Lower gastrointestinal bleeding endoscopic intervention: Difference between revisions

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{{CMG}} ; {{AE}} {{ADG}}
{{CMG}} ; {{AE}} {{ADG}}
==Overview==
==Overview==
The various endoscopic interventions employed in the management of lower gastrointestinal bleeding include [[Argon plasma coagulation|argon plasma coagulation,]] bipolar or heater probe, endoloops and hemoclips, and [[interventional radiology]].
==Other surgical options==
==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:
The endoscopic interventions of lower gastrointestinal bleeding include [[argon plasma coagulation]], bipolar or heater probe, endoloops and hemoclips, and [[Interventional radiology|interventional radiology.]] The following table summarizes the various endoscopic interventions emplyoed in the management of lower gastrointestinal bleeding:
{| class="wikitable"
{| class="wikitable"
!Surgical options
!Surgical options
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|'''Endoscopic Management'''
|'''Endoscopic Management'''
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* Under sedation, a fiberoptic scope is inserted for inspection of the mucosa to identify a bleeding site
* Under [[sedation]], a fiberoptic scope is inserted into [[Gastrointestinal tract|gastrointestinal trac]]<nowiki/>t.
* Further instrumentation inserted through the scope may aid in stopping the bleed.
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|
* All cases of gastrointestinal bleeding.
* All cases of gastrointestinal bleeding.
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* Perforation of the luminal wall, resulting in peritonitis and sepsis.
* Perforation of the luminal wall, resulting in [[peritonitis]] and [[sepsis]].
* Failure to control bleeding.
* Failure to control bleeding.
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* Most direct and effective approach.
* Most direct and effective approach.
|-
|-
|'''Argon plasma coagulation'''
|'''[[Argon plasma coagulation]]'''
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* Argon plasma coagulation uses ionized argon gas to causes tissue coagulation.
* [[Argon plasma coagulation]] uses ionized [[Argon|argon gas]] to causes tissue [[coagulation]].  
* A high-frequency electrical current is conducted through the gas to ionize it.
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* Variety of causes of LGIB
* All cases of LGIB
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* Failure to control bleeding
* [[Bleeding]] cannot be fully controlled.
* Full bowel preparation is required to prevent explosion from colonic gas, which is combustible
* Can lead to [[explosion]] of the [[gastrointestinal tract]] due to [[Normal flora|colonic bacteria]]
* APC causes limited depth coagulation and should be performed with caution in the right colon as it is thin-walled and more likely to perforate.
|
|
* APC is safe and easy to use
* [[Argon plasma coagulation|APC]] is safe and easy to use
* To reduce the risk of deeper wall injury, submucosal saline cushions have been used prior to APC treatment
* Sub-mucosal saline cushions  must be used prior to [[Argon plasma coagulation|APC]] to reduce the risk of deeper wall injury.
* Patients with coagulopathy do worse with APC unless the coagulopathy is corrected
* Cannot be used in patients with [[coagulation disorders]].
|-
|-
|'''Bipolar or Heater probe'''
|'''Bipolar or heater probe'''
|
|
* Provides controlled coagulation by a applying a heater probe to site of bleeding.
* Provides controlled coagulation by a applying a heat to site of bleeding.
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|
* May be used alone or in combination with other modalities for control of LGIB due to a variety of causes.
* Can be used alone or in combination with other modalities for control of LGIB.
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* Failure to control bleeding
* [[Bleeding]] cannot be fully controlled.
* Thermal necrosis and recurrent bleeding (''eg'', at polypectomy site).  
* Thermal [[necrosis]] and recurrent [[bleeding]].  
* Perforation
* [[Perforation]]
|
|
* Bipolar or heater probe coagulation is safe and effective in treating angiodysplasia and post-polypectomy bleeding.
* Bipolar or heater probe coagulation is safe and effective in treating [[angiodysplasia]] and post-[[Polypectomy|polypectomy bleeding.]]
 
