Lower GI bleeding therapy: the endoscopist Giorgio Saracco, MD Dpt Gastroenterology Molinette Hospital, Turin.

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Presentation transcript:

Lower GI bleeding therapy: the endoscopist Giorgio Saracco, MD Dpt Gastroenterology Molinette Hospital, Turin

Radiation colitisCMV colitisIschemic colitisNSAIDs colitis C. Difficile colitis Salmonella colitisRectal ulcer

ULCERATIVE COLITIS

ENDOSCOPIC TREATMENTS INJECTION (epinephrine, glue) LASER APC HEATER PROBE MONOPOLAR AND MULTIPOLAR ELECTROCOAGULATION CLIPPING BANDING

DIVERTICULA 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

DIVERTICULA Active bleeding Visible vessel Adherent clot Suspected diverticular bleeding Casual discovery Jensen 2000

DIVERTICULA Treatment Active bleeding  epinephrine injection Visible vessel  bipolar electrocoagulation Adherent clot  epinephrine injection + clot removal + bipolar electrocoagulation Jensen 2000

DIVERTICULA Therapeutic alternatives Epinephrine + heater probe/ ND-yag laser Prakash 1999 Banding Witte 2000 Clipping Hakama 1997

ANGIODYSPLASIA 3-12% of LGI bleeding Epinephrine injection + polidocanol Jaapersen 1994 APC Grund-Zambelli 2002

APC 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 67% 33%

POST POLYPECTOMY BLEEDING 2-6% of LGI bleeding Richter % of patients undergoing polypectomy show a clinically evident bleeding McRae 1983 Gilbert % of them need hospital staying

RISK OF BLEEDING AFTER ENDOSCOPIC POLYPECTOMY IN PATIENTS TAKING ASA OR OTHER NSAIDS No drugNSAIDS N of patients Minor self-limited bleeding8 (2.1%)20 (6.3%) Major bleeding (hosp/Rx)2 (0.3%) Shiffman et al GIE 1994

SALINE vs EPINEPHRINE Review of the literature AuthorSalineEpinephrineTot.P Hsieh et al Hepatogastr /762/759/151NS Rohde et al Endoscopy /201/206/40NS Folwaczny et al Endoscopy /490/289/770.01

PROPHILACTIC CLIP APPLICATION DOES NOT DECREASE DELAYED BLEEDING AFTER POLYPECTOMY (RCT) CLIPSNO CLIPS N of patients Bleeding0.98%0.96% Shioji et al. GIE 2003

POST POLYPECTOMY BLEEDING Treatment Clipping APC + epinephrine injection APC alone Epinephrine alone Endoloop

INTERNAL HEMORRHOIDS 2-9% of LGI bleedings Banding –success rate: 80% if medium size 54 % if large size Berkelhamer 2002 Anedoctal reports with N-2-butyl cyanoacrilate injection Chen 2000

BLEEDING FROM COLON CARCINOMA Nd-yag laser AuthorsSuccess rate Eckhauser % Gavers % Kozarek %

RADIATION PROCTITIS Treatment of choice: APC 98%Venkatesh %Villavicencio %Tjandra 2001 Alternative: cryotherapy (1-6 sessions) 100% Kantesevoy 2003

DIEULAFOY LESION BANDING Mizukami 2002

CONCLUSIONS 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 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)