Angiodysplasia differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nikita Singh, M.B.B.S.[2]

Overview

Angiodysplasia must be differentiated from other diseases that cause hematochezia, melena, and iron deficiency anemia, such as hemorrhoids, diverticular disease, and colon cancer.

Differentiating Angiodysplasia from other Diseases

Angiodysplasia must be differentiated from other diseases that cause hematochezia, melena, and iron deficiency anemia such as:

Diseases Clinical manifestations Para-clinical findings Gold standard
Symptoms Physical examination
Lab Findings Imaging Histopathology
Abdominal pain Lower GI Bleed Changes in bowel habits, weight loss Characteristic physical examination findings Pertinent laboratory findings Ultrasound/CT scan Endoscopy MRI
Diverticulitis[1][2][3][4][5][6][7][8] + + - Left lower quadrant abdominal tenderness, fever Leukocytosis, elevated ESR and CRP Radiological test of choice - CT of abdomen and pelvis with contrast which shows segmental bowel wall thickening, pericolic inflammation, abscess (30% cases) Endoscopy is not indicated in acute diverticulitis due to the risk of perforation Findings similar to CT scan Varying grades of inflammation seen in surgical specimens Abdominal computerized tomography (CT) scan
Hemorrhoids[9][10][11][12][13][14][12] - (anal pain) + - Skin tags, fistulas/fissures, prolapsed hemorrhoid Complete blood count may show iron deficiency anemia Ultrasound - "mosaic pattern" of anal cushion in grade III and IV internal hemorrhoids Anoscopy - bulging, dilated purplish-blue veins MRI is not recommended for the assessment of hemorrhoids Abnormally dilated, vessels within submucosal arteriovenous plexus Anoscopy
Colon cancer[15][16][17][18][19][20][21][22][23][24][25] +/- +/- + Lymphadenopathies, abdominal mass, hepatomegaly (metastasis) Complete blood count - iron deficiency anemia, tumor marker - CEA, methylated circulating DNA markers CT scan shows soft tissue mass causing narrowing of colonic lumen or asymmetric bowel wall thickening. Colonoscopy reveals mass protruding from the mucosa to the lumen which may sometimes bleed on touching MRI is better than CT to detect liver metastasis Majority of colorectal cancers are adenocarcinomas characterised by glandular formation Colonoscopy
Massive upper GI bleed[26][27][28][29][30] + + - Hemodynamic instability, upper abdominal tenderness, pale skin Complete blood count in acute bleeding - normocytic anemia. Elevated BUN-to-Creatinine ratio >30:1 CT angiography localises the site of GI bleed Upper GI endoscopy can play a diagnostic and therapeutic role in localising and stopping the bleed MRI is not indicated NA Endoscopy
Inflammatory bowel disease[31][32][33][34][35][36][37][38][39][40] + +/- + Tachycardia, fever, occult blood on digital rectal examinaton, anal fistulas
  • Complete blood count - microcytic anemia, leukocytosis.
  • Elevated ESR, CRP,
  • Elevated fecal calprotectin (non-specific),
  • Low serum vitamin B12 and folate levels,
  • Anti-Saccaromyces cerevisiae antibodies (ASCA) - Crohn's disease.
  • Anti-neutrophil cytoplasm antibodies (p-ANCA)-Ulcerative colitis.
 CT scan - Ulcerative colitis presents as thinning of bowel wall whereas, active Crohn's disease presents as bowel wall thickening with hyperenhancement of mucosa. Colonoscopy in:
  • Ulcerative colitis - edematous mucosa, decreased vascular markings, erosions.
  • Crohn's disease - discontinuous ulcers, cobblestone appearance of mucosa.
 Pelvi MRI for perianal involvement UC- crypt abscess

Crohn's- transmural involvement, granulomas

Endoscopy
Angiodysplasia[41][42][43][44] - Occult - Signs of anemia, systolic ejection murmur (if aortic stenosis), rarely, orthostasis or hypotension CT angiography - focal areas of contrast enhancement, early filling veins Upper GI endoscopy and colonoscopy: discrete, small foci with arborizing pattern from a visible central artery
 MRA may be used Tortuous, dilated veins, venules and capillaries in the colonic mucosa and submucosa Endoscopy

