Hereditary hemorrhagic telangiectasia
Updates to Synonym Attributes
Updates to Synonym Attributes
Updates to Article Attributes
Hereditary haemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome, is a rare inherited disorder characterised by abnormal blood vessel formation in the skin, mucous membranes, and organs including the lungs, liver, and central nervous system.
Epidemiology
Worldwide prevalence ~1.5 per 100,000. Wide geographic variability with a much higher incidence in certain regions, e.g. 1 in 200 in Dutch Antilles, 1 in 3500 in France.
Clinical presentation
TheAlthough the disease has a broad clinical spectrum, the classic clinical triad at presentation is epistaxis, multiple telangiectasias, and positive family history.
The diagnosis is a clinical diagnosis (Curacao criteria) based on the presence of 3 out of 4 of the following 8:
- recurrent spontaneous epistaxis
- multiple mucocutaneous telangiectasias
- characteristic sites include: oral cavity, lips, fingers and nose
-
positive family historyvisceral AVMs
Pathology
It is an autosomal dominant multi-organ vascular dysplasia, characterised by multiple arteriovenous malformations (AVMs) that lack an intervening capillary network. Telangiectasias (small superficial AVMs) are particularly common. Mutations have been found in one of several genes (three known so far). De novo mutations are rare, almost all have a first-degree relative affected.
Clinical spectrum
Hereditary haemorrhagic telangiectasia can involve multiple organ systems. The spectrum includes:
-
nasal: 90%
- telangiectasias of nasal mucosa
- complications: recurrent epistaxis
-
skin and mucosal membranes: 90%
- telangiectasias of skin, oral cavity, conjunctivae
- complications: recurrent bleeding
-
liver: 71-79%5,7
- symptomatic liver involvement in HHT is uncommon but does occur; it has been attributed to three distinct clinical subtypes and is believed to be a consequence of the predominant hepatic shunt pattern 2
- high-output cardiac failure
- shunting that increases cardiac preload
- typically arteriovenous or portovenous shunts
-
portal hypertension
- increased flow into the portal system (arterioportal shunt)
- hepatic anatomic abnormalities leading to increased intrahepatic resistance
- biliary disease
- shunting of the blood away from the peribiliary plexus (arteriovenous or arterioportal shunting)
- extensive arteriovenous shunting lead to biliary necrosis and bile leak
- complications: hepatomegaly, right upper quadrant pain, high-output cardiac failure, portal hypertension, mesenteric angina from steal phenomenon
-
gastrointestinal tract: 20-40%
- AVMs or angiodysplasia in the stomach, small bowel or large bowel
- complications: recurrent GI bleeding
-
pulmonary: 20%
-
pulmonary AVMs
- 36% of patients with solitary pulmonary AVM have HHT
- 57% of patients with multiple pulmonary AVMs have HHT
- complications
- pulmonary haemorrhage, haemoptysis (less common)
- complications of shunting (more common): paradoxical emboli (e.g. stroke), septic emboli (e.g. cerebral abscess), hypoxaemia, high-output cardiac failure
-
pulmonary AVMs
-
CNS: 5-10%
- cerebral AVMs, spinal AVMs or cerebral aneurysms
- complications: headache, seizures, paraparesis, haemorrhage
- one-third of cerebral complications in HHT are due to cerebral AVMs or aneurysms, and two-thirds are due to paradoxical emboli from pulmonary AVMs
- increased incidence ofcapillary telangiectasia and developmental venous anomalies
Radiographic assessmentfeatures
Diagnosis
The diagnosis is a clinical diagnosis and based on the presence of 3 out of 4 of the following diagnostic criteria (Curacao criteria) is required:
recurrent spontaneous epistaxismultiple mucocutaneous telangiectasiasvisceral AVMsfirst degree relative with HHT
Imaging of visceral arteriovenous malformations
-
lung
- chest x-ray: well-circumscribed mass (may be lobulated) with enlarged draining vein
- CT: well-circumscribed vascular mass with enhancing feeding artery and draining vein
- contrast echocardiography
- presence of contrast bubbles in the left atrium confirms the presence of a shunt
- characteristically, this occurs late (after several cardiac cycles), indicating a pulmonary shunt rather than intracardiac shunt
-
CNS
- MR: cerebral and cerebellar AVMs typically in superficial locations
-
gastrointestinal tract
- CT/CTA
- conventional angiography
- endoscopy
- pill-cam (capsule endoscopy)
- nuclear medicine GI bleed study for active bleeding
-
liver
- CT/CTA
- MRI
- conventional angiography
- ultrasound
Treatment and prognosis
Treatment of visceral lesions
-
lung
- embolisation; recanalisation occurs in up to 20% post embolisation
- surgical resection
-
CNS
- embolisation
- surgical resection
- stereotactic radiosurgery
-
gastrointestinal tract
- embolisation
- surgical resection
- endoscopic ablation/electrocautery
-
liver
- embolisation
- surgical resection
- liver transplantation
Prognosis
- most patients have a normal life expectancy
- 10% die of complications: usually stroke, cerebral abscess or massive haemorrhage
