Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

haemodynamically unstable (severe haemorrhage)

1st line – CT angiography + mesenteric angiography with embolisation

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ACUTE
|
haemodynamically unstable (severe haemorrhage)
1st line – 

CT angiography + mesenteric angiography with embolisation

In patients with unstable angiodysplastic bleeding, guidelines recommend CT angiography as the initial test to assess the arterial anatomy and localise the bleeding point.[18]​​[35][38]​​​​ This should be followed by a mesenteric angiography with a view to embolisation to control the source of bleeding.

Plus – supportive care

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ACUTE
|
haemodynamically unstable (severe haemorrhage)
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Intravenous access should be attained, preparing for replacement of fluid and blood loss with intravenous fluids and blood transfusions. Blood typing and cross-match with serial full blood counts are recommended to assess fluid status.

2nd line – interventional upper endoscopy

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ACUTE
|
haemodynamically unstable (severe haemorrhage)
2nd line – 

interventional upper endoscopy

An upper gastrointestinal endoscopy may be performed to rule out a source proximal to the distal duodenum. During this procedure, electrocautery, photocoagulation, clips, or an epinephrine (adrenaline) injection may be indicated to treat the lesion.

Plus – supportive care

Back
ACUTE
|
haemodynamically unstable (severe haemorrhage)
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Intravenous access should be attained, preparing for replacement of fluid and blood loss with intravenous fluids and blood transfusions. Blood typing and cross-match with serial full blood counts are recommended to assess fluid status.

3rd line – colonoscopy, device-assisted enteroscopy, and/or surgery

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ACUTE
|
haemodynamically unstable (severe haemorrhage)
3rd line – 

colonoscopy, device-assisted enteroscopy, and/or surgery

Colonoscopy or surgery may be appropriate in the absence of angiography. A colonoscopy is recommended to identify a lower gastrointestinal source of bleeding and to provide treatment. During this procedure, electrocautery, photocoagulation, clips, or an adrenaline (epinephrine) injection may be indicated to treat the lesion.

Careful treatment in the right colon is recommended, due to the thinner walls and higher risk for perforation.

Electrocautery uses heated probes to coagulate the bleeding lesions. Photocoagulation uses argon and Yag lasers and requires specific training.

[Figure caption and citation for the preceding image starts]: Endoscopic (device-assisted enteroscopy) image of small bowel angiodysplasia after treatment with argon plasma coagulation​From the personal collection of Dr Elli, Milan, Italy; used with permission [Citation ends].com.bmj.content.model.Caption@b517b4f[Figure caption and citation for the preceding image starts]: Endoscopic image of argon plasma coagulation of colonic angiodysplasiaPermission obtained from patient; GNU Free Documentation License [Citation ends].com.bmj.content.model.Caption@30632017​​

If the colonoscopy is negative and a small bowel source is suspected, device-assisted enteroscopy can be used to identify and treat the bleeding lesions. This can be done via the oral or retrograde route depending on the location of the suspected lesion in the small bowel.

Only patients with a large, life-threatening haemorrhage with little relief from interventional endoscopy or embolisation are appropriate for surgery.

At operation, if the patient is unstable, an on-table enteroscopy or blind sub-total colectomy may be appropriate.

Aortic valve replacement should be considered in patients with Heyde’s syndrome and ongoing bleeding.[8]

Plus – supportive care

Back
ACUTE
|
haemodynamically unstable (severe haemorrhage)
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Intravenous access should be attained, preparing for replacement of fluid and blood loss with intravenous fluids and blood transfusions. Blood typing and cross-match with serial full blood counts are recommended to assess fluid status.

haemodynamically stable

1st line – interventional endoscopy

Back
ACUTE
|
haemodynamically stable
1st line – 

interventional endoscopy

During the endoscopy, electrocautery, photocoagulation, clips, or an adrenaline (epinephrine) injection may be indicated to treat the lesion.

Careful treatment in the right colon is recommended, due to the thinner walls and higher risk for perforation.