References

  1. ↑ Swanson SM, Strate LL (2018). "Acute Colonic Diverticulitis". Ann Intern Med. 168 (9): ITC65–ITC80. doi:10.7326/AITC201805010. PMC 6430566. PMID 29710265.
  2. ↑ Laurell H, Hansson LE, Gunnarsson U (2007). "Acute diverticulitis--clinical presentation and differential diagnostics". Colorectal Dis. 9 (6): 496–501, discussion 501-2. doi:10.1111/j.1463-1318.2006.01162.x. PMID 17573742.
  3. ↑ Laméris W, van Randen A, van Gulik TM, Busch OR, Winkelhagen J, Bossuyt PM; et al. (2010). "A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department". Dis Colon Rectum. 53 (6): 896–904. doi:10.1007/DCR.0b013e3181d98d86. PMID 20485003.
  4. ↑ Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V; et al. (2020). "Diverticulitis: An Update From the Age Old Paradigm". Curr Probl Surg. 57 (10): 100862. doi:10.1016/j.cpsurg.2020.100862. PMC 7575828 Check |pmc= value (help). PMID 33077029 Check |pmid= value (help).
  5. ↑ Hulnick DH, Megibow AJ, Balthazar EJ, Naidich DP, Bosniak MA (1984). "Computed tomography in the evaluation of diverticulitis". Radiology. 152 (2): 491–5. doi:10.1148/radiology.152.2.6739821. PMID 6739821.
  6. ↑ Doringer E (1992). "Computerized tomography of colonic diverticulitis". Crit Rev Diagn Imaging. 33 (5): 421–35. PMID 1418606.
  7. ↑ Destigter KK, Keating DP (2009). "Imaging update: acute colonic diverticulitis". Clin Colon Rectal Surg. 22 (3): 147–55. doi:10.1055/s-0029-1236158. PMC 2780264. PMID 20676257.
  8. ↑ Pesce A, Barchitta M, Agodi A, Salerno M, La Greca G, Magro G; et al. (2020). "Comparison of clinical and pathological findings of patients undergoing elective colectomy for uncomplicated diverticulitis". Sci Rep. 10 (1): 8854. doi:10.1038/s41598-020-65727-1. PMC 7264214 Check |pmc= value (help). PMID 32483125 Check |pmid= value (help).
  9. ↑ Kluiber RM, Wolff BG (1994). "Evaluation of anemia caused by hemorrhoidal bleeding". Dis Colon Rectum. 37 (10): 1006–7. doi:10.1007/BF02049313. PMID 7924705.
  10. ↑ Lohsiriwat V (2015). "Treatment of hemorrhoids: A coloproctologist's view". World J Gastroenterol. 21 (31): 9245–52. doi:10.3748/wjg.v21.i31.9245. PMC 4541377. PMID 26309351.
  11. ↑ Lohsiriwat V (2013). "Approach to hemorrhoids". Curr Gastroenterol Rep. 15 (7): 332. doi:10.1007/s11894-013-0332-6. PMID 23715885.
  12. ↑ 12.0 12.1 Mounsey AL, Halladay J, Sadiq TS (2011). "Hemorrhoids". Am Fam Physician. 84 (2): 204–10. PMID 21766771.
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  14. ↑ Aimaiti A, A Ba Bai Ke Re MMTJ, Ibrahim I, Chen H, Tuerdi M (2017). "Sonographic appearance of anal cushions of hemorrhoids". World J Gastroenterol. 23 (20): 3664–3674. doi:10.3748/wjg.v23.i20.3664. PMC 5449423. PMID 28611519.
  15. ↑ Hamilton W, Round A, Sharp D, Peters TJ (2005). "Clinical features of colorectal cancer before diagnosis: a population-based case-control study". Br J Cancer. 93 (4): 399–405. doi:10.1038/sj.bjc.6602714. PMC 2361578. PMID 16106247.
  16. ↑ Majumdar SR, Fletcher RH, Evans AT (1999). "How does colorectal cancer present? Symptoms, duration, and clues to location". Am J Gastroenterol. 94 (10): 3039–45. doi:10.1111/j.1572-0241.1999.01454.x. PMID 10520866.
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  19. ↑ Moreno CC, Mittal PK, Sullivan PS, Rutherford R, Staley CA, Cardona K; et al. (2016). "Colorectal Cancer Initial Diagnosis: Screening Colonoscopy, Diagnostic Colonoscopy, or Emergent Surgery, and Tumor Stage and Size at Initial Presentation". Clin Colorectal Cancer. 15 (1): 67–73. doi:10.1016/j.clcc.2015.07.004. PMID 26602596.
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  21. ↑ Symonds EL, Pedersen SK, Baker RT, Murray DH, Gaur S, Cole SR; et al. (2016). "A Blood Test for Methylated BCAT1 and IKZF1 vs. a Fecal Immunochemical Test for Detection of Colorectal Neoplasia". Clin Transl Gastroenterol. 7: e137. doi:10.1038/ctg.2015.67. PMC 4737873. PMID 26765125.
