Volume 65 - 2002 - Fasc.4 - Symposium
Vascular lesions of the gastrointestinal tract
Vascular lesions of the gastrointestinal (GI) tract include arte- rio-venous malformations as angiodysplasia and Dieulafoy's lesion, venous ectasias (multiple phlebectasias and haemorroids), teleangiectasias which can be associated with hereditary hemor- rhagic teleangiectasia (HHT), Turner's syndrome and systemic sclerosis, haemangioma' s, angiosarcoma' s and disorders of con- nective tissue affecting blood vessels as pseudoxanthoma elasticum and Ehlers-Danlos's disease.
As a group, they are relatively rare lesions that however may be a major source of upper and lower gastrointestinal bleeding.
Clinical presentation is variable, ranging from asymptomatic cases over iron deficiency anaemia to acute or recurrent bleeding that may be life-threatening. Furthermore, patients may present with other symptoms, e.g. pain, dysphagia, odynophagia, the presence of a palpable mass, intussusception, obstruction, haemo- dynamic problems resulting from high cardiac output, lymphatic abnormalities with protein loosing enteropathy and ascites, or der- matological and somatic features in syndromal cases. Diagnosis can usually be made using endoscopy , sometimes with additional biopsy. Barium radiography, angiography, intraoperative enteroscopy, tagged red blood cell scan, CT-scan and MRI-scan may offer additional information. Treatment can be symptomatic, including iron supplements and transfusion therapy or causal, including therapeutic endoscopy (laser, electrocautery, heater probe or injection sclerotherapy), therapeutic angiography and surgery. The mode of treatment is of course depending on the mode of presentation and other factors such as associated disor- ders. If endoscopic or angiographic therapy is impossible and sur- gical intervention not indicated, pharmacological therapy may be warranted. Good results have been reported with different drugs, albeit most of them have not been tested in large trials. (Acta gas- troenterol. belg., 2002, 65, 213-219).
Economic evaluation of chronic hepatitis C treatment by interferon-ribavirin combination therapy in Belgium
With present treatments for chronic hepatitis C by the combi- nation of interferon alpha and ribarivin, it is possible to obtain a sustained viral response in a large number of patients. This viral response is associated with long-term disappearance of the C virus, improvement of histology, improvement in quality of life and, most than likely, a reduction in the risk of premature death or infection-linked complications. This therapy is, however, expen- sive and the number of potentially treatable patients is high in view of the relatively high prevalence of the disease in the popula- tion. An economic evaluation is thus indispensable in order, on the one hand, to assess the cost-effectiveness ratio of the treatment (i.e. the extra cost to be paid for obtaining the greater effectiveness provided by the therapeutic combination in comparison with absence of treatment or treatment by interferon alone), and, on the other hand, to estimate practically the global cost of treatment for Belgium (i.e. the annual expense for society according to the number of patients treated per year). (Acta gastroenterol. belg., 2002, 65, 233-236).
Vasculitis and the gastrointestinal tract
Vasculitis, defined as a non-infectious inflammatory disorder of blood vessels, can affect vessels of any type in any organ. The gas- trointestinal (GI) tract may thus also be involved. In systemic dis- orders as mixed connective tissue disease (MCTD) and systemic lupus erythematodes (SLE), patients may present with symptoms of gastrointestinal disfunction such as motility disorders, caused by alterations in the connective tissue. True vasculitis however also occurs in the GI tract. Severe, occlusive damage often leads to ischemia that may result in ulceration and perforation. Non-occlu- sive vascular disease may lead to vascular leakage resulting in oedema and haemorrhage. Those patients often present with diar- rhoea or symptoms of bleeding.
GI involvement is frequent in Henoch-Schönlein purpura and also often noted in polyarteritis nodosa (PAN), microscopic polyangiitis, Wegener's syndrome and Churg-Strauss syndrome. Furthermore, GI vasculitis has also been described in giant cell arteritis, Takayasu's disease, Buerger's disease and leucocytoclas- tic vasculitides as essential mixed cryoglubulinemia, lupus vasculi- tis, rheumatoid disease, MCTD, drug-induced vasculitis and Behçet's disease. The diagnosis and classification of vasculitis relies upon a combination of clinical, serological, haematological, radiological and histological findings. Establishing a precise diag- nosis can be difficult but is important because treatment and prog- nosis can be highly variable. (Acta gastroenterol. belg., 2002, 65, 204-212).
