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Lower GI bleeding therapy: the endoscopist

Lower GI bleeding therapy: the endoscopist. Giorgio Saracco, MD Dpt Gastroenterology Molinette Hospital, Turin. Radiation colitis. CMV colitis. Ischemic colitis. NSAIDs colitis. C. Difficile colitis. Salmonella colitis. Rectal ulcer. ULCERATIVE COLITIS. ENDOSCOPIC TREATMENTS.

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Lower GI bleeding therapy: the endoscopist

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  1. Lower GI bleeding therapy: the endoscopist Giorgio Saracco, MD Dpt Gastroenterology Molinette Hospital, Turin

  2. Radiation colitis CMV colitis Ischemic colitis NSAIDs colitis C. Difficile colitis Salmonella colitis Rectal ulcer

  3. ULCERATIVE COLITIS

  4. ENDOSCOPIC TREATMENTS • INJECTION (epinephrine, glue) • LASER • APC • HEATER PROBE • MONOPOLAR AND MULTIPOLAR ELECTROCOAGULATION • CLIPPING • BANDING

  5. DIVERTICULA • 3-5% of patients with diverticula show a LGI bleeding • most frequent cause of LGI bleeding (42-55%) • In 10-13% of cases, a recent stigmata of bleeding is found Prakash 1999

  6. DIVERTICULA • Active bleeding • Visible vessel • Adherent clot • Suspected diverticular bleeding • Casual discovery Jensen 2000

  7. DIVERTICULA Treatment • Active bleeding  epinephrine injection • Visible vessel  bipolar electrocoagulation • Adherent clot  epinephrine injection + clot removal + bipolar electrocoagulation Jensen 2000

  8. DIVERTICULA Therapeutic alternatives • Epinephrine + heater probe/ ND-yag laser Prakash 1999 • Banding Witte 2000 • Clipping Hakama 1997

  9. ANGIODYSPLASIA • 3-12% of LGI bleeding • Epinephrine injection + polidocanol Jaapersen 1994 • APC Grund-Zambelli 2002

  10. APC AND ANGIODYSPLASIA Efficacy of APC Success: no additional treatment Partial success: markedly reduced need of blood transfusion Warnings: power setting 40W and argon flow 2l/min microperforation 33% 67%

  11. POST POLYPECTOMY BLEEDING • 2-6% of LGI bleeding Richter 1995 • 2-3% of patients undergoing polypectomy show a clinically evident bleeding McRae 1983 Gilbert 1984 • 0.2-0.6% of them need hospital staying

  12. RISK OF BLEEDING AFTER ENDOSCOPIC POLYPECTOMY IN PATIENTS TAKING ASA OR OTHER NSAIDS Shiffman et al GIE 1994

  13. SALINE vs EPINEPHRINEReview of the literature

  14. PROPHILACTIC CLIP APPLICATION DOES NOT DECREASE DELAYED BLEEDING AFTER POLYPECTOMY (RCT) Shioji et al. GIE 2003

  15. POST POLYPECTOMY BLEEDING Treatment • Clipping • APC + epinephrine injection • APC alone • Epinephrine alone • Endoloop

  16. INTERNAL HEMORRHOIDS • 2-9% of LGI bleedings • Banding • success rate: 80% if medium size 54 % if large size Berkelhamer 2002 • Anedoctal reports with N-2-butyl cyanoacrilate injection Chen 2000

  17. BLEEDING FROM COLON CARCINOMA • Nd-yag laser

  18. RADIATION PROCTITIS • Treatment of choice: APC 98% Venkatesh 2002 96% Villavicencio 2002 92% Tjandra 2001 • Alternative: cryotherapy (1-6 sessions) 100% Kantesevoy 2003

  19. DIEULAFOY LESION • BANDING Mizukami 2002

  20. CONCLUSIONS I • Management of LGI bleeding begins with development of a differential diagnosis • The source of bleeding cannot be definitively identified in up to 25% of patients • Timing of colonoscopy still controversial

  21. CONCLUSIONS II • Methods of hemostatic therapy include injection, heater probe, electrocoagulation, clipping, APC • Data on the effectiveness of endoscopic therapy are limited….”but the global experience suggests that there is likely to be benefit” (Rockey, Gastroenterology 2006)

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