* Can be applied to other conditions as deemed appropriate by the endoscopist.
|-
|-
|'''Endoloops and hemoclips'''
|'''Endoloops and hemoclips'''
|
|
* Mechanical hemostasis is achieved by direct application of an endoloop or hemoclip.
* Mechanical hemostasis is achieved by direct application of an endoloop or hemoclip.
|Bleeding from:
* Polyps
* Diveriticulum
|
|
* To stop bleeding from the pedicle of a resected pedunculated polyp or from a diverticulum.
* Necrosis of the colonic wall.
|
* Failure to control bleeding
* Care is necessary, as vigorous suction with the endoloop can pull on serosa, leading to subsequent necrosis of the colonic wall.
* Failure to stop bleeding
|
|
* An endoloop or hemoclip can be applied to the bleeding stalk if a reasonable length of stalk remains following polypectomy and if resnaring is not effective.
* Requires a reasonable length of stalk for the application of loop or clip.
* Massive postpolypectomy bleeding has been successfully managed with band ligation.
* Can be used to control massive bleeding.
* If a bleeding vessel has been identified, a hemoclip can be used to occlude the vessel.
* Hemoclip is used to occlude a bleeding vessel.
|-
|-
|'''Interventional radiology'''
|'''Interventional radiology'''
|
|
* Interventional radiography entails angiography and super selective arterial embolization with various agents (gelatin sponge, microcoils, polyvinyl alcohol particles, and balloons)
* Interventional radiography includes use of angiography and embolization of the bleeding vessel.
* Uses a microcatheter that is passed co-axially through a main angiographic catheter to facilitate passage into smaller vessels
* Angiography is facilitated by using a microcatheter that passes co-axially through a main angiographic catheter  
* A distal embolization technique is used to reduce the risk of bowel infarction.
|
|
* Angiography and embolization are indicated in patients in whom endoscopy is not possible due to the rate of bleeding or the presence of an unprepared bowel
* Indicated when other procedures have been failed to control bleeding.
* It is also indicated in persistent or recurrent bleeding and in situations in which colonoscopy has failed to identify the source of bleeding
* Persistent or recurrent bleeding.
|
|
* Bowel infarction, arterial thrombosis, embolization to a nontarget site, and renal failure.
* Bowel infarction  
* Complications occur in approximately 9% of patients.
* Aterial thrombosis
* The risk of postembolization intestinal infarction has been quoted as up to 20%. However, the use of superselective angiography and microcatheters has resulted in a lower risk of 3% to 4%.
* Renal failure
|
|
* Angiographic arterial embolization is a more definitive means of controlling hemorrhage than endoscopic methods
* Most advanced and preferred technique.
* The main limitation of this method is the bleeding rate of  0.5 to 1 mL/min required for positive identification of a bleeding site
* 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, have been quoted for determining the bleeding source with angiography
* Sensitivity and specificity rates of 100% and 30% to 47%, respectively.
* The advantage of coils is that they are visible and, therefore, more controllable
* Embolization of bleeding vessels has been achieved successfully in patients with Meckel diverticulum. However, surgery is often required and should not be delayed in an unstable patient
|}
|}
== 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.
====<u>Endoscopic '''Coagulation'''</u>====
*Thermal contact probes are the mainstay of endoscopic hemostasis in upper GI bleeding.<ref name="pmid26421105">{{cite journal |vauthors=Szura M, Pasternak A |title=Upper non-variceal gastrointestinal bleeding - review the effectiveness of endoscopic hemostasis methods |journal=World J Gastrointest Endosc |volume=7 |issue=13 |pages=1088–95 |year=2015 |pmid=26421105 |pmc=4580950 |doi=10.4253/wjge.v7.i13.1088 |url=}}</ref>
**'''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 [[Electrocoagulation|multipolar electrocoagulation]] (MPEC) probe, also referred to as a ''[[Electrocoagulation|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.
====<u>Endoscopic injection sclerotherapy (EIS)</u>====
*Comprises endoscopic delivery of a sclerosant, such as [[ethanol]], morrhuate sodium, [[polidocanol]], or [[sodium tetradecyl sulfate]].<ref name="pmid18567095">{{cite journal |vauthors=Shi B, Wu W, Zhu H, Wu YL |title=Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol |journal=World J. Gastroenterol. |volume=14 |issue=22 |pages=3598–601 |year=2008 |pmid=18567095 |pmc=2716629 |doi= |url=}}</ref><ref name="pmid21037987">{{cite journal |vauthors=Al-Ali J, Pawlowska M, Coss A, Svarta S, Byrne M, Enns R |title=Endoscopic management of gastric variceal bleeding with cyanoacrylate glue injection: safety and efficacy in a Canadian population |journal=Can. J. Gastroenterol. |volume=24 |issue=10 |pages=593–6 |year=2010 |pmid=21037987 |pmc=2975471 |doi= |url=}}</ref>
*[[Injections]] may be intravariceal or be delivered into the [[Esophageal|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]].<ref name="pmid18818787">{{cite journal |vauthors=Zepeda-Gómez S, Marcon NE |title=Endoscopic band ligation for nonvariceal bleeding: a review |journal=Can. J. Gastroenterol. |volume=22 |issue=9 |pages=748–52 |year=2008 |pmid=18818787 |pmc=2661278 |doi= |url=}}</ref><ref name="pmid11905861">{{cite journal |vauthors=Ertekin C, Taviloglu K, Barbaros U, Guloglu R, Dolay K |title=Endoscopic band ligation: alternative treatment method in nonvariceal upper gastrointestinal hemorrhage |journal=J Laparoendosc Adv Surg Tech A |volume=12 |issue=1 |pages=41–5 |year=2002 |pmid=11905861 |doi=10.1089/109264202753486911 |url=}}</ref>
*Bands are typically delivered at the [[gastroesophageal junction]] first, then [[Proximal|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 diseases|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 [[Bleeding|active bleeding]], operator visibility is limited by the device holding the bands prior to their delivery.