Acute mesenteric ischemia : Classification, evaluation and therapy
Mortality rates of acute mesenteric ischemia still range between 60 and 100%. Unfortunately, retrospective series have not shown any significant improvement in mortality in the past decades. With approximately 50%, superior mesenteric artery (SMA) embolism is the most common form of acute mesenteric ischemia, followed by SMA thrombosis (~25%), nonocclusive mesenteric ischemia (~20%) and mesenteric venous thrombosis (~5%). Clinical pre- sentation may be unspecific, but is often characterised by an initial discrepancy between severe subjective pain and relatively unspec- tacular findings on physical examination. The key to a better out- come (and the main problem in clinical practice) is early diagno- sis. Up to now, helas, there are no simple and noninvasive diag- nostic tests of sufficient sensitivity and specificity. Thus, angiogra- phy remains the cornerstone of diagnosis and should be performed early in all patients with a risk profile and a clinical presentation suspicious of AMI. The initial therapeutic step in all patients with AMI is resuscitation and a stabilization of circulation. If an advanced stage of ischemia is suspected, broad spectrum antibi- otics have to be given. Nonocclusive mesenteric ischemia without signs of peritoneal infarction may be managed by pharmacologi- cal vasodilation, and vasodilators are also considered as a valuable supportive treatment option in patients with obstructive mesen- teric ischemia. Patients with mesenteric venous thrombosis have to be treated by immediate anticoagulation, followed by laparotomy if peritoneal signs are present. Standard treatment for patients with obstructive mesenteric arterial syndromes is a laparotomy with embolectomy or revascularization and, if indicated, resection of infarcted bowel. - . This review will give an overview on the dif- ferent forms of mesenteric ischemia and then focus on the diagno- sis and on generally recommended forms of treatment. (Acta gas- troenterol. belg., 2002, 65, 220-225).
Pregnancy and inflammatory bowel disease
Overall, around 25% of women with inflammatory bowel disease will conceive during their disease. Most of the women with inflammatory bowel disease will have a normal pregnancy and healthy children. However, specific problems may arise related to these pregancies. This paper reviews what is known on fertility, risk of disease transmission, effect of the disease on the pregnancy and the reverse, delivery, medical follow up and treatment as well as breastfeeding in the setting of inflammatory bowel disease. (Acta gastroenterol. belg., 2002, 65, 230-232).
Vascular lesions of the liver and gastrointestinal tract
In the liver, imaging can show lesions of large and medium-sized vessels, perfusion disorders related to vascular lesions, and paren- chymal lesions including infarcts, regenerative nodules, and focal nodular hyperplasia. In the gastrointestinal tract, vascular lesions often result in bowel ischemia. Imaging can be used to show the vascular lesions and bowel wall abnormalities, including mural thickening, lack of perfusion, and pneumatosis.
Doppler sonography, multislice helical computed tomography (CT), magnetic resonance (MR) imaging, and angiography are useful to demonstrate vascular lesions. Doppler sonography offers high spatial and temporal resolution. Information about blood flow and velocity can be obtained. However, the visualization of retroperitoneal vessels is often limited because of intestinal gas.
A global view of the abdominal vasculature can be observed by using helical CT. High spatial and temporal resolution are obtain- ed, especially when new multislice CT scanners are used. MR imaging has a better contrast resolution than CT, but its spatial resolution is lower. MR imaging can also be used to measure flow with phase contrast methods.
The role of arteriography in the diagnosis of vascular lesions is decreasing. However, its role remains important to definitively demonstrate obstruction of the hepatic artery and to show arteri- al lesions in acute mesenteric ischemia. In addition, it is used as a problem-solving method to detect lesions in medium-sized vessels and to guide intravascular treatment. (Acta gastroenterol. belg., 2002, 65, 226-229).
