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Efficacy of Combination Therapy with Epinephrine Local Injection and Hemostatic Clips on Active Diverticular Bleeding. J Clin Med 2022; 11:jcm11175195. [PMID: 36079125 PMCID: PMC9457277 DOI: 10.3390/jcm11175195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022] Open
Abstract
Epinephrine local injection is a hemostatic procedure used in active diverticular bleeding that elicits vasoconstriction and tamponade effects. We compared the additional benefit of combination therapy with HSE-C (hypertonic saline epinephrine injection with clipping) to clipping monotherapy. Retrospective data on diverticular bleeding between 2011 and 2016 was reviewed. Those with an active bleeding source confirmed by colonoscopy (excluding non-bleeding vessels and adherent clots) who received either HSE-C or clipping were evaluated. Endpoints were rates of successful primary hemostasis, recurrent bleeding, and surgical intervention during hospitalization. A total of 320 patients with diverticular bleeding were evaluated, on which either HSE-C (n = 35) or clipping monotherapy (n = 18) was performed. Rates of successful primary hemostasis (91.4% vs. 66.7%, p = 0.048) and direct placement of endoclips (60.0% vs. 16.7%, p = 0.004) were significantly higher in the HSE-C group. Although not statistically significant, the HSE-C group had a higher rate of early rebleeding (18.8% vs. 8.3%, p = 0.653), while no difference was seen in the number of patients requiring surgery (11.4% vs. 5.5%, p = 0.651). HSE-C is associated with a higher rate of successful primary hemostasis for severe active diverticular bleeding but has no significant difference in reducing early recurrent bleeding or the number of patients requiring surgery, suggesting that hemostatic effects may be temporary.
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Lamonaca L, Auriemma F, Paduano D, Bianchetti M, Spatola F, Galtieri P, Maselli R, Repici A, Mangiavillano B. Rectal band ligation as a treatment for chronic radiation proctitis: a feasibility study. Endosc Int Open 2022; 10:E787-E790. [PMID: 35692922 PMCID: PMC9187420 DOI: 10.1055/a-1821-0776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 04/06/2022] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Chronic radiation proctitis (CRP) occurs in 5 % to 20 % of patients undergoing pelvic radiation therapy and frequently manifests with rectal bleeding. Endoscopic management of more severe and refractory cases can be challenging. Rectal band ligation (RBL) has been shown to be a feasible alternative to current available techniques, especially in extensive CRP. Our aim is to evaluate clinical and technical success of RBL. Patients and methods We enrolled all consecutive patients treated with RBL for severe or recurrent hemorrhagic CRP. Success was defined as endoscopic evidence of complete rectal healing and/or cessation of bleeding not requiring further treatment or blood transfusion. Results We enrolled 10 patients (7 males, mean age 75.6 years). Median length of the CRP from the anal verge was 4.5 cm and mean surface area involved was 89 %. Eight patients (80 %) were naïve to endoscopic treatment, while two had undergone argon plasma coagulation (APC). Median follow-up was 136.5 days. Success was achieved in 100 % of patients after a mean number of 1.8 RBL sessions. A mean number of 4.7 bands were released in the first session while a mean of 3.1 and 2 bands were placed in the second and third sessions, respectively. As for adverse events, only one patient reported mild tenesmus and pelvic pain after the procedure. Conclusions RBL is a safe and effective therapeutic modality for the treatment of hemorrhagic CRP. It could be considered a valid first-line option in case of extensive rectal involvement as well as a viable rescue treatment after failed APC.
