1	Rare But Curious Finding …a rapid review of a few vascular lesions of the GI tract.
2	Presentation 73 year old male To endoscopy suite for colonoscopy No complaints PMHx: 15mm polyp resected from sigmoid 5/2000 which was discovered to have adenocarcinoma in situ. Endoscopic surveillance with flex sig 4/2001; presents for 3 year colonoscopy. Has history of coronary artery disease requiring CABG 1998, DM, HTN, hypercholesterolemia. Meds: Pravachol, ASA, metformin, insulin, HCTZ, metoprolol.
3	Unrevealing review of systems No change in bowel habits, no weight loss, no abdominal pain. No previous history of GI blood loss. Has history of normochromic, normocytic anemia (hemoglobin 11-12).
4	Family/Social History No family history of GI malignancy or any other notable GI abnormality Retired mason. Lives with wife. Denies tobacco use, occasional alcohol.
5	Physical Exam Vitals normal Oropharynx moist without lesion, good dentition Lungs clear, sternotomy scar noted Heart regular Abdomen soft without surgical stigmata Rectal exam with external skin tag, otherwise normal
6	Endoscopic findings
7	Endoscopic findings
8	Endoscopic findings
9	Endoscopic findings
10	Endoscopic findings
11	Endoscopic findings
12	Endoscopic findings
13	The Attending Requests the Differential Diagnosis “Angiodysplasia” “Blue Rubber Nevi” “Hemangiomas” “Kaposi Sarcoma” “Random ‘Varicosities’ ”
14	Vascular Lesions of the Gastrointestinal Tract Aneurysms of the aorta and its branches Blue rubber bleb nevus Congenital arteriovenous malformation Dieulafoy’s lesion Glomus tumor Hemangioma Hemangiomatosis Hemangiopericytoma Hemangiosarcoma Hemorrhoids Kaposi’s sarcoma Vascular ectasia (angiodysplasia) Capillary phlebectasia …
15	Representative photos of angiodysplasia
16	Representative photos of angiodysplasia
17	Syndromic Angiodysplasia? Hereditary Hemorrhagic Telangectasia
18	Pathogenesis of Angiodysplasia
19	Blue rubber nevi, serosal visualization
20	Blue Rubber Nevi, epithelial surface
21	Blue Rubber Bleb Syndrome Cutaneous vascular nevi associated with intestinal lesions and gastrointestinal bleeding Familial history is infrequent, although a few cases of autosomal dominant transmission have been reported The lesions are distinctive: blue and raised, varying from 0.1 to 5.0 cm, and leaving a characteristic wrinkled sac when the contained blood is emptied by direct pressure Lesions may be single or innumerable and are usually found on the trunk, extremities, and face but not on mucous membranes; they are most common in the small intestine. The lesions are cavernous hemangiomas composed of clusters of dilated capillary spaces lined by cuboidal or flattened endothelium with connective tissue stroma. Resection of the involved segment of bowel is recommended for recurrent hemorrhage Endoscopic laser coagulation may be dangerous because these lesions may involve the full thickness of the bowel wall.
22	Hemangiomas
23	Kaposi Sarcoma
24	Kaposi Sarcoma Thought to be related to HHV-8 (with HIV co-infection) Pathogenesis complex: involving cytokines, integrins, and altered apoptosis and cell cycle controls Histopathology characterized by proliferation of abnormal vascular structures with proliferation within the tumor of vascular structures and slits, often lined by abnormally large, malignant-appearing endothelial cells and extravasation of erythrocytes.
25	Phlebectasias, medical literature Markedly dilated and tortuous submucosal veins, unassociated with portal hypertension. These veins have a normal endothelium and scant connective tissue stroma. Usually occur in clusters: generally classified as multiple, small hemangiomas, but this classification is somewhat controversial Can also occur at the base of the tongue, where they are called caviar varices; and in the genitalia, where they are called Fordyce lesions At colonoscopy, they are dark bluish-gray, small, soft, compressible, and blanch with pressureOccasionally cause GI bleeding. Cappell MS - Med Clin North Am - 01-Nov-2002; 86(6): 1253-88
26	Phlebectasias, GI literature Venous ectasias, also called phlebectasias, differ from angiodysplasias and varices pathologically and clinically. These lesions consist of dilated submucosal veins usually with thin overlying mucosa. These venous varicosities have a normal endothelial lining, are nonneoplastic, and are not associated with liver disease. Endoscopically, they appear as multiple, bluish red nodules and occur predominantly in the rectum and the esophagus. Small bowel lesions have been described. They are an uncommon cause of bleeding and are usually asymptomatic. Lewis BS - Gastroenterol Clin North Am - 01-Mar-2000; 29(1): 67-95
27	"Given the asymptomatic nature of..." Given the asymptomatic nature of the lesions, the patient’s history (absence of HIV) and the appearance of the lesions… The final diagnosis is phlebectasia, and no further evaluation or treatment is indicated.