TISANGIODYSPLASIA?Often insidious,symptoms may bemistaken for canceror diverticulosis.

DOROTHY STEWART

Until recently, many episodes oflower gastrointestinal bleeding inpersons 65 and older were attri­buted to diverticular disease. Be­cause of improved diagnostic tech­niques, specifically selective viscer­al angiography and colonoscopy,these episodes are being more fre­quently identified as angiodyspla­sia of the colon(l-6).

Approximately 10 years ago, J.S. Galdabini coined the term "an­giodysplasia," meaning deformityof blood vessels, to describe the tan­gles of vessels. Angiodysplasia is anacquired disease in which bloodvessels, primarily those in the ce­cum and proximal descending co­lon, become dilated and tortuous.The lesions have been called he­mangiomas, angiomas, arteriove­nous malformation, and vascularectasias (dilation)(7).

Pathogenesis

One of the most widely acceptedexplanations of the pathogenesis of

180 Geriatric Nursing July/August 1986

angiodysplasia is proposed by S. J.Boley who claims that the "directcause of ectasias is chronic, partial,intermittent low grade obstructionof the submucosal veins especiallywhere they pierce the circular andlongitudinal muscle layers of thecolon"(l).

During muscular contraction anddistention of the bowel, pressureexerted against the submucosalveins causes transient and partialocclusion and, consequently, in­creasing pressure within the vein.Accumulated effects of such epi­sodes repeated over time can pre­cipitate the primary event in theangiodysplasia sequence-dilata­tion and deformity of the submuco­sal veins. The process is progressiveand eventually the venules and cap­illaries become dilated, and theprecapillary sphincters lose compe­tency, thus permitting blood to beshunted through arteriovenouscommunications with subsequentdilatation of arterioles. Mucosaover severe advanced lesions is re­placed by a maze of dilated anddistorted blood vessels(l).

Angiodysplasia is associated withseveral diseases commonly seen in

Dorothy Stewart, RN, MS, is assistant pro­fessor, Purdue University School of Nurs­ing, West Lafayette, IN.

Illustration depicts the more common sitesfor angiodysplastic lesions of the colon.

the elderly: atherosclerosis, corQna­ry artery disease, hypertension, pe­ripheral vascular disease, andchronic obstructive pulmonary dis­ease, in addition to diverticulosisand cancer of the cecum. Severalstudies indicate that approximately20-25% of persons with angiodys­plasia have aortic stenosis. In aorticstenosis there is a drop in perfusionpressure secondary to decreasedleft ventricular output. Oxygen ten­sion in the end-arteriolar supply ofthe superior mesenteric artery is

POSSIBLE NURSINGDIAGNOSES

FOR CUENTS WITHANGIODYSPLASIA

• Alterations in bowel elimination: constipation or diarrhea related toiron therapy

• Knowledge deficit related to home management regimen

AFTER SURGERY

• Knowledge deficit related to post-surgery management

• Potential alterations in bowel elimination: diarrhea related to bowelresection

• Actual or potential alterations in comfort; acute pain related tosurgical trauma

AFTER ASSESSMENT

• Activity intolerance related to fatigue secondary to chronic bloodloss

• Anxiety related to declining health status

• Anxiety related to unknown cause of rectal bleeding

• Potential for injury: falling, related to decreased cerebral perfusionsecondary to blood loss

• Ineffective coping related to persistent stress secondary to multi·pie bleeding episodes

• Fear related to invasive diagnostic procedure

• Fear related to outcome of diagnostic procedure

• Fluid volume deficit related to abnonnaJ blood loss

• Knowledge deficit related to angiodysplasia, invasive diagnosticprocedures, and treatment plan

• Self-care deficit related to fatigue

• Self-care deficit related to decrease in vision and motor abilities

• Powerlessness related to loss of privacy

• Grieving related to actual or perceived loss of independence

WITH IRON THERAPY

diminished. Early investigators ofangiodysplasia believed that chron­ic low perfusion pressure somehowcaused the vascular lesions. Re­cently investigators postulated thatcardiovascular changes do not con­tribute to the development of an­giodysplasia. but do cause ischemicnecrosis of the endothelium thatcovers the ectatic lesions, therebyincreasing the chance of bleed­ing(I,4,7-11).

