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 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.
  • 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.