lower gi bleeding therapy: the endoscopist giorgio saracco, md dpt gastroenterology molinette...
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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)