Electrocautery uses heated probes to coagulate the bleeding lesions. Photocoagulation uses argon and Yag lasers and requires specific training.[Figure caption and citation for the preceding image starts]: Endoscopic (device-assisted enteroscopy) image of small bowel angiodysplasia after treatment with argon plasma coagulation​From the personal collection of Dr Elli, Milan, Italy; used with permission [Citation ends].com.bmj.content.model.Caption@e8707f1[Figure caption and citation for the preceding image starts]: Endoscopic image of argon plasma coagulation of colonic angiodysplasiaPermission obtained from patient; GNU Free Documentation License [Citation ends].com.bmj.content.model.Caption@1e365d53​​​

Consider – supportive care

Back
ACUTE
|
haemodynamically stable
Consider – 

supportive care

Additional treatment recommended for SOME patients in selected patient group

Intravenous access should be attained, preparing for replacement of fluid and blood loss with intravenous fluids and blood transfusions. Blood typing and cross-match with serial full blood counts are recommended to assess fluid status.

The European Society of Gastrointestinal Endoscopy recommends red blood cell transfusion in haemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, with a haemoglobin threshold of ≤ 70  g/L (≤ 7  g/dL) prompting red blood cell transfusion.[38]​ In those with a history of cardiovascular disease, a haemoglobin threshold of ≤ 80  g/dL (≤ 8  g/dL) should prompt red blood cell transfusion.[38]

2nd line – wireless capsule enteroscopy or CT angiography + mesenteric angiography with embolisation or enteroscopy

Back
ACUTE
|
haemodynamically stable
2nd line – 

wireless capsule enteroscopy or CT angiography + mesenteric angiography with embolisation or enteroscopy

If the endoscopy is negative and the bleeding continues, based on local expertise, capsule endoscopy or CT angiography should be performed which may guide further intervention. If CT angiography confirms active bleeding, it should be followed by a mesenteric angiography with a view to embolisation to treat the bleeding or endoscopic management using device-assisted enteroscopy if a small bowel source is seen.[40][51][Figure caption and citation for the preceding image starts]: ​Small bowel angiodysplasia seen during small bowel capsule endoscopy​From the personal collection of Dr Elli, Milan, Italy; used with permission [Citation ends].com.bmj.content.model.Caption@655a2f5[Figure caption and citation for the preceding image starts]: ​Small bowel angiodysplasia seen during small bowel capsule endoscopy​From the personal collection of Dr Elli, Milan, Italy; used with permission [Citation ends].com.bmj.content.model.Caption@1d0933c7

Consider – supportive care

Back
ACUTE
|
haemodynamically stable
Consider – 

supportive care

Additional treatment recommended for SOME patients in selected patient group

Intravenous access should be attained, preparing for replacement of fluid and blood loss with intravenous fluids and blood transfusions. Blood typing and cross-match with serial full blood counts are recommended to assess fluid status.

The European Society of Gastrointestinal Endoscopy recommends red blood cell transfusion in haemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, with a haemoglobin threshold of ≤ 70  g/L (≤ 7  g/dL) prompting red blood cell transfusion.[38]​ In those with a history of cardiovascular disease, a haemoglobin threshold of ≤ 80  g/L (≤ 8  g/dL) should prompt red blood cell transfusion.[38]

3rd line – surgery

Back
ACUTE
|
haemodynamically stable
3rd line – 

surgery

If angiography is unsuccessful or unavailable and the patient is a surgical candidate, surgery can be considered. Surgery should not be used as a diagnostic tool to localise the site of bleeding in haemodynamically stable patients.[34]​ The exact procedure used will depend on the likely site(s) of the bleeding based on preoperative and intraoperative investigations.

Consider – supportive care

Back
ACUTE
|
haemodynamically stable
Consider – 

supportive care

Additional treatment recommended for SOME patients in selected patient group

Intravenous access should be attained, preparing for replacement of fluid and blood loss with intravenous fluids and blood transfusions. Blood typing and cross-match with serial full blood counts are recommended to assess fluid status.

