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

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

3. ULCERATIVE COLITIS

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

5. 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

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

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

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

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

10. 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%

11. POST POLYPECTOMY BLEEDING 2-6% of LGI bleeding Richter 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

12. RISK OF BLEEDING AFTER ENDOSCOPIC POLYPECTOMY IN PATIENTS TAKING ASA OR OTHER NSAIDS No drugNSAIDS N of patients374320 Minor self-limited bleeding8 (2.1%)20 (6.3%) Major bleeding (hosp/Rx)2 (0.3%) Shiffman et al GIE 1994

13. SALINE vs EPINEPHRINE Review of the literature AuthorSalineEpinephrineTot.P Hsieh et al Hepatogastr 2001 7/762/759/151NS Rohde et al Endoscopy 2000 5/201/206/40NS Folwaczny et al Endoscopy 1997 9/490/289/770.01

14. PROPHILACTIC CLIP APPLICATION DOES NOT DECREASE DELAYED BLEEDING AFTER POLYPECTOMY (RCT) CLIPSNO CLIPS N of patients205208 Bleeding0.98%0.96% Shioji et al. GIE 2003

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

16. 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

17. BLEEDING FROM COLON CARCINOMA Nd-yag laser AuthorsSuccess rate Eckhauser 1992100% Gavers 200083% Kozarek 200283%

18. RADIATION PROCTITIS Treatment of choice: APC 98%Venkatesh 2002 96%Villavicencio 2002 92%Tjandra 2001 Alternative: cryotherapy (1-6 sessions) 100% Kantesevoy 2003

19. DIEULAFOY LESION BANDING Mizukami 2002

20. 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

21. 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)