| Surgical options
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Procedure
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Indications
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Complications
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Comments
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| Endoscopic Intervention
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- 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.
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- All cases of gastrointestinal bleeding.
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- Perforation of the luminal wall, resulting in peritonitis and sepsis.
- Failure to control bleeding.
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- Most direct and effective approach.
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| Argon plasma coagulation
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- Argon plasma coagulation uses ionized 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
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- 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.
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- 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
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| Bipolar or Heater probe
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- Provides controlled coagulation by a applying a heater probe 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.
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- Failure to control bleeding
- Thermal necrosis and recurrent bleeding (eg, at polypectomy site).
- Perforation
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- 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.
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| Endoloops and hemoclips
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- Mechanical hemostasis is achieved by direct application of an endoloop or hemoclip.
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- To stop bleeding from the pedicle of a resected pedunculated polyp or from a diverticulum.
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- 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
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- 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.
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| Interventional radiology
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- 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.
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- 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
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- 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%.
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- 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
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