The European Society of Gastrointestinal Endoscopy recommends red blood cell transfusion in haemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, with a haemoglobin threshold of ≤ 70  g/L (≤ 7  g/dL) prompting red blood cell transfusion.[38]​ In those with a history of cardiovascular disease, a haemoglobin threshold of ≤ 80  g/L (≤ 8  g/dL) should prompt red blood cell transfusion.[38]

3rd line – pharmacological therapy

Back
ACUTE
|
haemodynamically stable
3rd line – 

pharmacological therapy

If angiography is unsuccessful or unavailable and if the patient is not a surgical candidate, then pharmacological therapy may be considered. One systematic review and meta-analysis found that pharmacological treatment led to significantly reduced bleeding episodes and notable improvement in haemoglobin levels.[66]​ Somatostatin analogues (e.g., octreotide, lanreotide) and thalidomide have shown benefit in this setting. There is poor evidence for oestrogen derivatives. One multi-centre randomised controlled trial found that octreotide reduced transfusion requirements and the annual volume of endoscopic procedures in patients with angiodysplasia-related anaemia.[69] Long-term lanreotide therapy has shown to significantly improve anaemia and reduce hospitalisations, blood transfusions, and endoscopies in patients with angiodysplasias.[70][71]​​ Systematic reviews suggest that somatostatin analogue therapy is safe and effective in patients with gastrointestinal angiodysplasia; octreotide therapy may be more effective than lanreotide therapy.[72][73]​ One retrospective study reported that somatostatin analogue therapy plus endoscopic therapy reduced bleeding episodes in patients with recurrent anaemia and small bowel angioectasia.[47]

Primary options

octreotide: consult specialist for guidance on dose

OR

lanreotide: consult specialist for guidance on dose

OR

thalidomide: consult specialist for guidance on dose

Consider – supportive care

Back
ACUTE
|
haemodynamically stable
Consider – 

supportive care

Additional treatment recommended for SOME patients in selected patient group

Intravenous access should be attained, preparing for replacement of fluid and blood loss with intravenous fluids and blood transfusions. Blood typing and cross-match with serial full blood counts are recommended to assess fluid status.

The European Society of Gastrointestinal Endoscopy recommends red blood cell transfusion in haemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, with a haemoglobin threshold of ≤ 70  g/L (≤ 7  g/dL) prompting red blood cell transfusion.[38]​ In those with a history of cardiovascular disease, a haemoglobin threshold of ≤ 80  g/L (≤ 8  g/dL) should prompt red blood cell transfusion.[38]

ONGOING

recurrent bleed

1st line – repeat interventional endoscopy

Back
ONGOING
|
recurrent bleed
1st line – 

repeat interventional endoscopy

If bleeding continues, a repeat endoscopy is recommended with therapeutic intervention. During the procedure, electrocautery, photocoagulation, clips, or an adrenaline (epinephrine) injection may be indicated to treat the lesion.

For patients with colonic angiodysplasias, careful treatment in the right colon is recommended, due to the thinner walls and higher risk for perforation.

For patients with recurrent small bowel bleeding, endoscopic management with device-assisted enteroscopy can be considered depending on the patient’s clinical course and response to prior therapy.[8]

Electrocautery uses heated probes to coagulate the bleeding lesions. Photocoagulation uses argon and Yag lasers and requires specific training.[Figure caption and citation for the preceding image starts]: Endoscopic (device-assisted enteroscopy) image of small bowel angiodysplasia after treatment with argon plasma coagulation​From the personal collection of Dr Elli, Milan, Italy; used with permission [Citation ends].com.bmj.content.model.Caption@3ea73162[Figure caption and citation for the preceding image starts]: Endoscopic image of argon plasma coagulation of colonic angiodysplasiaPermission obtained from patient; GNU Free Documentation License [Citation ends].com.bmj.content.model.Caption@2d9bcdcd​​

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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