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Create a Free AccountProcedures - Hemostasis of GI bleeding
Modification of the endoscopic hemostatic powder application technique
EndoClot Polysaccharide Hemostatic System (EndoClot PHS; Micro-Tech Europe, Dusseldorf, Germany) is a starch-derived compound that consists of biocompatible absorbable hemostatic polysaccharides that absorb water when in contact with blood or liquids, creating a gelled matrix over the bleeding lesion. It also accelerates the in situ coagulation process through hyperconcentration of platelets and coagulation factors.1 Hemostatic powders are considered an endoscopic hemostatic option for upper and lower nonvariceal bleeding, which are easy to use and have a good safety profile.Novel simulator of endoscopic hemostasis with actual endoscope and devices
Endoscopic hemostasis is an essential skill for endoscopists and has been the first-line treatment.1 For example, we reported that 70% of bleeding ulcers were treated with endoscopic hemostasis.2 Endoscopic hemostasis, similar to most techniques, is currently acquired through on-the-job training with real patients. However, such high-risk situations are not preferable for trainees. To perform a hemostatic procedure safely, the operator needs skills such as maintaining an appropriate view, stabilizing the scope, and controlling hemostatic devices precisely.Use of helical tack system for management of a high-risk fibrotic peptic ulcer
GI bleeding because of peptic ulcer disease is a well-described entity in its diagnosis and management. Although hemostatic clips and thermal therapy have been the primary tools in bleeding from peptic ulcer disease, some bleeds remain refractory. New data have shown that obliteration of the underlying arterial blood flow is needed to control refractory peptic ulcer bleeding. Although this has been shown with over-the-scope clips, we present a case where GI bleeding is controlled via a helical tack system.Endoscopic ultrasound–guided embolization of refractory splenic pseudoaneurysm
Visceral arterial pseudoaneurysms are common sequelae of chronic pancreatitis, occurring in 10% of patients, and carry a non-negligible 50% risk of rupture and 14% to 50% mortality with rupture.1-4 Transcatheter arterial embolization (TAE) is an effective modality for treatment of visceral arterial pseudoaneurysms with high technical and clinical success rates (97%-100% and 94%-100%, respectively) but a variable adverse event rate of splenic infarction of 6% to 24%.1-4 However, in cases refractory to TAE, EUS embolization approaches have demonstrated clinical efficacy, with studies demonstrating up to 100% technical and clinical success in this setting when using thrombin or cyanoacrylate glue.The use of water immersion technique during device-assisted (single-balloon) enteroscopy to treat actively bleeding jejunal Dieulafoy's lesion
Dieulafoy’s lesion (DL) is an uncommon but potentially life-threatening condition, which can result in sudden, massive gastrointestinal bleeding. The water immersion technique can be helpful in localizing the source of active bleeding during an endoscopy. Herein, we present a case of gastrointestinal bleeding due to jejunal DL found on a video capsule endoscopy (VCE). We describe the use of the water immersion technique in localization and treatment of actively bleeding DL during single-balloon enteroscopy.Utility of red dichromatic imaging for identifying the bleeding point in endoscopic hemostasis of colonic diverticular bleeding
An 82-year-old woman was admitted to our hospital because of hematochezia without pain. She had been admitted to our hospital several times in the previous year for colonic diverticular bleeding (CDB) and had already undergone multiple hemostatic treatments for the CDB. A previous plain computed tomography scan had showed multiple colonic diverticula in the ascending colon and sigmoid colon (Fig. 1), so recurrent colonic diverticular hemorrhage was the primary differential diagnosis.Cholangioscopic diagnosis of hemobilia: an unusual case of left hepatic portal hypertension by plasma cell tumor
Hemobilia refers to potentially life-threatening bleeding, of diverse causes, into the biliary tree. Digital direct cholangioscopy could be a useful tool to identify the source of biliary bleeding in cases in which it cannot be clarified by imaging modalities.Direct clipping using underwater inversion method for colonic diverticular bleeding
Colonic diverticular bleeding is the most common cause of acute lower GI bleeding, sometimes requiring hemostatic interventions, such as endoscopic hemostasis, transcatheter arterial embolization, and surgery. Recently, various methods have been developed to achieve endoscopic hemostasis for colonic diverticular bleeding.1 Endoscopic clipping is widely used because of its rare association with tissue damage and is classified as direct or indirect types. Direct clipping is performed on the exposed vessel in the diverticulum, whereas indirect clipping is performed to close the responsible diverticulum in a zipper fashion.Balloon tamponade for control of myotomy bleeding during peroral endoscopic myotomy
Peroral endoscopic myotomy has revolutionized the management of achalasia. Although capnoperitoneum or capnomediastinum are not uncommonly seen in the immediate postprocedure setting, severe adverse events such as perforation and bleeding requiring cessation of the procedure are rare. Individuals with a sigmoid-shaped esophagus are known to be at increased risk for adverse events. Minor bleeding is relatively common during submucosal tunneling and is treated easily using coagulation from the dissecting needle itself, cap tamponade, or coagulation forceps for larger vessels.Balloon-compression endoscopic injection sclerotherapy for the treatment of esophageal varices
