia lesions. The total complication rate
in our series was nil.
Table 4
Endoscopic characteristics of patients
|
Characteristics
|
Group A (n = 107)
|
Group B (n = 91)
|
p
|
|
Number of lesions
|
2 [1–3]
|
2 [1–4]
|
0,019
|
|
Esophagus
|
|
4(4,4%)
|
|
|
Fundus
|
|
27(29,7%)
|
|
|
Antre
|
|
22(24,2%)
|
|
|
Bulb
|
|
6(6, 6%)
|
|
|
Duodenum
|
|
10(11,1%)
|
|
|
Jejunum
|
|
13(19,1%)
|
|
|
Gastric stump
|
|
4(4,4%)
|
|
|
Related/efferent handle
|
|
5(5,6%)
|
|
|
Oeso-jejunal anastomosis
|
|
1(1,3%)
|
|
|
Coecum
|
|
25(30,9)
|
|
|
Straight colon
|
|
7(8,6%)
|
|
|
Transverse colon
|
|
4(4,9%)
|
|
|
Left colon
|
5(4,7%)
|
5(5,6%)
|
|
|
Rectum
|
105(98,1%)
|
6(6,7%)
|
|
|
Active bleeding
|
11(10,7)
|
9(11%)
|
0,9
|
|
Complementary endoscopic haemostasis maneuvers
|
|
3(3,3%)
|
0,09
|
Discussion
Vascular abnormalities of the gastrointestinal tract are a rare cause of digestive
hemorrhage and pose a diagnostic and therapeutic problem. They were first described
in 1839, and in 1974 the term intestinal angiodysplasia (IA) was defined as a single
or multiple superficial acquired vascular lesion developed in the mucosa and/or submucosa
of the gastrointestinal tract wall, without being associated with a cutaneous or visceral
angiomatous lesion.[3]
[4]
Their prevalence in the general population is 0.83%,[5] they are equally present in both sexes and are more frequent after the sixties.[6]
Various equivalent terms can be found in the literature: “arteriovenous malformation”,
“telangiectasia” or “vascular ectasia”. On the other hand, intestinal angiodysplasia
are to be differentiated from benign vascular tumors called hemangiomas or malignant
tumors called angiosarcomas.
The typical appearance of an IA is that of a bright red, rounded, irregularly contoured,
slightly raised, bright red “spot”, usually small, less than 10 mm in size ([Fig. 1]). A halo around the lesion is sometimes described, corresponding to a paler peri-lesional
mucosa.
Fig. 1 Right colonic angiodysplasia (Image from the Hepato-Gastroenterology II department
of Mohammed V Military Hospital).
An IA corresponds histologically to a dilatation of the mucosal capillaries in communication
with ectasic and tortuous submucosal veins ([Fig. 2]).
Fig. 2 Histological section of digestive angiodysplasia.[7]
They account for 4% of the aetiologies of upper digestive haemorrhages.[8]
Gastric and/or duodenal localization is preferred, but they are more frequent in the
small intestine[9] and the colon, particularly in the ascending portion and in the cecum.
In our study the lesions were mainly located in the stomach in 58.3% followed by the
coecum in 30.9%, the jejunum in 19.1% and the duodenum in 17.7%.
The development of endoscopy techniques and the quality of the video endoscopes used,
particularly in terms of image resolution, make endoscopy the first avenue to follow
for the diagnosis of IA; when located in the small intestine, diagnosis is made using
endoscopic videocapsule or high or low enteroscopy.
It is not uncommon to miss some IA due to localization behind a fold or in the small
intestine which is highly mobile, so there should be no hesitation to repeat endoscopic
examinations when clinical suspicion is strong.[10]
Approximately 90% of IAs stop bleeding spontaneously,[11] but the risk of recurrence is high. This risk is between 25% and 65% depending on
the studies.[12]
[13] Surgical treatment is infrequent, up to 12% in some studies.[13] Mortality from hemorrhagic IA is approximately 2%.[14]
In another retrospective study,[15] haemorrhagic angiodysplasia was reported in 50% of the 261 patients investigated
by double-balloon enteroscopy for unexplained digestive bleeding who were treated
with argon plasma hemostatic therapy. The rate of hemorrhagic recurrence at 3 years
was 46%, with a high number of vascular lesions and the presence of rhythmic and/or
valvular heart disease being predictive factors for recurrence. In the colon, the
rate of hemorrhagic recurrence after coagulation with argon plasma treatment ranged
from 7% to 15% with a median follow-up of 6 to 20 months.[16]
[17]
[18]
In our study active bleeding was present in 11% of our patients; thus the use of hemostatic
clip was present in only 3.3%.