Assessment

Because the typical client withangiodysplasia is over 65 years ofage with several chronic patholog­ical. conditions. early symptomsmay be overlooked, attributed toother causes, or dismissed as justanother sign of old age. Blood lossis the principal problem. If theblood loss has been slow but suffi­cient to produce chronic anemia.then symptoms of anemia such asfatigue, apathy, and depression willbe present. The client or those closeto him or her may notice a recentonset of mild confusion and disori­entation. If the bleeding has beensubstantial (> lOOOcc) and has oc­curred over a short period of time.the client may have symptoms ofhypovolemia and shock requiringprompt intervention.

Complete and relevant informa­tion is more readily obtained whenthe nurse allows for the client'sdiminished physiological status.When immediate intervention isnot required and the client is notdiscomforted by waiting. appoint­ments for diagnostic procedures onan outpatient basis can be sched­uled over several days. Since thecondition of the client rather thanchronological age must be consid­ered when planning care, take acareful health history. Includingsignificant others will help thenurse obtain additional and per­haps more accurate data if theclient is acutely ill or has impairedmemory. Particular attention isgivs:n to any antecedent bowelproblems and current bowel func­tion. Some people are embarrassedby such detailed discussion of theirfeces and bowel habits. A direct,matter-of-fact approach will help

the person maintain dignity. Con­ducting the interview where theconversation will not be overheardwill respect the individual's right toprivacy.

Rectal bleeding does not neces­sarily occur in angiodysplasia. butif it is reported it is important forthe nurse to elicit an accurate de­scription. Because angiodysplastic

lesions are small and initially in­volve venules and capillaries, theusual pattern of bleeding is a slowintermittent ooze. Continuous andmassive bleeding suggests arterialdiverticular hemorrhage or an ad­vanced stage of angiodysplasia. Le­sions in the cecum and proximal as­cending colon are most common;the client will report blood in the

Geriatric Nursing July/August 1986181

stool as bright red, maroon, bur­gundy, or port wine in color. Mel­ena, dark, pitchy stools, will be re­ported when blood from lesionshigher in the GI tract has been oxi­dized by intestinal enzymes.

Some clients are not able to de­scribe bleeding accurately becauseof the intermittent nature of theepisodes or because they attributethe bleeding to other causes such ashemorrhoids. Testing for occultblood in the feces and a hematocritscreen may be done by the nurse toconfirm suspicions of blood loss,but normal results do not precludethe necessity of performing moreconclusive diagnostic procedures.

When blood loss is slow, symp­toms of anemia may not be noticeduntil the client's hemoglobin isquite low, around 8 gm/dl. Fa­tigue, dyspnea, diaphoresis, andpalpitations associated with exer­tion are among the first to be no­ticed. Orthostatic dizziness (whichmay result in falls), sensitivity tocold, complaints of feeling "pinsand needles" in the fingers andtoes, tachycardia, weakness, andheadache may be reported whenthe blood loss is more severe.Symptoms of myocardial ischemiamay occur particularly in thoseclients who have co-existing cardio­vascular or lung diseases. Bleedingcaused by angiodysplasia is pain­less, whereas bleeding accompan­ied by colic and local abdominalpain is typical of inflammatory andischemic processes.

After the health history has beencompiled, a complete physical ex­amination and sigmoidoscopy aredone. A hemogram will help deter­mine the nature and extent of bloodloss. Coagulation studies, includingtests to determine platelet function,are necessary because of the re­ported association with coagulopa­thies. Radionuclide imaging helpslocate the angiodysplastic lesionsand can detect bleeding when bloodloss is as slow as 0.1 ml/min. Afterradiopharmaceutical agents aregiven intravenously, a sequence ofimages is taken. Accumulation ofthe radiopharmaceutical agent willbe seen only if angiodysplastic le­sions are bleeding(6,12).

