Refractory Anaemia Secondary to Small Bowel Angioectasias - Comparison between Endotherapy Alone versus Combination with Somatostatin Analogues

Abstract

Background & Aims: Patients with small bowel angioectasias (SBAs) can be difficult to manage as they are generally elderly with multiple co-morbidities. Angioectasias are multiple and tend to recur. Argon plasma coagulation (APC), despite being a commonly used method to treat these patients has an associated persistent rate of re-bleeding necessitating additional treatment to manage these patients.Methods: All patients with refractory iron deficiency anaemia secondary to SBAs were retrospectively subdivided into two groups. Patients in group 1 were managed with double balloon enteroscopy (DBE) and APC alone and those in group 2 received Lanreotide in addition to DBE and APC.Results: A total of 49 patients were included in this study: group 1: 37 patients (75.5%), group 2: 12 patients (24.5%). All had significant comorbidities and the mean duration of anaemia was 114.3, SD 307.0 months. Significant improvements in haemoglobin (Hb) (11g/L vs 3.2g/L p=0.043), transfusion requirements per month (0.8 vs 4.7 p=0.052) and mean bleeding episodes (1.08 vs 2.6 p=0.032) were demonstrated in group 2 when compared to group 1. One patient developed symptomatic gallstone disease and one patient stopped Lanreotide due to a lack of response.Conclusions: This is the first study comparing endotherapy to a combination of endotherapy and pharmacotherapy. It shows a significantly better outcome in patients receiving a combination of endotherapy and Lanreotide. Lanreotide can be a safe additional treatment in patients not responding to APC alone.Abbreviations: APC: argon plasma coagulation; CE: capsule endoscopy; DBE double balloon enteroscopy; Hb: hemoglobin; OGIB: over gastrointestinal bleeding; SBAs: small bowel angioectasias.

Curriculum for small-bowel capsule endoscopy and device-assisted enteroscopy training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

“…Patients with angioectasias will need regular monitoring of their hemoglobin level. The management of such patients may include repeat DAE with APC, in conjunction with iron therapy and pharmacotherapy, such as somatostatin analogues in those who have refractory anemia [127,141,142]. Patients with small-bowel tumors without metastatic disease should be considered for surgery after discussion at appropriate MDTs [86,143].…”

Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease

“…A 2017 study evaluated the use of combination endoscopic therapy and the somatostatin analog lanreotide compared to endoscopic therapy alone in patients with refractory iron deficiency anemia secondary to small-bowel angioectasia. Combination therapy led to statistically significant reduction in transfusion requirements and bleeding episodes with an increase in hemoglobin compared with the other group [96].…”

Quality Indicators for Capsule Endoscopy and Deep Enteroscopy

“…The rate of recurrent GI bleeding after endoscopic therapy is high in those with medical comorbid conditions or left ventricular assist devices. Conservative management using endotherapy combined with a somatostatin analogue (125) or somatostatin with intravenous iron and transfusions with or without endotherapy (126) Evidence summary: DE is a labor-intensive procedure. Lesions identified in the small bowel should be photographed and described, including with a diagnostic impression, in the endoscopy report.…”