A 74 year old male with a history of hypertension, diabetes, hyperlipidemia, presented for an outpatient endoscopy after he was found to have iron deficiency anemia and fecal occult blood positive on a stool sample by his primary care physician. The patient underwent an esophagogastroduodenoscopy (EGD) that revealed multiple angioectasias throughout the gastric fundus, body, and antrum, as well as numerous angioectasias in the duodenal bulb and the second portion of the duodenum. Fresh blood was noted throughout the stomach. Argon plasma coagulation (APC) was used to treat the angioectasias in the stomach and duodenum and achieved excellent hemostasis. The APC catheter was used in an en face fashion at 20 watts, 1 L/min, and was placed approximately 1 mm from the lesion. All visible lesions were successfully ablated. The patient tolerated the procedure well with no further bleeding. His hemoglobin levels have been stable after the procedure.
Angioectasias are aberrant and ectatic blood vessels made of thin walls,
with or without an endothelial lining and they are found within the gastrointestinal tract. Histologic samples show dilated vessels within the mucosa and submucosa, and sometimes only covered by a single layer of epithelium.1 Angioectasias may cause obscure or overt gastrointestinal bleeding, which often manifests as iron deficiency anemia or occult gastrointestinal bleeding. They usually occur in individuals over 60 years of age and can involve any segment of the GI tract, with 20% of patients having them involve at least two different sections of the GI tract.1,2
Endoscopic therapy of angioectasias involves multiple modalities, including thermal probe coagulation, APC, band ligation, or injection therapy. APC is a safe and effective method used to treat angioectasias.3 The ease of use, low cost, and limited depth of coagulation make it a popular choice for treatment due to the superficial nature and location of angioectasias in the gastrointestinal mucosa. The treatment of actively bleeding angioectasias is important secondary to their high rate of recurrent of bleeding.4 The application of therapy is noncontact which allows for larger areas to be treated rapidly with less smoke than laser therapy, which allows for better visualization. In patients with bleeding sources treated with APC, long term follow up revealed an increase in hemoglobin levels and a decrease in blood/red blood cell transfusion requirements.5
1. Raju GS, Gerson LB, Das A, Lewis. American Gastroenterological Association (AGA) Institute Technical Review on Obscure Gastrointestinal Bleeding. Gastroenterology, Volume 133, Issue 5, November 2007, Pages 1697-1717
2. Savides, T, Jensen, D. “Gastrointestinal Bleeding.” Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed. St Louis: Saunders, 2010. 315-316
3. Rochalon A, Papillon E, Fournet J. Is argon plasma coagulation an efficient treatment for digestive system vascular malformations and radiation proctitis? Gastroenterol Clin Biol 2000;24:1205-10.
4. Nahon S, Lahmek P, Barclay F, Macaigne G, Poupardin C, Jounnaud V, Delas N, Lesgourgues B. Long-term follow-up and predictive factors of recurrence of anemia in a cohort of 102 very elderly patients explored for iron-deficiency anemia. J Clin Gastroenterol. 2008 Oct;42(9):984-90.
5.May, A, et al. Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleeding. Endoscopy 2011; 43: 759-765
Christian Jackson, MD, Loma Linda VA Medical Center, Loma Linda University Medical Center
Elliot Joo, MD, Loma Linda VA Medical Center, Loma Linda University Medical Center
Scott Lee, MD, Loma Linda VA Medical Center, Loma Linda University Medical Center