A prospective controlled evaluation of endoscopic detection of angiodysplasia and its association with aortic valve disease

doi:10.1016/S0016-5107(95)70038-2

Gastrointestinal Endoscopy

Volume 42, Issue 5, November 1995, Pages 398-402

https://doi.org/10.1016/S0016-5107(95)70038-2 Get rights and content

Abstract

Background: In view of controversy about the association of aortic stenosis and angiodysplasia of the gut, we performed a prospective, controlled study to evaluate the relationship between aortic valve disease and gastrointestinal angiodysplasia.

Methods: Forty patients who had endoscopy for clinical indications such as gastrointestinal bleeding, anemia, polyps, colon cancer, and dyspepsia, and who were found to have angiodysplasia of the gastrointestinal tract, underwent two-dimensional and Doppler echocardiography. Thirty-seven controls matched for age, sex, indication, and nature of endoscopic examination, but without angiodysplasia, underwent similar echocardiographic examination.

Results: None of the patients in either group had aortic stenosis. The prevalence of aortic sclerosis, aortic insufficiency, and low left ventricular ejection fraction was similar in patients with and without angiodysplasia.

Conclusions: This study does not support the role of aortic valve disease as the cause of angiodysplasia of the gastrointestinal tract. A subgroup of patients with angiodysplasia with aortic sclerosis, with or without low left ventricular ejection fraction, and with or without other valvular disease (but none with aortic stenosis), had increased prevalence of gastrointestinal bleeding when compared with controls. When aortic valve disease or decreased left ventricular ejection fraction were analyzed as independent predictors, none of them in and of itself appeared to be a factor in bleeding from these gastrointestinal lesions. (Gastrointest Endosc 1995;42:398-402.)

Section snippets

MATERIALS AND METHODS

Forty patients who underwent gastrointestinal endoscopy between July 1992 and November 1993 for clinical indications and were found to have angiodysplasia constituted the study group. Indications for performing esophagogastroduodenoscopy (EGD) or colonoscopy are shown in Table 1. All the endoscopic procedures were performed by GI Fellows of Wright State University under direct supervision of two attending gastroenterologists (NG, CB). The criterion for the diagnosis of angiodysplasia was the

RESULTS

All patients in the study were men ranging in age from 50 to 91 years. Twenty-one patients had angiodysplasias of the UGI tract and 20 patients had colonic angiodysplasias (1 patient had both). These lesions were discovered during the performance of 1103 upper endoscopy examinations and 554 colonoscopic examinations during the study period of July 1992 to November 1993. Nine patients in the study group and four patients in the control group had both upper endoscopy and colonoscopy. The

DISCUSSION

In 1958 Heyde¹ reported 10 patients with gastrointestinal bleeding of unknown origin who had clinical signs of aortic stenosis. About a month later, Schwartz³ suggested a similar association. Thus the foundation of this controversial association was laid, which has continued to spark case reports and studies to date. Cattell was quoted in a clinicopathological conference on such a case in 1965.⁴ He suggested that these patients bled from a vascular lesion in the ascending colon that the

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We studied the trends and outcomes of patients with intestinal angiodysplasia-associated gastrointestinal bleeding (Heyde's syndrome [HS]) with aortic stenosis (AS) who underwent surgical aortic valve replacement (SAVR) versus transcatheter aortic valve implantation (TAVI). The National Inpatient Sample (2007 to 2014) and International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify HS hospitalizations, pertinent co-morbidities, and outcomes of SAVR versus TAVI from 2011 to 2014. The incidence of HS with AS was 3.1%. The trends in hospitalizations and all-cause inpatient mortality showed relative surges of 29.16% (from 48 to 62 per 100,000) and 22.7% (from 3.7 to 4.54 per 100,000) from 2007 to 2014. HS patients were older (mean age ∼80 vs 77 years) females (54.3% vs 52.2%) compared with AS without HS. The all-cause mortality (6.9% vs 4.1%), length of stay (LOS) (∼7.0 vs 5.8 days), and hospitalization charges ($58,519.31 vs $57,598.67) were higher in HS (p<0.001). No differences were reported in all-cause mortality and hospital charges in HS patients who underwent either SAVR or TAVI. However, the TAVI cohort showed lower rates of stroke (1.7% vs 10.0%) and blood transfusion (1.7% vs 11.7%), a shorter LOS (18.3 vs 23.9 days; p<0.001), and more routine discharges (21.7% vs 14.8%, p = 0.01). An older age, male gender, Asian race, congestive heart failure, coagulopathy, fluid and/or electrolytes disorders, chronic pulmonary disease, and renal failure raised the odds of mortality in HS patients. In conclusion, we observed increasing rates of hospitalizations with HS and higher inpatient mortality from 2007 to 2014. The HS patients who underwent TAVI had fewer complications without any difference in the all-cause mortality compared with SAVR.
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Citation Excerpt :
This relationship has not been observed with any other form of valvular heart disease or with ischaemic heart disease. Current opinion is that the passage of blood through a defective aortic valve causes the destruction of high molecular weight multimers of von Willebrand factor, leading to an acquired form of von Willebrand disease and a consequent bleeding tendency [12–15]. There is a more convincing association between GIAD and chronic renal failure (CRF), with AD responsible for an up to a third of GI bleeding events in this population [16,17].
Gastrointestinal angiodysplasia are rare but clinically important vascular aberrations found within the gastrointestinal mucosa and submucosa. Their clinical impact varies from being an asymptomatic incidental finding, to causing life threatening bleeding. In this review we critically appraise the key findings from the current literature on the pathology, clinical presentation and management of these lesions.
Gastrointestinal Bleeding, Aortic Stenosis, and the Hiding Culprit
2015, American Journal of Medicine
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Among the methods for detection, the most reliable test is gel electrophoresis.4 The reported prevalence of aortic stenosis in patients with gastrointestinal angiodysplasia ranges from 0 to 41%, and this variable association has led some to question the existence of Heyde's syndrome.5 The strongest evidence in support of the association between aortic stenosis and gastrointestinal hemorrhage is the consistent alleviation of bleeding after aortic valve replacement.6
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^☆: From the Department of Medicine, Wright State University School of Medicine, Dayton, Ohio; and the Department of Medicine, Department of Veterans Affairs Medical Center, Dayton, Ohio.

^☆☆: Reprint requests: Manoop S. Bhutani, MD, Medical Service (111), VAMC, 4100 W. Third St., Dayton, OH 45428.

^★: 37/1/63437

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A prospective controlled evaluation of endoscopic detection of angiodysplasia and its association with aortic valve disease☆,☆☆,★

Abstract

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

Gastroenterology

Am J Surg

Am J Med

J Thorac Cardiovasc Surg

Ann Thorac Surg

Lancet

Am J Med

Gastrointestinal bleeding in aortic stenosis

N Engl J Med

Additional note on bleeding in aortic stenosis

N Engl J Med