182 Geriatric Nursing July/August 1986

Selective Mesenteric Angiography

Selective mesenteric angiogra­phy is a primary tool in definingangiodysplasia as a pathologicalentity. Complications that may re­sult are allergic reactions to thecontrast media, embolism, infec­tion, and hemorrhage. Before theprocedure, advise the client that heor she will feel a slight shock whenthe catheter is inserted into the ar­tery and will experience a bad tastewhen the contrast media is in­jected. After the procedure, bedrest with the involved leg extendedand immobile is maintained for

Electrocoagulation oflesions through thecolonoscope avoidsh~zards of surgery.

several hours. The nurse will checkthe vital signs, dressing over the fe­moral artery, and peripheral pulsesin the ipsilateral lower extremity atfrequent intervals( 13).

Because bleeding from angiodys­plastic lesions is usually low gradeand occurs in the venous phase,there is little or no extravasation ofcontrast media into the bowel. Forthis reason the radiologist mustlook for more subtle signs. Thepresence of dense slowly emptyingveins, a tangle of small vessels, andan early filling vein are criteria forestablishing the diagnosis of angio­dysplasia(14).

Colonoscopy

Diagnosis may also be confirmedby colonoscopy. Biopsy and some­times treatment of local lesions byelectrocoagulation techniques canbe done through the colonoscope.The nurse must be alert to the com­plications that may result from co­lonoscopy and electrocoagulation:perforation of the bowel, uncon­trolled bleeding, cardiac and respi­ratory arrest from oversedation,and vagal stimulation. Thorough

preparation of the colon is neces­sary in order to visualize all of thecolonic mucosa and to eliminatethe hazard of explosion of the colonfrom accumulated gases (hydrogenand methane) when electrocauteryis used. Intravenous meperidineand diazepam are given immedi­ately before insertion of the colon­oscope. Angiodysplastic lesions areinconspicuous and difficult to iden­tify. Those that are seen throughthe colonoscope are cherry red andusually between 5-10 mm in diame­ter(1,10,15).

Treatment

With the completion of assess­ment, medical and nursing diag­noses are made. (See box on pre­ceeding page.) If bleeding is mild,anemia may be corrected with irontherapy. If there have been recur­rent episodes of bleeding and/orbleeding has been severe, transfu­sions will be done before more ag­gressive treatment is tried.

The accepted treatment for an­giodysplasia of the colon is surgicalremoval of the involved area. Whenthe lesions are confined to the ce­cum and the proximal colon, righthemicolectomy is rep<?rted to be cu­rative in the majority of clients. Butas previously noted, angiodysplas­tic lesions are frequently inconspi­cuous and may occur throughoutthe colon. Recurrent colonic bleed­ing after the client has had a righthemicolectomy has been reportedto occur in as many as 23% ofcases. Subtotal colectomy is thetreatment of choice when there aremultiple lesions and bilateral coloninvolvement or when there is co­existing diverticular disease andmultiple polyps(1,4,16).

Reports of successful treatmentof angiodysplasia of the colon byelectrocoagulation through a colon­oscope have been encouraging. Atreatment that avoids the hazardsand costs of major surgery is ap­pealing, especially when the clientis elderly and has other serious sys­temic diseases. But because it isdifficult to identify and cauterizeall lesions, repeated electrocoagula­tion or surgical resection may berequired(9,1 0, I5).

I;'XPEGTE.D;CU.ENt ,QU:'teOMES'WllHJ1flON'tHE/1A'P~

.) HemogJ1UfiwiD: IfmI \W11hrllJnonnft~ nmrtitl.

.' StQ(l(Qld fj~1 ,nQI)li.a1anmufit and1..mfl$T~I~ngyJ.i • INO' avoTl1~l;)r(llCl)mp1foalTo.ml1 willi occur..