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Affiliation(s)
- Laura Lamonaca
- Gastrointestinal Endoscopy Unit – Humanitas Mater Domini, Castellanza (VA), Italy
| | - Francesco Auriemma
- Gastrointestinal Endoscopy Unit – Humanitas Mater Domini, Castellanza (VA), Italy
| | - Danilo Paduano
- Gastrointestinal Endoscopy Unit – Humanitas Mater Domini, Castellanza (VA), Italy
| | - Mario Bianchetti
- Gastrointestinal Endoscopy Unit – Humanitas Mater Domini, Castellanza (VA), Italy
| | - Federica Spatola
- Gastrointestinal Endoscopy Unit – Humanitas Mater Domini, Castellanza (VA), Italy
| | - Piera Galtieri
- Humanitas Clinical and Research Center IRCCS, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (MI), Italy
| | - Roberta Maselli
- Humanitas Clinical and Research Center IRCCS, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (MI), Italy
| | - Alessandro Repici
- Humanitas Clinical and Research Center IRCCS, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (MI), Italy,Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Milan, Italy
| | - Benedetto Mangiavillano
- Gastrointestinal Endoscopy Unit – Humanitas Mater Domini, Castellanza (VA), Italy,Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Milan, Italy
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Cañamares-Orbís P, Lanas Arbeloa Á. New Trends and Advances in Non-Variceal Gastrointestinal Bleeding-Series II. J Clin Med 2021; 10:3045. [PMID: 34300211 PMCID: PMC8303152 DOI: 10.3390/jcm10143045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022] Open
Abstract
The gastrointestinal tract is a long tubular structure wherein any point in the mucosa along its entire length could be the source of a hemorrhage. Upper (esophagel and gastroduodenal) and lower (jejunum, ileum, and colon) gastrointestinal bleeding are common. Gastroduodenal and colonic bleeding are more frequent than bleeding from the small bowel, but nowadays the entire gastrointestinal tract can be explored endoscopically and bleeding lesions can be locally treated successfully to stop or prevent further bleeding. The extensive use of antiplatelet and anticoagulants drugs in cardiovascular patients is, at least in part, the cause of the increasing number of patients suffering from gastrointestinal bleeding. Patients with these conditions are usually older and more fragile because of their comorbidities. The correct management of antithrombotic drugs in cases of gastrointestinal bleeding is essential for a successful outcome for patients. The influence of the microbiome in the pathogenesis of small bowel bleeding is an example of the new data that are emerging as potential therapeutic target for bleeding prevention. This text summarizes the latest research and advances in all forms of acute gastrointestinal bleeding (i.e., upper, small bowel and lower). Diagnosis is approached, and medical, endoscopic or antithrombotic management are discussed in the text in an accessible and comprehensible way.
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Affiliation(s)
- Pablo Cañamares-Orbís
- Gastroenterology, Hepatology and Nutrition Unit, San Jorge University Hospital, 22004 Huesca, Spain
| | - Ángel Lanas Arbeloa
- IIS Aragón, CIBERehd, 50009 Zaragoza, Spain;
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, 50009 Zaragoza, Spain
- University of Zaragoza, 500009 Zaragoza, Spain
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Yamauchi A, Kou T, Kishimoto T, Mori Y, Osawa K, Iimori K, Iwano K, Kawai Y, Sawada K, Hamada K, Nishimura S, Mori Y, Watanabe K, Azuma S, Morita T, Kurita A, Kawaguchi K, Suginoshita Y, Katayama T, Yazumi S. Risk factor analysis for early rebleeding after endoscopic treatment for colonic diverticular bleeding with stigmata of recent hemorrhage. JGH OPEN 2021; 5:573-579. [PMID: 34013057 PMCID: PMC8114991 DOI: 10.1002/jgh3.12535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/17/2021] [Accepted: 03/18/2021] [Indexed: 11/11/2022]
Abstract
Background and Aim Colonic diverticular bleeding is a common cause of acute lower gastrointestinal bleeding. Endoscopic hemostasis is generally selected as the first-line treatment; however, a considerable number of patients experience early rebleeding after endoscopic treatment. We investigated the risk factors for early rebleeding after endoscopic treatment. Methods We retrospectively evaluated the data of 142 consecutive patients who underwent endoscopic treatment (endoscopic clipping or endoscopic band ligation) for colonic diverticular bleeding with stigmata of recent hemorrhage between April 2012 and April 2020. Multivariate logistic regression analysis was conducted to evaluate the statistical relationship between patient characteristics and the incidence of early rebleeding occurring within 30 days after endoscopic