-<p><strong>Hereditary haemorrhagic telangiectasia (HHT)</strong>, also known as <strong>Osler-Weber-Rendu syndrome</strong>, is a rare inherited disorder characterised by abnormal blood vessel formation in the skin, mucous membranes, and organs including the lungs, liver, and central nervous system.</p><h4>Epidemiology</h4><p>Worldwide prevalence ~1.5 per 100,000. Wide geographic variability with a much higher incidence in certain regions, e.g. 1 in 200 in Dutch Antilles, 1 in 3500 in France.</p><h4>Clinical presentation</h4><p>The classic clinical triad at presentation is:</p><ol>-<li>epistaxis</li>-<li>multiple telangiectasias</li>-<li>positive family history</li>-</ol><h4>Pathology</h4><p>It is an autosomal dominant multi-organ vascular dysplasia, characterised by multiple arteriovenous malformations (AVMs) that lack an intervening capillary network. Telangiectasias (small superficial AVMs) are particularly common. Mutations have been found in one of several genes (three known so far). De novo mutations are rare, almost all have a first-degree relative affected.</p><h4>Clinical spectrum</h4><p>Hereditary haemorrhagic telangiectasia can involve multiple organ systems. The spectrum includes:</p><ul>- +<p><strong>Hereditary haemorrhagic telangiectasia (HHT)</strong>, also known as <strong>Osler-Weber-Rendu syndrome</strong>, is a rare inherited disorder characterised by abnormal blood vessel formation in the skin, mucous membranes, and organs including the lungs, liver, and central nervous system.</p><h4>Epidemiology</h4><p>Worldwide prevalence ~1.5 per 100,000. Wide geographic variability with a much higher incidence in certain regions, e.g. 1 in 200 in Dutch Antilles, 1 in 3500 in France.</p><h4>Clinical presentation</h4><p>Although the disease has a broad clinical spectrum, the classic clinical triad at presentation is epistaxis, multiple <a title="Telangiectasias" href="/articles/telangiectasiae">telangiectasias</a>, and positive family history. </p><p>The diagnosis is a clinical diagnosis (Curacao criteria) based on the presence of 3 out of 4 of the following <sup>8</sup>:</p><ul>
- +<li>recurrent spontaneous epistaxis</li>
- +<li>multiple mucocutaneous telangiectasias<ul><li>characteristic sites include: oral cavity, lips, fingers and nose</li></ul>
- +</li>
- +<li>visceral AVMs</li>
- +<li>first degree relative with HHT</li>
- +</ul><h4>Pathology</h4><p>It is an autosomal dominant multi-organ vascular dysplasia, characterised by multiple <a title="Arteriovenous malformations" href="/articles/arteriovenous-malformations">arteriovenous malformations (AVMs)</a> that lack an intervening capillary network. Telangiectasias (small superficial AVMs) are particularly common. Mutations have been found in one of several genes (three known so far). De novo mutations are rare, almost all have a first-degree relative affected.</p><p>Hereditary haemorrhagic telangiectasia can involve multiple organ systems. The spectrum includes:</p><ul>
-<strong>liver: 71-79%</strong><sup>5,7</sup><ul>- +<strong>liver: 71-79% </strong><sup>5,7</sup><ul>
-<li>extensive arteriovenous shunting lead to biliary necrosis and bile leak</li>-<li>complications: hepatomegaly, right upper quadrant pain, high-output cardiac failure, portal hypertension, mesenteric angina from steal phenomenon</li>- +<li>extensive arteriovenous shunting lead to <a title="Biliary necrosis" href="/articles/biliary-necrosis">biliary necrosis</a> and <a title="bile leak" href="/articles/bile-leak">bile leak</a>
- +</li>
- +<li>complications: hepatomegaly, right upper quadrant pain, <a title="High-output cardiac failure" href="/articles/high-output-cardiac-failure">high-output cardiac failure</a>, portal hypertension, mesenteric angina from steal phenomenon</li>
-<li>AVMs or <a href="/articles/gastrointestinal-angiodysplasia">angiodysplasia</a> in stomach, small bowel or large bowel</li>- +<li>AVMs or <a href="/articles/gastrointestinal-angiodysplasia">angiodysplasia</a> in the stomach, small bowel or large bowel</li>
-<li>complications of <a href="/articles/cardiovascular-shunts">shunting</a> (more common): paradoxical emboli (e.g. stroke), septic emboli (e.g. cerebral abscess), hypoxaemia, high-output cardiac failure</li>- +<li>complications of <a href="/articles/cardiovascular-shunts">shunting</a> (more common): <a title="Paradoxical embolism" href="/articles/paradoxical-embolism">paradoxical emboli</a> (e.g. stroke), septic emboli (e.g. <a title="Cerebral abscess" href="/articles/brain-abscess-1">cerebral abscess</a>), hypoxaemia, high-output cardiac failure</li>
-<li>increased incidence of<a href="/articles/cns-capillary-telangiectasia-1"> capillary telangiectasia</a> and <a href="/articles/developmental-venous-anomaly">developmental venous anomalies</a>- +<li>increased incidence of <a href="/articles/cns-capillary-telangiectasia-1">capillary telangiectasia</a> and <a href="/articles/developmental-venous-anomaly">developmental venous anomalies</a>
-</ul><h4>Radiographic assessment</h4><h5>Diagnosis</h5><p>The diagnosis is a clinical diagnosis and based on the presence of 3 out of 4 of the following diagnostic criteria (<a href="/articles/curacao-criteria">Curacao criteria</a>) is required:</p><ul>-<li>recurrent spontaneous epistaxis</li>-<li>multiple mucocutaneous telangiectasias</li>-<li>visceral AVMs</li>-<li>first degree relative with HHT</li>-</ul><h5>Imaging of visceral arteriovenous malformations</h5><ul>- +</ul><h4>Radiographic features</h4><h5>Imaging of visceral arteriovenous malformations</h5><ul>
References changed:
- 8. Shovlin CL, Guttmacher AE, Buscarini E, Faughnan ME, Hyland RH, Westermann CJ, Kjeldsen AD, Plauchu H. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). (2000) American journal of medical genetics. 91 (1): 66-7. <a href="https://www.ncbi.nlm.nih.gov/pubmed/10751092">Pubmed</a> <span class="ref_v4"></span>