.'Client williparJICJ.pate, ill:da-1&'~mi at o.pfinmlJ if.aD.1J iQfi fUtlofionTng.I .1 GIJellt endj is.TgnIfic.ant' others: bav.a,a, cbancre (OJ:expTara, COfi'" '

cem$..i aUeni elldi iSlgnIDoJulJ] lothem lwiItde.scDbmIU\$lGl rOJ)i'lCepUII (it an:gjo.tJj$'prB~raidiet~rtm IfOUtlwEd,l):tQcetfilrsJ IOJfaRingJ ~roj)) ltteparJil[onstD.e}lsuteBi tel promote nonnal) lRlWeE e1i1nTl:ralJ'aDJ$YJ'Qpf11ms, that requTre»hYstcianlcm mRDcmilaati<tlma alld,damsof; lolrow·uj); care~

IIFiCEIt8I1J1G.E1W

• Inoision' wtrr !b:e~J ,normallYJ.•• Utifia~ 8.fid bowel 'elimina:tion,wlltbe ,re.e~fabtrshedi

• No avofdable' corriplicatloos WiD occur.-Olient willi ,peJticTpateln dalty !oare!at:oPtlmallev:efoff.unctiOJlIilD~

-onent afitfslgniftcantothers havee Cha-nceta, ,gxpl<1re 'CQIl~cems.

-Sefore, dlscbarQe~cJrentandsignIficant 'Olber$i will:·desclibe:diet to be :foJ(Qw.ed.need:f<1r adequate fJUJd! Iruak.s,c.araot ilt'iClslOfil'mm.«i1 'fa trnQrJ;ra.~~~Q1M~ !tt~t()lemledJ

m"Q!liCDlJons., d"os.age"IItne~ ,P_Ur'Pns.e.. aOdlst(f.eJeff.e,tt$!symploms: 1bat: Ire:qQJrephyslctan: iOl1nurse CpnlaCf)time ~ntl)(lQle~ fonOW;·JJPiCare.

Client TeachingRegardless of the treatment op­

tion chosen, there is a need forclient teaching. Including signifi­cant others is a must. For the clientwho is in a retirement or nursingfacility, this will mean includingnursing and dietary personnel.

Lack of knowledge about a dis­ease of which few people haveheard and whose name and pres­enting symptoms may be confusedwith cancer can increase fear andanxiety. Fear and anxiety mayheighten feelings of powerlessnessand dependency. Identifying andutilizing the client's existing sup­port systems and constructive cop­ing strategies will ease this uncom­fortable state and help the client tobecome more receptive to learningabout the disease.

Supportive Therapies

For those persons whose anemiawill be treated medically, instruc­tions about diet and iron replace­ment therapy will be necessary.The client must be told that ironpreparations will cause the feces tobe dark brown or black' in color.Since iron therapy will produce afalse positive result in tests for oc­cult blood in the feces, it will bemore difficult to monitor furtherbleeding. The client can be in­structed to be alert for other indica­tions of bleeding and report anythat occur. Iron preparations con­tribute to constipation. Strainingwith defecation increases intralu­minal pressure and may initiate anepisode of bleeding. Good bowelhygiene and the occasional use of amild laxative will prevent constipa­tion problems.

A person who is anemic will ab­sorb up to 30% of ingested iron dif­fering from the 3-10% absorbed bynon-iron deficient persons. Oraliron preparations with ascorbicacid (Vitamin C or citrus juices)will increase the absorption of ironfrom the GI tract, while antacidscontaining magnesium trisilicate(Gaviscon tablets), tetracyclines,eggs, and milk will interfere. Oraliron preparations irritate GI muco­sa and may cause nausea, vomiting,and diarrhea. For this reason, it

may be necessary to take iron withmeals or snacks even though it isbetter absorbed if taken when thestomach is empty. Dental stainingfrom liquid iron preparations canbe avoided by removing any dentalprosthesis, and diluting the iron so­lution and drinking it through astraw(I7).

