Lower GI bleeding therapy: the endoscopist

Giorgio Saracco, MD

Dpt Gastroenterology

Molinette Hospital, Turin

Radiation colitis CMV colitis Ischemic colitis NSAIDs colitis

C. Difficilecolitis

Salmonella colitis

Rectal ulcer

ULCERATIVE COLITISULCERATIVE COLITIS

ENDOSCOPIC TREATMENTSENDOSCOPIC TREATMENTS

• INJECTION (epinephrine, glue)

• LASER

• APC

• HEATER PROBE

• MONOPOLAR AND MULTIPOLAR ELECTROCOAGULATION

• CLIPPING

• BANDING

DIVERTICULADIVERTICULA

• 3-5% of patients with diverticula show a LGI bleeding

• most frequent cause of LGI bleeding (42-55%)

• In 10-13% of cases, a recent stigmata of bleeding is found

Prakash 1999

DIVERTICULADIVERTICULA

• Active bleeding

• Visible vessel

• Adherent clot

• Suspected diverticular bleeding

• Casual discoveryJensen 2000

DIVERTICULA DIVERTICULA TreatmentTreatment

• Active bleeding epinephrine injection

• Visible vessel bipolar electrocoagulation

• Adherent clot epinephrine injection + clot removal + bipolar electrocoagulation

Jensen 2000

DIVERTICULA DIVERTICULA Therapeutic alternativesTherapeutic alternatives

• Epinephrine + heater probe/ ND-yag laser

Prakash 1999

• Banding Witte 2000

• Clipping Hakama 1997

ANGIODYSPLASIAANGIODYSPLASIA

• 3-12% of LGI bleeding

• Epinephrine injection + polidocanol Jaapersen 1994

• APCGrund-Zambelli 2002

APC AND ANGIODYSPLASIAAPC AND ANGIODYSPLASIA

Efficacy of APC

Success: no additional treatment

Partial success: markedly reduced need of blood transfusion

Warnings: power setting 40W and argon flow 2l/min

microperforation

SUCCESS

PARTIALSUCCESS

67%33%

POST POLYPECTOMY POST POLYPECTOMY BLEEDINGBLEEDING

• 2-6% of LGI bleedingRichter 1995

• 2-3% of patients undergoing polypectomy show a clinically evident bleeding

McRae 1983

Gilbert 1984

• 0.2-0.6% of them need hospital staying

RISK OF BLEEDING AFTER RISK OF BLEEDING AFTER ENDOSCOPIC POLYPECTOMY IN ENDOSCOPIC POLYPECTOMY IN

PATIENTS TAKING ASA OR OTHER PATIENTS TAKING ASA OR OTHER NSAIDSNSAIDS

No drug NSAIDS

N of patients 374 320

Minor self-limited bleeding 8 (2.1%) 20 (6.3%)

Major bleeding (hosp/Rx) 2 (0.3%) 2 (0.3%)

Shiffman et al GIE 1994

SALINE vs EPINEPHRINESALINE vs EPINEPHRINEReview of the literatureReview of the literature

Author Saline Epinephrine Tot. P

Hsieh et al

Hepatogastr 2001

7/76 2/75 9/151 NS

Rohde et al

Endoscopy 2000

5/20 1/20 6/40 NS

Folwaczny et al

Endoscopy 1997

9/49 0/28 9/77 0.01

PROPHILACTIC CLIP APPLICATION PROPHILACTIC CLIP APPLICATION DOES NOT DECREASE DELAYED DOES NOT DECREASE DELAYED

BLEEDING AFTER POLYPECTOMY BLEEDING AFTER POLYPECTOMY (RCT)(RCT)CLIPS NO CLIPS

N of patients 205 208

Bleeding 0.98% 0.96%

Shioji et al. GIE 2003

POST POLYPECTOMY BLEEDINGPOST POLYPECTOMY BLEEDING Treatment Treatment

• Clipping

• APC + epinephrine injection

• APC alone

• Epinephrine alone

• Endoloop

INTERNAL HEMORRHOIDSINTERNAL HEMORRHOIDS

• 2-9% of LGI bleedings

• Banding– success rate: 80% if medium size

54 % if large sizeBerkelhamer 2002

• Anedoctal reports with N-2-butyl cyanoacrilate injection

Chen 2000

BLEEDING FROM COLON BLEEDING FROM COLON CARCINOMACARCINOMA

• Nd-yag laser

Authors Success rate

Eckhauser 1992 100%

Gavers 2000 83%

Kozarek 2002 83%

RADIATION PROCTITISRADIATION PROCTITIS

• Treatment of choice: APC

98% Venkatesh 2002

96% Villavicencio 2002

92% Tjandra 2001

• Alternative: cryotherapy (1-6 sessions)

100% Kantesevoy 2003

DIEULAFOY LESIONDIEULAFOY LESION

• BANDINGMizukami 2002

CONCLUSIONS ICONCLUSIONS I

• Management of LGI bleeding begins with development of a differential diagnosis

• The source of bleeding cannot be definitively identified in up to 25% of patients

• Timing of colonoscopy still controversial

CONCLUSIONS IICONCLUSIONS II

• Methods of hemostatic therapy include injection, heater probe, electrocoagulation, clipping, APC

• Data on the effectiveness of endoscopic therapy are limited….”but the global experience suggests that there is likely to be benefit” (Rockey, Gastroenterology 2006)