treatment. Results Of 142 patients, early rebleeding was detected in 34 (23.9%) patients. According to univariate analysis, platelet count of <10 × 104/μL, bleeding from the left-sided colon, and endoscopic clipping usage were associated with early rebleeding (P < 0.05). The subsequent multivariate logistic regression analysis identified bleeding from the left-sided colon (odds ratio [OR], 4.16; 95% confidence interval [CI], 1.73-10.0; P = 0.001) and endoscopic clipping usage (OR, 2.92; 95% CI, 1.21-7.00; P = 0.017) as the independent risk factors for early rebleeding. Conclusions Bleeding from the left-sided colon and endoscopic clipping usage were the risk factors for early rebleeding after endoscopic treatment. Using endoscopic band ligation was associated with a decreased risk for early rebleeding compared with the use of endoscopic clipping, indicating that endoscopic band ligation was a preferable endoscopic modality to prevent early recurrent bleeding.
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Affiliation(s)
- Atsushi Yamauchi
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Tadayuki Kou
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Takuya Kishimoto
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Yuki Mori
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Kazuki Osawa
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Kei Iimori
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Kosuke Iwano
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Yuya Kawai
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Kenji Sawada
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Kensuke Hamada
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Satoshi Nishimura
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Yoshiharu Mori
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Kotaro Watanabe
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Shunjiro Azuma
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Toshihiro Morita
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Akira Kurita
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Kiyotaka Kawaguchi
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Yoshiki Suginoshita
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
| | - Toshiro Katayama
- Department of Medical Engineering, Faculty of Health Science Morinomiya University of Medical Sciences Osaka Japan
| | - Shujiro Yazumi
- Department of Gastroenterology and Hepatology Tazuke Kofukai Medical Research Institute, Kitano Hospital Osaka Japan
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Okamoto T, Takasu A, Yoshimoto T, Yamamoto K, Shiratori Y, Ikeya T, Fukuda K. Digital compression for hemostasis in acute hemorrhagic rectal ulcer: a report of 4 cases and review of the literature. Clin J Gastroenterol 2021; 14:796-804. [PMID: 33550538 DOI: 10.1007/s12328-021-01353-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Abstract
Acute hemorrhagic rectal ulcer is a relatively rare cause of lower gastrointestinal bleeding. It most commonly occurs in bedridden elderly patients with multiple comorbidities. While the diagnosis can be confirmed on colonoscopy, achieving hemostasis may be difficult due to the poor visual field resulting from severe bleeding and stool remaining in the rectum, the stiffness of ulcers which may preclude effective clipping, the poor tolerability of patients for the procedure, and high risk of recurrence. Here, we present 4 cases of acute hemorrhagic rectal ulcer, where hemostasis could not be achieved through traditional methods. In each case, the assistant introduced his finger into the rectal lumen and digitally compressed the bleeding vessel under endoscopic guidance. Once hemostasis was achieved, the responsible vessel could be visualized and traditional hemostatic measures were taken. No recurrence was observed in any of the cases during follow-up. This simple maneuver can be applied safely and effectively even by assistants attempting the maneuver for the first time. The technique was effective with the endoscope in retroflexed position and could be combined with gel immersion endoscopy to first identify the location of hemorrhage. We also review the existing literature on acute hemorrhagic rectal ulcers.
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Affiliation(s)
- Takeshi Okamoto
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan.
| | - Ayaka Takasu
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Takaaki Yoshimoto
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Kazuki Yamamoto
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Yasutoshi Shiratori
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Katsuyuki Fukuda
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
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