Angiodysplasia and Aortic Stenosis

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Colonoscopic appearance of angiodysplasia courtesy of Dr. Aram Manoukian.

Vascular ectasias of the right side of the colon are also called arteriovenous malformations, angiomas, or angiodysplasias. They are cited as a frequent cause of lower intestinal tract bleeding in the elderly.

There are case reports in the medical literature describing resolution of gastrointestinal bleeding after aortic valve replacement in patients with aortic stenosis. (Lancet. 1996 Mar 9;347(9002):689-90) (Arch Mal Coeur Vaiss. 1991 Apr;84(4):569-72) (Ann Intern Med 1986;105:54-7)(N Engl J Med 1980;302:968)

Long term follow-up of two such cases was used to propose acquired type IIA von Willebrand's syndrome as an explanation for the hemorrhagic diathesis. (N Engl J Med 2002;347:858-859)

However, both aortic stenosis and angiodysplasia are common in the elderly, and the association between the two may be coincidental, rather than causal. (Endoscopy 1988;20:144-148)

The association of aortic stenosis and gastrointestinal bleeding was first noted in the July 24, 1958 issue of the New England Journal of Medicine. Dr. E. C. Heyde wrote a short letter to the editor stating that in the past ten years he had seen at least 10 patients with calcific aortic stenosis who had massive gastrointestinal bleeding "for which we could discover no cause". Their age ranged from sixty to eighty.

In another letter in the August 28, 1958 issue Dr. B.M. Schwartz "noted this association once or twice a year since 1942".

A methodologic critique of the literature cast doubt on the association of aortic stenosis, idiopathic gastrointestinal bleeding, and angiodysplasia. (Gastroenterology 1988 Dec;95(6):1670-6)

A recent prospective controlled evaluation of endoscopic detection of angiodysplasia and its association with aortic valve disease "does not support the role of aortic valve disease as the cause of angiodysplasia of the gastrointestinal tract". (Gastrointest Endosc 1995 Nov;42(5):398-402)

Echocardiographic findings were reported in a retrospective study of 83 patients who underwent gastrointestinal endoscopy and were found to have angiodysplasia. Of the 83 patients, 24 (16 male and 8 female) had died from causes unrelated to cardiovascular diseases. The 59 patients still alive (27 male and 32 female) underwent a complete clinical, electrocardiographic and echocardiographic (M-mode, B-mode, pulsed and continuous-wave Doppler) evaluation.

Fifteen patients (25%) had a normal examination, both clinical and echocardiographic. Eleven (19%) had minor cardiac abnormalities but had no murmurs. Although no murmurs were present in 15 patients (25%), some echocardiographic abnormalities such as aortic leaflet sclerosis, mitral annular calcification, their association, or trivial mitral regurgitation detectable only with pulsed wave Doppler were found. In 18 patients (31%) both systolic murmurs and valvular abnormalities, as revealed by echocardiographic examination, were detected: 10 had a regurgitant and 8 an ejection murmur; of these only 1 (1.6%) had a true severe calcified aortic valve stenosis at echo-Doppler examination.

The authors conclude that the low prevalence of aortic valve stenosis in patients with gastrointestinal angiodysplasia (1/59 or 1.6%) in this retrospective study argues against the association of gastrointestinal angiodysplasia and aortic valve stenosis. (Eur J Med 1993 Feb;2(2):75-8)

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