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* 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
* 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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=== 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}}

Revision as of 18:47, 15 December 2017

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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 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

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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