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ANGIODYSPLASTIC LESIONS INTHE TERMINAL ILEUM
Jayashri S Pandya*, J Rodrigues**
*Associate Professor; **Lecturer; Dept. of General Surgery, BYL Nair Ch. Hospital, Mumbai 400 008.
A case of angiodysplasia of the terminal ileum is reported. Superior mesenteric angiography showed two abnormal collections of small blood vessels supplied by distal branches of ileocaecal artery situated 7-8 cms from IC junction in the terminal ileum. On laparotomy, there was no abnormality seen on the bowel wall. The angiography findings helped in diagnosis and planning of treatment. Histology proved the diagnosis.INTRODUCTION
Diagnosis of vascular malformation of GIT is a difficult undertaking. An array of investigations comprising barium studies, upper and lower GI scopy may not resolve the dilemma. Triple vessel angiography has been the hallmark in the diagnosis of upper and lower GI bleed. The lesions may be solitary, multiple or diffuse. They may be present anywhere in GIT.
We present an unusual case of multiple angiodysplastic lesions in the terminal ileum. Angiography played a major role in the identification and planning, in the management of this condition.
Based on symptomatology and angiographic findings patient was explored.
CASE REPORT
A 60 year old male was admitted with history of intermittent melaena and anaemia. Patient had melaena since 6 months. It recurred at every 7-10 days interval with normal stools in between the episodes.
In the past, the patient was admitted three times in a private institution, where four bottles of blood were required to correct his anaemia.
Upper GI scopy was normal. Colonoscopy, barium enema and small bowel enema could not detect the cause of his bleed. A superior mesenteric angiography showed two abnormal collections of blood vessels 7-8 cm from distal ileum. On laparotomy there was no abnormality seen on bowel wall. To the naked eye, the mucous membrane of the resected bowel was intact and no abnormality was visible. Histopathology showed evidence of angiodysplasia.
The patient has remained well over the ensuing 24 months.
DISCUSSION
Vascular lesions of the gastrointestinal tract are unusual causes of lower GI bleed.[1] The lesions of terminal ileum, ileocaecal junction and ascending colon are being recognized with increased frequency as the cause of GI bleed.[2] The vascular abnormalities have been considered by different authors to be congenital, neoplastic or acquired.
Based upon studies[3] it was believed that they are acquired vascular ecstasias resulting from degenerative changes that accompany aging. The direct cause of these lesions is chronic partial, intermittent low grade obstruction of submucosal veins. Due to this chronic obstruction, there is loss of competency of precapillary sphincters producing a small arteriovenous communication. This finding is noted in angiography as "early filling veins".
On reviewing the literature, it was found that only 16% of lesions in small intestine are multiple. Solitary lesions of the terminal ileum are seen more often.[4],[5]
According to modified Moore classification, our lesion falls in type IA category. Proposed modification of original Moore classification is shown in Table 1.[6] Angiodysplasias cause an important cause of GI haemorrhage. They lead to diagnostic difficulties, as they are small and frequently present only with anaemia. They are not seen in barium studies and thus there is difficulty during exploratory laparotomy.
Recognition of the nature of vascular ecstasies should stimulate earlier diagnosis in elderly patients with chronic anaemia and lower GI bleed. Life threatening complications can be avoided by prompt angiography, and on identification, to deal with surgically is the best option possible.
Type Description 1. Acquired vascular lesions limited to mucosa and submucosa and therefore rarely detected at operation. 1A. Limited to caecum and right colon or terminal ileum most common type. 1B. Multiple lesions in colon or right colon lesion seen angiographically with involvement of other portion of gastrointestinal tract. 2. Congenital arteriovenous malformation and may be found throughout gastrointestinal tract. Frequently seen in small bowel. Full thickness gastrointestinal involvement common. Therefore, may be detected at operation. 3. Hereditary haemorrhagic telangiectasia characterized by oral mucosal lesion and pangastrointestinal involvement with telangiectases (Osler - Weber - Rendu) 4. Multiple acquired vascular lesion. Most commonly occur in elderly patients with cardiac disease or patients with associated disease such as chronic renal failure or collagen vascular disease. No hereditary tendency. Surgical treatment not an option.
REFERENCES1.Goligher JC. Surgery of the anus, rectum and colon. Third edition, Springfield, III CC Thomas. 1975; 831.
2.Whitehouse GH. Solitary angiodysplastic lesions in the ileocaecal region diagnosed by angiography. Gut 1973; 14 : 977-82.
3.Whitehouse GH. Solitary angiodysplastic lesions in the ileocaecal region diagnosed by angiography. Gut 1973; 14 : 977-82.
4.River J, Silverstein J, Tope JW. Benign neoplasms of the small intestine : A clinical comprehensive review with report of 20 new cases. Arch Surg. 1956; 102 : 1-38.
5.Whitehouse GH. Solitary angiodysplastic lesion in the ileocaecal region diagnosed by angiography. Gut 1973; 14 : 177-982.
6.David J, Richardson. Vascular lesions of the intestines. AJR 1991; 284-93.
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