Endoscopic management of colonic diverticular bleeding

Colonic diverticular bleeding is the most common cause of lower gastrointestinal bleeding. Colonoscopy can be used for both diagnosis and treatment of colonic diverticular bleeding. Identification of the stigmata of recent hemorrhage allows for various endoscopic hemostasis methods. Clipping, endoscopic band ligation, injection therapy, and thermal contact are available methods for endoscopic hemostasis. However, the optimal technique remains to be determined. Herein, we review the techniques and clinical outcomes of endoscopic hemostasis for colonic diverticular bleeding.     

Case Report: Gastrointestinal bleeding from a hepatocellular carcinoma invading the transverse colon

A 72-year-old woman with cirrhosis of the liver was treated repeatedly by transcatheter arterial embolization for multifocal hepatocellular carcinomas. She developed gastrointestinal bleeding secondary to direct invasion of the wall of the transverse colon. The diagnosis was made pre-operatively by colonoscopy and the patient was treated successfully. This rare complication of hepatocellular carcinoma was due to the protrusive type of growth exhibited by this tumour and may have been affected by the transcatheter arterial embolization.     

Massive bleeding from a duodenal diverticulum successfully treated with transarterial embolization and endoscopic coagulation

Duodenal diverticula are common in adults, but are usually asymptomatic. Massive hemorrhage is a rare, but potentially lethal, complication that can be difficult to diagnose and treat. A 21‐year‐old woman was referred with duodenal hemorrhage of uncertain origin. Endoscopy revealed a duodenal diverticulum, but a discrete bleeding source was not identified. Transarterial embolization via the posterior pancreaticoduodenal artery decreased bleeding to where endoscopic electrocoagulation could be used effectively to stop all blood loss. Initial management of duodenal diverticular hemorrhage should be endoscopic. If unsuccessful, transarterial embolization should be attempted. When bleeding is slowed, but not arrested completely by embolization, endoscopic coagulation should be attempted again before surgery is undertaken. Advances in endoscopic hemostasis and angiography allow patients with bleeding duodenal diverticula to be managed non‐operatively in some cases.     

Endoscopic management of upper gastrointestinal bleeding from a duodenal diverticulum

Hemorrhage from duodenal diverticulum is a rare cause of upper gastrointestinal hemorrhage. The side-viewing endoscope was used for almost all cases of diagnosis and endoscopic hemostasis. However, a forward-viewing endoscope is used in emergent endoscopic study for upper gastrointestinal hemorrhage. We report a case in which the endoscopic hemostasis of bleeding duodenal diverticulum was performed during emergent forward-viewing endoscopic study.     

肝硬化合并贲门区曲张静脉破裂出血134例内镜诊疗分析

目的回顾性分析急诊内镜治疗肝硬化合并贲门区曲张静脉破裂出血的疗效。方法以内镜下硬化术、套扎术和组织粘合剂栓塞术等手段治疗134例肝硬化合并贲门区曲张静脉破裂出血。结果 134例中,121例(90.3%)止血成功,内镜下硬化术和组织粘合剂栓塞术的止血率分别为89.8%和95.8%。死亡4例,72 h内病死率为4.5%,原因为失血性休克、肝性脑病和多脏器功能衰竭。胃镜操作过程中未见死亡病例。结论肝硬化合并贲门区曲张静脉破裂出血,以内镜下硬化术和栓塞术治疗可获得较好的近期效果。     

Endoscopic injection sclerotherapy of bleeding duodenal varices

Bleeding from duodenal varices is a rare finding in patients with liver cirrhosis. We report a 43 year old male with alcoholic liver cirrhosis who presented with upper gastrointestinal bleeding. Panendoscopy identified prominent tortuous varices over the second portion of duodenum with spurting of blood. At first, the varices were treated successfully with sodium tetradecyl sulfate and bleeding stopped. Consequent endoscopic sclerotherapy was done 1 week later. The varices almost disappeared 2 weeks after the second endoscopic sclerotherapy and the patient was in good condition following this.     

Role of endoscopy in the management of acute diverticular bleeding

Colonic diverticulosis is one of the most common causes of lower gastrointestinal bleeding. Endoscopy is not only a useful diagnostic tool for localizing the bleeding site, but also a therapeutic modality for its management. To date, haemostatic methods have included adrenaline injection, mechanical clipping, thermal and electrical coagulation or combinations of them. The results of all published data are herein reviewed.     

Large-volume endoscopic injection of epinephrine plus normal saline for peptic ulcer bleeding

BACKGROUND AND AIM: Large-volume endoscopic injection of epinephrine has been proven to significantly reduce rates of recurrent peptic ulcer bleeding. Injection of normal saline may be equally effective for the similar hemostatic effect of local tamponade. The aim of our study was to compare the therapeutic effects of large-volume (40 mL) endoscopic injections of epinephrine, normal saline and a combination of the two in patients with active bleeding ulcers. METHOD: A total of 216 patients with actively bleeding ulcers (spurting or oozing) were randomly assigned to three groups (1:10,000 epinephrine, normal saline or diluted epinephrine plus normal saline). The hemostatic effects and clinical outcomes were compared between the three groups. RESULTS: The initial hemostatic rate was significantly lower in the normal saline group (P < 0.05). The volume of injected solution required for the arrest of bleeding was significantly larger in the normal saline group (P < 0.01). Mean duration for arrest of bleeding was significantly longer in the normal saline group (P < 0.01). There were no significant differences between the three groups with respect to the rates of recurrent bleeding, surgical intervention, 30-day mortality, amount of transfusion and duration of hospitalization. Significant elevation of systolic blood pressure (P < 0.05) and persistent high pulse rate after endoscopic injection were observed in the epinephrine group. CONCLUSIONS: For patients with active bleeding ulcers (spurting or oozing), we recommend a large-volume (40 mL) combination injection using diluted epinephrine to cease bleeding, followed by injection of normal saline to achieve sustained hemostasis.     