Intramuscular injections of irondextran can be given to those per­sons unable to take oral iron prepa­rations. Iron given in this manner isirritating to subcutaneous tissueand will stain the skin if allowed toleak back into superficial tissues.Superficial stains and irritation canbe prevented by injecting iron dex­tran into the larger gluteal muscles

using Z track technique and rotat­ing sites(18). The nurse is alert tocomplaints of pain, staining, andinfl.ammation around injectionsites. The client is instructed to re­port these and any other adversereactions to iron therapy.

Blood replacement may be neces­sary for those clients with more se­vere blood losses. Multiple transfu­sions, which are often required, in­crease the possibility of complica­tions. The nurse must be alert forhemolytic reactions. Early signsand symptoms may occur within tominutes after the transfusion hasbegun and include fever, chills,headache, chest tightness, low backpain, tachypnea, dyspnea, hypoten-

Geriatric Nursing July/August 1986 183

sion, and shock. If these occur, stopthe transfusion and follow agencyprotocol. After therapy, persistentlow hemoglobin and low grade fev­er will be indications of a delayedhemolytic reaction. The washingtechniques used to prepare leuko­cyte-poor and frozen-thawed red\Jlood cells remove many of the sub­stances which cause hemolyticreactions.

The elderly person with arterios­clerotic vessel disease is at greaterrisk for developing fluid volumeoverload. Symptoms which may beevident as early as one hour afterthe transfusion has begun includeheadache, distended neck veins,rapid bounding pulse, dyspnea,anxiety, and moist breath sounds,especially in the. base of thelungs(l9). Fluid overload may beprevented by giving packed redblood cells instead of whole blood,administering furosemide (Lasix),and infusing a unit slowly overthree to four hours~

Surgical Treatmept

The care for the client who willbe treated surgically is not substan­tially different from care that allsurgical clients receive. Changesassociated with advanced age, par­ticularly diminished cardiovascu­lar, pulmonary, renal, and muscu­loskeletal function, increase therisk for intraoperative and postop­erative complications. The goal ofpreoperative care is to minimize therisks by ensuring that the client isin the best possible condition beforesurgery. The nurse assists with ef­forts to improve or stabilize co­existing clinical problems. Fluidand electrolyte imbalances will becorrected, and blood losses will bereplaced. Pulmonary toilet may berequired. The bowel will' becleansed, and antibiotics that areeffective against intestinal florawill be given two to three days be­fore surgery in order to reduce therisk of wound infection. The de­creased ability of the elderly to me­tabolize and eliminate drugs re­quires that anesthetic, analgesic,and antibiotic agents be carefullyselected. Monitoring blood urea ni­trogen and serum creatinine levels

184 Geriatric Nursing July/August 1986

is necessary for prompt detection ofrenal dysfunction.

Recognizing how the decreasedphysiological status of older clientsincreases the risks for postoperativecomplications will help the nurseplan interventions that will reducemorbidity. The elderly often have adecrease in vital capacity and lungcompliance and thicker mucus andsaliva. These changes plus the pres­ence of a nasogastric tube and post­operative pain increase the need forthe nurse to encourage the client todo postoperative respiratory exer­cises and change positions every 1to 2 hours. Assisting the client towalk as soon as possible will in­crease ventilation and perfusion. Italso decreases venous stasis andthereby the risk for developingthrombophlebitis, promotes elimi~

nation, maintains muscle tone, andfosters a more hopeful outlook.

When peripheral vascular circu­lation is impaired, absorption of in­tramuscular analgesia will be de­layed, and pain relief will be inade­quate. If the second dose is givenbefore the first dose is completelyabsorbed, sedation and respiratorydepression may occur. Accumula­tion of drugs in the elderly also oc­curs because of decreased clear­ance by the liver and kidneys. Fre­quent assessment of the client's lev­el of pain and vital signs will helpthe nurse schedule analgesia for op­timal effect. Increasing the intervalbetween doses and giving analgesiaintravenously might be considered.

