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

Endoscopic Intervention

• Endoscopic Intervention is the best initial step in the management of lower gastrointestinal bleeding and considered as the most direct and effective approach.
• Indicated in all cases of gastrointestinal bleeding.
• Common complications include perforation of the luminal wall, resulting in peritonitis and sepsis and failure to control bleeding.

Argon plasma coagulation

• Argon plasma coagulation uses ionized argon gas to causes tissue coagulation. A high-frequency electrical current is conducted through the gas to ionize it.
• Argon plasma coagulation is safe and easier to use
• Submucosal saline cushions are administered prior to APC treatment to reduce the risk of deeper wall injury.
• Coagulopathies has to be corrected before APC treatment.

Bipolar or Heater probe

• Bipolar or Heater probe provides controlled coagulation by a applying a heater probe to site of bleeding

Surgical options	Procedure	Indications	Complications	Comments
Endoscopic Intervention	Under sedation, a fiberoptic instrument is inserted for inspection of the mucosa to identify a bleeding site Further instrumentation inserted through the scope may aid in stopping the bleed.	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. A high-frequency electrical current is conducted through the gas to ionize it.	Variety of causes of LGIB	Failure to control bleeding Full bowel preparation is required to prevent explosion from colonic gas, which is combustible 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 To reduce the risk of deeper wall injury, submucosal saline cushions have been used prior to APC treatment Patients with coagulopathy do worse with APC unless the coagulopathy is corrected
Bipolar or Heater probe	Provides controlled coagulation by a applying a heater probe to site of bleeding.	May be used alone or in combination with other modalities for control of LGIB due to a variety of causes.	Failure to control bleeding Thermal necrosis and recurrent bleeding (eg, at polypectomy site). Perforation	Bipolar or heater probe coagulation is safe and effective in treating angiodysplasia and post-polypectomy bleeding. Can be applied to other conditions as deemed appropriate by the endoscopist.
Endoloops and hemoclips	Mechanical hemostasis is achieved by direct application of an endoloop or hemoclip.	To stop bleeding from the pedicle of a resected pedunculated polyp or from a diverticulum.	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. Massive postpolypectomy bleeding has been successfully managed with band ligation. If a bleeding vessel has been identified, a hemoclip can be used to occlude the vessel.
Interventional radiology	Interventional radiography entails angiography and super selective arterial embolization with various agents (gelatin sponge, microcoils, polyvinyl alcohol particles, and balloons) Uses a microcatheter that is passed co-axially through a main angiographic catheter to facilitate passage into smaller vessels 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 It is also indicated in persistent or recurrent bleeding and in situations in which colonoscopy has failed to identify the source of bleeding	Bowel infarction, arterial thrombosis, embolization to a nontarget site, and renal failure. Complications occur in approximately 9% of patients. 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%.	Angiographic arterial embolization is a more definitive means of controlling hemorrhage than endoscopic methods 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 Sensitivity and specificity rates of 100% and 30% to 47%, respectively, have been quoted for determining the bleeding source with angiography 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