The endoscopic evolution was favorable in all our patients with a clear improvement
of rectal lesions and digestive angiodysplasia lesions. The total complication rate
in our series was nil.
On the other hand, the risk of occurrence of radiation rectitis increases above all
with the dose of irradiation administered, the threshold dose is 45 grays. The risk
is also influenced by the volume irradiated, the mode of radiotherapy (external irradiation
or curietherapy), time fractionation and dose spread.[19]
[20]
[21]
The main symptom of chronic radiation rectitis is rectorragies, but it can also be
revealed by mucusy diarrhoea secondary to the chronic irritative phenomenon of the
rectal wall, and can also be accompanied by anal incontinence or an anaemic syndrome.[22]
The diagnosis of radiation rectitis is primarily endoscopic. The appearance of the
rectal mucosa is variable. It may present in two ways: either by a mucosa covered
with telangiectasia taking on the appearance of more or less regular, dilated and
fragile, disseminated neo-vessels ([Fig. 3]); or it may be diffusely congestive, friable and hemorrhagic at the slightest contact
or spontaneously ([Fig. 4]). In extreme cases one may find scattered ulcerations that may be superficial or
deepening ([Fig. 5]).
Fig. 3 Endoscopic aspect of a telangiectasic radiolucent rectitis.[23]
Fig. 4 Endoscopic aspect of diffuse congestive radioconjugate rectitis[23]
Fig. 5 Endoscopic appearance of an ulcerated radionuclide rectitis.[3]
Sometimes recto-vaginal or recto-vesical fistulas may occur secondary to the mucosal
remodeling of the rays and its healing.
The treatment of choice for both digestive angiodysplasias and radiation rectitis
is Argon Plasma Coagulation (APC),[24] except for asymptomatic non-haemorrhagic AIs, of incidental discovery, where therapeutic
abstention is well recommended.[25] The main goal is to control bleeding and prevent recurrence.
The principle is based on the transformation of the energy produced by a high electric
current into thermal energy, resulting in coagulation, debridement and/or desiccation
of the tissues,[26] as the simultaneous release of an electric current and a gas argon, which in its
ionized form will destroy, in a targeted and non-contact manner (3 to 5 mm of distance),
the superficial mucosa (0.5 to 3 mm deep) by means of an electric arc ([Figs. 6] and [7]).
Fig. 6 APC probe at a distance from the mucosa (Image from the Hepato-Gastroenterology II
department of Mohammed V Military Hospital)).
Fig. 7 Coagulated colonic angiodysplasia at the APC (Image from the Hepato-Gastroenterology
II department of Mohammed V Military Hospital).
The power of the generator should be adjusted according to the location of the angiodysplasia.[27] The recommended settings are (expert opinion): in the stomach: 0.8 L/min, 50W; in
the esophagus, duodenum, small intestine, and right colon/cecum: 0.6 L/ min, 40W;
in the left colon: 0.8 to 1 L/min, 50W.
May and al[28] showed in a recent retrospective series a significant reduction in transfusion requirements
in 50 patients treated with argon plasma coagulation. However, recurrence of bleeding
occurred in 42% of patients after a mean follow-up of 4.5 years.
Gerson and al[29] showed a similar rate of hemorrhagic recurrence (45%) 30 months after treatment
of angiodysplasias.
Other studies[30]
[31]
[32] involving at least 300 patients have all reported argon plasma coagulation efficacy
rates in the treatment of radiation rectitis of more than 80% on bleeding after an
average of 1 to 3 sessions (extremes of 1 to 8), with complete or partial cessation
of bleeding. Several sessions are often required, with a correlation between the number
of sessions and the extent of the lesions to be treated.[33]
However, a minimum delay of two to four weeks between two sessions is preferable in
order to allow sufficient healing time.
The complication rate of argon plasma coagulation treatment ranges from 1.7% to 7%
and includes fever with bacteremia, urinary disorders, ulceration, bleeding from pressure
ulcer, rectal stenosis, microrectitis, recto-vaginal fistula, perforation, and intracolic
explosion.[34]
[35]
[36]
[37]
Perforation occurs preferentially in the cecum where the wall is thin. Some authors
have proposed injecting saline, with or without adrenaline, into the submucosa to
elevate the angiodysplasia before argon coagulation.[38]
[39]
Finally, exceptional cases of explosions have been reported with the use of argon
in ill-prepared patients.[40] It is therefore recommended that patients be prepared orally in order to obtain
a perfectly clean colonic lumen.