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  25. ↑ Shia J, Schultz N, Kuk D, Vakiani E, Middha S, Segal NH; et al. (2017). "Morphological characterization of colorectal cancers in The Cancer Genome Atlas reveals distinct morphology-molecular associations: clinical and biological implications". Mod Pathol. 30 (4): 599–609. doi:10.1038/modpathol.2016.198. PMC 5380525. PMID 27982025.
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  28. ↑ Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M; et al. (2015). "Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline". Endoscopy. 47 (10): a1–46. doi:10.1055/s-0034-1393172. PMID 26417980.
  29. ↑ Srygley FD, Gerardo CJ, Tran T, Fisher DA (2012). "Does this patient have a severe upper gastrointestinal bleed?". JAMA. 307 (10): 1072–9. doi:10.1001/jama.2012.253. PMID 22416103.
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  32. ↑ Rosen MJ, Dhawan A, Saeed SA (2015). "Inflammatory Bowel Disease in Children and Adolescents". JAMA Pediatr. 169 (11): 1053–60. doi:10.1001/jamapediatrics.2015.1982. PMC 4702263. PMID 26414706.
  33. ↑ Nocerino A, Nguyen A, Agrawal M, Mone A, Lakhani K, Swaminath A (2020). "Fatigue in Inflammatory Bowel Diseases: Etiologies and Management". Adv Ther. 37 (1): 97–112. doi:10.1007/s12325-019-01151-w. PMC 6979464 Check |pmc= value (help). PMID 31760611.
  34. ↑ Satsangi J, Silverberg MS, Vermeire S, Colombel JF (2006). "The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications". Gut. 55 (6): 749–53. doi:10.1136/gut.2005.082909. PMC 1856208. PMID 16698746.
  35. ↑ van Rheenen PF, Van de Vijver E, Fidler V (2010). "Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis". BMJ. 341: c3369. doi:10.1136/bmj.c3369. PMC 2904879. PMID 20634346. Review in: Ann Intern Med. 2011 Jan 18;154(2):JC1-12
  36. ↑ Pan Y, Liu Y, Guo H, Jabir MS, Liu X, Cui W; et al. (2017). "Associations between Folate and Vitamin B12 Levels and Inflammatory Bowel Disease: A Meta-Analysis". Nutrients. 9 (4). doi:10.3390/nu9040382. PMC 5409721. PMID 28406440.
  37. ↑ Alkhouri RH, Hashmi H, Baker RD, Gelfond D, Baker SS (2013). "Vitamin and mineral status in patients with inflammatory bowel disease". J Pediatr Gastroenterol Nutr. 56 (1): 89–92. doi:10.1097/MPG.0b013e31826a105d. PMID 22832510.
  38. ↑ Strobel D, Goertz RS, Bernatik T (2011). "Diagnostics in inflammatory bowel disease: ultrasound". World J Gastroenterol. 17 (27): 3192–7. doi:10.3748/wjg.v17.i27.3192. PMC 3158394. PMID 21912467.
  39. ↑ Spiceland CM, Lodhia N (2018). "Endoscopy in inflammatory bowel disease: Role in diagnosis, management, and treatment". World J Gastroenterol. 24 (35): 4014–4020. doi:10.3748/wjg.v24.i35.4014. PMC 6148432. PMID 30254405.
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  41. ↑ Tonea A, Andrei S, Andronesi D, Ionescu M, Gheorghe C, Herlea V; et al. (2008). "[Difficulties in diagnosis and surgical treatment of the angiodysplasia of the gastrointestinal tract]". Chirurgia (Bucur). 103 (5): 513–28. PMID 19260627.
  42. ↑ Danesh BJ, Spiliadis C, Williams CB, Zambartas CM (1987). "Angiodysplasia--an uncommon cause of colonic bleeding: colonoscopic evaluation of 1,050 patients with rectal bleeding and anaemia". Int J Colorectal Dis. 2 (4): 218–22. doi:10.1007/BF01649509. PMID 3500991.
  43. ↑ Howard OM, Buchanan JD, Hunt RH (1982). "Angiodysplasia of the colon. Experience of 26 cases". Lancet. 2 (8288): 16–9. doi:10.1016/s0140-6736(82)91153-9. PMID 6123752.
  44. ↑ Pounder DJ, Rowland R, Pieterse AS, Freeman R, Hunter R (1982). "Angiodysplasias of the colon". J Clin Pathol. 35 (8): 824–9. doi:10.1136/jcp.35.8.824. PMC 497797. PMID 6980903.

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