Endoscopic management of acute esophageal variceal bleeding

Esophageal varices develop in the setting of portal hypertension, most commonly caused by cirrhosis. Esophagogastroduodenoscopy is considered the gold standard for both diagnosis and treatment of acute variceal bleeding. In this review, we highlight the management of both acute and refractory bleeding from esophageal varices, with an emphasis on endoscopic therapies, including injection sclerotherapy, band ligation, and esophageal stent placement.     

Efficacy of transcatheter arterial embolization for first-line treatment of colonic diverticular bleeding with extravasation on contrast-enhanced computed tomography

Colonic diverticular bleeding (CDB) is the most frequent cause of acute lower gastrointestinal bleeding. The aim of this study was to evaluate the efficacy and safety of transcatheter arterial embolization (TAE) for CDB as first-line treatment with extravasation on contrast-enhanced computed tomography (CECT), compared with endoscopic hemostasis. Three Japanese institutions participated in this retrospective cohort study. Data from consecutive patients admitted with a diagnosis of CDB with extravasation on CECT were reviewed. One hospital performed TAE and the others conducted urgent colonoscopy (CS) as the first-line treatment for CDB with extravasation on CECT. The primary outcome was rebleeding rate within 30 days after first-line treatment. In total, 165 CDB cases with extravasation on CECT (TAE group, n = 39; CS group, n = 126) were analyzed in this study. The rebleeding rate within 30 days was significantly lower in the TAE group (7.69%) than in the CS group (23.02%; P = .038). The bleeding point detection rate was significantly higher in the TAE group (89.74%, 35/39) than in the CS group (37.30%, 47/126; P < .0001). Even in those cases in which a bleeding point was detected, the rebleeding rate was significantly lower in the TAE group (0%) than in the endoscopic hemostasis-success group (23.91%; P = .005). No severe complications of Grade 3 or more were seen with TAE. We showed that TAE is an effective, safe hemostatic method, and a useful alternative to endoscopic hemostasis for first-line treatment of CDB.     

Management of duodenal ulcer bleeding resistant to endoscopy:Surgery is dead!

Acute massive duodenal bleeding is one of the most frequent complications of peptic ulcer disease.Endoscopy is the first-line method for diagnosing and treating actively bleeding peptic ulcers because its success rate is high.Of the small group of patients whose bleeding fails to respond to endoscopic therapy,increasingly the majority is referred for embolotherapy.Indeed,advances in catheter-based techniques and newer embolic agents,as well as recognition of the effectiveness of minimally invasive treatment options,have expanded the role of interventional radiology in the management of hemorrhage from peptic ulcers over the past decade.Embolization may be effective for even the most gravely ill patients for whom surgery is not a viable option,even when extravasation is not visualized by angiography.However,it seems that careful selection of the embolic agents according to the bleeding vessel may play a role in a successful outcome.The role of the surgeon in this clinical sphere is dramatically diminishing and will certainly continue to diminish in ensuing years,surgery being typically reserved for patients whose bleeding failed to respond all previous treatments.Such a setting has become extremely rare.     

十二指肠静脉曲张内镜诊治方法研究

目的探讨十二指肠静脉曲张内镜下诊断及治疗方法。方法对2000年11月至2008年8月93283例内镜检查发现的26例十二指肠静脉曲张的内镜下表现,采用位置（L）、直径（D）、危险因素（跗）即LDRf分型方法进行分型,观察依照分型对十二指肠静脉曲张治疗的效果,并进行随访。结果内镜下分型：Ld1 5例（19．2％）,Ld1.2 22例（7．7％）,Ld2 19例（73．1％）;D。0例,D0.5 2例,D1 10例,D2 13例,D3 1例;Rf0 23例,Rf1 0例,Rf2 3例。其中伴食管及（或）胃底静脉曲张18例。17例住院患者中乙型肝炎肝硬化9例（52．9％）。对其中的3例Rf2患者行内镜下治疗,1例活动出血者（Ld：D,Rf2）行组织粘合剂治疗后即刻止血,1例（Ld2D2Rf2）行组织粘合剂治疗,另1例患者（Ld2D1Rf2）进行了套扎治疗,随后进行了平均14．6个月的随访,3例患者在治疗后1．0～3．5个月内静脉曲张消失,且无复发;其余患者未行内镜治疗,对其中11例进行随访,未发现静脉曲张出血,有2例患者因其他原因死亡。结论LDRf内镜下分型能基本反映十二指肠静脉曲张的内镜特点,依照该分型选择十二指肠静脉曲张内镜治疗方法是安全可行的。