High rebleeding rate after argon-plasma coagulation of angiodysplasia of the small bowel during double-balloon enteroscopy

Introduction: Angiodysplasia (AD) of the small bowel are frequently detected in patients with obscure gastrointestinal bleeding (OGIB). If they are considered to represent the source of hemorrhage, treatment with argon-plasma coagulation (APC) is recommended. However, there are only limited data in the literature concerning long-term outcome and rebleeding rate after APC-treatment of AD of the small bowel.

Patients and methods: A total of 1.006 consecutive capsule endoscopies (CE) performed at our centre between 2002 and 2011 were analysed. In 160/672 (23.8%) patients, who underwent CE for evaluation of OGIB, AD of the small bowel were detected. 20 of these patients (m/f: 12/8; mean age±SD: 67.3±11 years) were further assessed by double-balloon enteroscopy (DBE) and included in this study. Transfusion dependent anemia was present in 11/20 (55%) patients, 2/20 (10%) were under oral anticoagulation therapy and 6/20 (30%) were under anti-platelet therapy.

Results: During DBE the diagnosis of small bowel AD could be confirmed in 17/20 (85%) patients. All these 17 patients were successfully treated by APC. There were no procedure related complications.

12/17 patients were followed for a mean±SD of 32.4±19.4 months; 5 patients were lost to follow-up. Rebleeding occurred in 5/12 (42%) after a mean±SD of 8.8±10.2 months after APC-therapy.

7/12 patients had no episodes of rebleeding during a mean±SD follow-up of 32.4±19.4 months after APC. Rebleeding was not associated with age, oral anticoagulation, anti-platelet therapy or transfusion requirement at baseline.

Discussion: In our series the rebleeding rate after APC of small bowel AD was considerably high. This may have been caused by several reasons: First, if CE detects AD of the small bowel in a patient with OGIB, it is usually assumed, that these AD represent the bleeding source. However, it seems likely that some of these patients had bleeding from colonic diverticula or lesions caused by ASA or NSAIDs, that were not detectable anymore when CE was performed. Second, many AD which can be seen in CE, are not visible during DBE when the wall of the small bowel is distended by insufflation of air. Third, recurrence of AD seems to be frequent. Facing the high rebleeding rate we conclude, that in multimorbid patients with OGIB and AD of the small bowel the indication for DBE with APC has to be weighed carefully against the risk of the procedure.