Lower gastrointestinal bleeding endoscopic intervention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

The various endoscopic interventions employed in the management of lower gastrointestinal bleeding include argon plasma coagulation, bipolar or heater probe, endoloops and hemoclips, and interventional radiology.

Other surgical options

The endoscopic interventions of lower gastrointestinal bleeding include argon plasma coagulation, bipolar or heater probe, endoloops and hemoclips, and interventional radiology. The following table summarizes the various endoscopic interventions emplyoed in the management of lower gastrointestinal bleeding:

Surgical options	Procedure	Indications	Complications	Comments
Endoscopic Management	Under sedation, a fiberoptic scope is inserted into gastrointestinal tract.	All cases of gastrointestinal bleeding.	Perforation of the luminal wall, resulting in peritonitis and sepsis. Failure to control bleeding.	Best initial step Most direct and effective approach.
Argon plasma coagulation	Argon plasma coagulation uses ionized argon gas to causes tissue coagulation.	All cases of LGIB	Bleeding cannot be fully controlled. Can lead to explosion of the gastrointestinal tract due to colonic bacteria	APC is safe and easy to use Sub-mucosal saline cushions must be used prior to APC to reduce the risk of deeper wall injury. Cannot be used in patients with coagulation disorders.
Bipolar or heater probe	Provides controlled coagulation by a applying a heat to site of bleeding.	Can be used alone or in combination with other modalities for control of LGIB.	Bleeding cannot be fully controlled. Thermal necrosis and recurrent bleeding. Perforation	Bipolar or heater probe coagulation is safe and effective in treating angiodysplasia and post-polypectomy bleeding.
Endoloops and hemoclips	Mechanical hemostasis is achieved by direct application of an endoloop or hemoclip.	Bleeding from: Polyps Diveriticulum	Necrosis of the colonic wall. Failure to control bleeding	Requires a reasonable length of stalk for the application of loop or clip. Can be used to control massive bleeding. Hemoclip is used to occlude a bleeding vessel.
Interventional radiology	Interventional radiography includes use of angiography and embolization of the bleeding vessel. Angiography is facilitated by using a microcatheter that passes co-axially through a main angiographic catheter	Indicated when other procedures have been failed to control bleeding. Persistent or recurrent bleeding.	Bowel infarction Aterial thrombosis Renal failure	Most advanced and preferred technique. Can be used only when bleeding rate is of 0.5 to 1 mL/min. Sensitivity and specificity rates of 100% and 30% to 47%, respectively.

Management of Occult bleeding

Treatment of occult bleeding varies according to the bleeding's etiology and severity and patient comorbidities. Treatment options include endoscopic, angiographic, medical, and surgical therapies.

Endoscopic therapies include thermal contact probes, laser coagulation, injection sclerotherapy, and banding.

Endoscopic Coagulation

• Thermal contact probes are the mainstay of endoscopic hemostasis in upper GI bleeding.
  • Contact types :Heater probe, monopolar and bipolar electrocoagulation
  • Noncontact types :Laser treatment, argon plasma coagulation 

Contact probes

• Contact probes physically tamponade a blood vessel to stop bleeding and interrupt underlying blood flow.
• Thermal energy is then applied to seal the underlying vessel (coaptive coagulation).
• The most commonly used probe is a multipolar electrocoagulation (MPEC) probe, also referred to as a bipolar electrocoagulation probe , with which heat is created by current flowing between intertwined electrodes on the tip of the probe.
• Heater probes provide a predetermined amount of joules of energy, which does not vary with tissue resistance and can effectively coagulate arteries up to 2 mm in diameter.
• The main risk of using a thermal probe is perforation with excessive application of coagulation or pressure, especially in acute or nonfibrotic lesions.
• Thermal probes can also cause a coagulation injury that can make lesions larger and deeper and may induce delayed bleeding in patients with a coagulopathy.

Noncontact types

• Noncontact thermal therapy includes argon plasma coagulation and laser.
• Noncontact types rarely used now in endoscopic management.

Endoscopic injection sclerotherapy (EIS)

• Comprises endoscopic delivery of a sclerosant, such as ethanol, morrhuate sodium, polidocanol, or sodium tetradecyl sulfate.
• Injections may be intravariceal or be delivered into the esophageal wall near the varices.
• Bucrylate is an adhesive that has been used successfully.
• Typical injection volume is 1 to 2 mL per injection, for a total volume of 10 to 15 mL.
• Interval between injections varies according to patient tolerance and response, and complications.
• After an initial injection to control bleeding, there is usually a follow-up injection 2 to 3 days later, followed by weekly or biweekly procedures until complete obliteration of the varices is achieved, which usually takes five or six sessions.

Endoscopic band ligation (EBL)

• EBL involves the placement of elastic circular ring ligatures around the varices to cause strangulation.
• Bands are typically delivered at the gastroesophageal junction first, then proximally six to ten bands may be delivered with a single intubation.
• Endoscopic therapy can halt bleeding in 80% to 90% of patients.
• Follow-up endoscopies are recommended at various intervals depending on the size/appearance of varices and severity of liver disease.
• EBL is equivalent to EIS in establishing initial control of bleeding.
• EBL is widely favored over EIS for primary prevention due to similar or superior efficacy with fewer complications.
• The primary drawback of EBL is that during active bleeding, operator visibility is limited by the device holding the bands prior to their delivery.