There is an increased potentialfor delayed return of bowel func­tion because of sluggish peristalsisassociated with aging and the ex­tensive surgical procedure. Naso­gastric intubation will be necessaryuntil peristalsis returns to preventaccumulation of fluid and gas inthe bowel. Removal of all or part ofthe colon reduces the capacity toabsorb water, some electrolytes,and bile salts. Diarrhea may occurafter the bowel begins to function.When large portions of the colonare removed, feces will always bemore liquid. The nurse must moni­tor for fluid and electrolyte imbal­ances and maintain appropriate in­travenous therapy.

EyaluationThorough and ongoing assess­

ment of the client will give thenurse appropriate data by which toevaluate care. Expected client out­comes are listed in the box on page183. Angiodysplasia of the colon isa disease entity that is not wellknown. The nurse who is knowledg­able about this common, progres­sive disease will be more effectivein all aspects of nursing care.

ReferencesI. Boley. S. J.• and others. On the nature and

etiology of vascular ectasias of the colon. De­generative lesions of aging. Gastroenterology72:650-660. Apr. 1977. .,

2. Nath, R. L., and others. Lower gastroIntestt­nal bleeding. Diagnostic approach and man­agement conclusions. Am.J.Surg. 141:478­481, Apr. 1981.

3. Patras, A. Z., and others. Managing GIbleeding: it takes a two-tract mind. Nursing84 14:26-33, July 198.4.

4. Groff, W. L. Angiodysplasia of the colon.Dis.Colon Rectum 26:64-67, Jan. 1983.

5. Ryan, P: Changing concepts in diverticulardisease. Dis.Colon Rectum 26:12-18, Jan.1983.

6. Smith, G. F., and others. Angiodysplasia ofthe colon. A review of 17 cases. Arch.Surg.119:532-536, May 1984.

7. Scully, R. E., and McNeely, B. U. Weeklyclinical pathological exercises (Case 36)N.Engl.J.Med. 291:569-575, 1974.

8. Weaver, G. A., and others. Gastrointestinalangiodysplasia associated with a?rtic val~edisease: part of a spectrum of angtodysplaslaof the gut. Gastroenterology 77: I-II, July1979.

9. Rogers, B. H. Acquired angiodysplasia. (let­ter) Am.J.Gastroenterol. 78:846-847. Dec.1983.

10. Howard, O. M., and others. Angiodysplasia ofthe colon. Experience of 26 cases. Lancet2:16-19, July 3,1982.

I I. Galloway, S. J., and others. Vascular malfor­mations of the right colon as a cause of bleed­ing in patients with aortic stenosis. Radiology113:11-15, Oct. 1974.

12. Johnson, D. G., and Coleman, R. E. Newtechniques in radionuclide imaging of the ali­mentary system. Radiol.Clin.North Am.20:635-651, Dec. 1982.

13. Fischbach, F. T. A Manual of Laboratory Di­agnostic Tests. 2nd ed. Philadelphia, J. B.Lippincott Co.• 1984, pp. 775-778.

14. Sprayregen. S .• and Boley. S. J. Vascular ec­tasias of the right colon. JAMA 239~962-964,

Mar. 6. 1978. .15. Rogers, B. H. G., and Adler, F. Hemangio­

mas of the cecum: colonoscopic diagnosis andtherapy. Gastroenterology 71(6):1079-1082,1976.

16 Carpenito, L. J. Nursing Diagnosis: Applica­tion to Clinical Practice. Philadelphia, J. B.Lippincott Co., 1983.

17. Scherer. J. C. Lippincott's Nurses' DrugManual. Philadelphia, J. B. Lippincott Co.,1985, pp. 597-599.

18. Shepherd, M. J., and Swearington, P. L. Z·track injections. Am.J.Nurs. 84:746-747,June 1984.

19. Querin, J. J., and Stahl, L. D. Twelve simple,sensible steps for successful blood transfu­sions. Nursing 83 13:34-43, Nov. 1983.