==References==
==References==
{{reflist|2}}
{{reflist|2}}

Latest revision as of 02:27, 4 January 2018

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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
  • 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
  • All cases of LGIB
  • 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.
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.[1]
    • 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

Endoscopic injection sclerotherapy (EIS)

  • Comprises endoscopic delivery of a sclerosant, such as ethanol, morrhuate sodium, polidocanol, or sodium tetradecyl sulfate.[2][3]
  • 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.[4][5]
  • 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.

References

  1. ↑ Szura M, Pasternak A (2015). "Upper non-variceal gastrointestinal bleeding - review the effectiveness of endoscopic hemostasis methods". World J Gastrointest Endosc. 7 (13): 1088–95. doi:10.4253/wjge.v7.i13.1088. PMC 4580950. PMID 26421105.
  2. ↑ Shi B, Wu W, Zhu H, Wu YL (2008). "Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol". World J. Gastroenterol. 14 (22): 3598–601. PMC 2716629. PMID 18567095.
  3. ↑ Al-Ali J, Pawlowska M, Coss A, Svarta S, Byrne M, Enns R (2010). "Endoscopic management of gastric variceal bleeding with cyanoacrylate glue injection: safety and efficacy in a Canadian population". Can. J. Gastroenterol. 24 (10): 593–6. PMC 2975471. PMID 21037987.
  4. ↑ Zepeda-Gómez S, Marcon NE (2008). "Endoscopic band ligation for nonvariceal bleeding: a review". Can. J. Gastroenterol. 22 (9): 748–52. PMC 2661278. PMID 18818787.
  5. ↑ Ertekin C, Taviloglu K, Barbaros U, Guloglu R, Dolay K (2002). "Endoscopic band ligation: alternative treatment method in nonvariceal upper gastrointestinal hemorrhage". J Laparoendosc Adv Surg Tech A. 12 (1): 41–5. doi:10.1089/109264202753486911. PMID 11905861.
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