Endoscopic injection sclerotherapy (EIS) is an effective therapeutic option for esophageal varices (EVs). However, the outflow of sclerosant impairs its effectiveness and increases the incidence of adverse events. Hence, we developed a novel EIS technique with compression by an inflated balloon. The present study reports a case of EVs treated with balloon-compression EIS (bc-EIS).The use of the cap and underwater technique as an aid in endoscopic diagnosis and treatment of upper gastrointestinal bleeding: case series
Upper GI bleeding (UGIB) is a medical emergency associated with elevated mortality and significant costs to the health care system. EGD is currently the method of choice for the diagnosis and management of these conditions. However, the location of bleeding lesions and technical difficulties in achieving endoscope stability may challenge even the most experienced endoscopists. Herein, we demonstrate the use of the cap and underwater technique as a helpful aid in these situations.A case of improved visibility with gel immersion in the presence of ongoing bleeding during colorectal endoscopic submucosal dissection
During endoscopic submucosal dissection (ESD), it is often difficult to secure a visual field in the presence of ongoing massive bleeding because water, which is injected through the accessory channel to wash out debris and blood clots, rapidly mixes with fresh blood in the lumen. Gel immersion is safe and effective for securing the visual field, creating a space for endoscopic visualization and treatment in patients with ongoing bleeding.1EUS-guided blood patch delivery during liver biopsy: nature’s gel foam
EUS-guided liver biopsy is emerging as an alternative form of tissue acquisition to percutaneous or interventional radiology–guided liver biopsy. Recent studies have shown adequate specimen acquisition and an enhanced safety profile. EUS-guided liver biopsy has been found to be extremely safe. The most common adverse events are mainly due to bleeding events. Unfortunately, there are limited endoscopic interventions available to prevent bleeding during liver biopsy.Bone wax-tipped catheter and 3-way stopcock to optimize hemostatic powder deployment
TC-325 Hemospray (Cook Medical, Winston-Salem, NC, USA) is a highly absorptive mineral powder used for endoscopic hemostasis in the setting of nonvariceal upper GI bleeding. The hemostatic powder is propelled by compressed CO2 through either a 7F or 10F catheter inserted through the working channel of the endoscope.Endoscopic hemostatic spray for uncontrolled bleeding after complicated endoscopic mucosal resection or endoscopic submucosal dissection: a report of 2 cases
There is a significant bleeding risk after gastric endoscopic submucosal dissection (ESD) and EMR cases. This case series describes the use of an endoscopic hemostasis spray, which is not typically used to treat this type of bleeding, after multiple attempts with other modalities failed.Successful hemostasis for refractory colonic diverticulum bleeding by clipping with polyglycolic acid sheets
There are various methods of achieving endoscopic hemostasis for diverticular hemorrhage, such as endoscopic clipping1-3 and band ligation.3-6 Endoscopic clipping is the most commonly used method. However, direct placement of the hemoclips on the bleeding site is often challenging, and inadequate clipping may lead to early recurrent bleeding. Generally, it is easy to directly place the hemoclips on the exposed vessel when it is visible at the neck of the diverticulum (Fig. 1A). However, it is difficult to directly place the hemoclips on the exposed vessel when it is located at the dome and the diverticular orifice is small (Fig. 1B).Endoscopic resection of large Paris 0-Ip pedunculated polyps: video demonstration of recent U.S. Multi-Society Task Force recommendations on resection and removal for general endoscopists
Large pedunculated polyps have several unique features that contribute to the complexity of their removal. Pedunculated polyps typically have larger feeding blood vessels in their stalk, which increases the risk of immediate and delayed postpolypectomy bleeding. In addition, maneuvering instruments around the head of very large polyps can be difficult within the confined space of the colon lumen. The 2020 U.S. Multi-Society Task Force Recommendations on the Endoscopic Removal of Colorectal Lesions have offered best practice recommendations on the resection and removal of pedunculated lesions.Novel approaches to minimize intraoperative bleeding during endoscopic submucosal dissection of a large rectal lateral spreading tumor extended to the dentate line with internal hemorrhoids
Endoscopic treatment of rectal lateral spreading tumors (LSTs) extending to the dentate line with hemorrhoids is a challenging procedure because of the risk of bleeding and the reduced visual field caused by the dilated venous packages and the narrow anal lumen. Although a few Japanese reports have described the safety and efficacy of endoscopic submucosal dissection (ESD) for these tumors,1,2 technical approaches to reduce intraoperative bleeding are not fully described. We present a successful ESD of a large rectal LST that extended to the dentate line with large internal hemorrhoids and describe novel approaches to minimize intraoperative bleeding.Active bleeding from downhill varices: case report and management
Proximal esophageal varices, or downhill varices, develop in the setting of venous hypertension of the superior systemic circulation, commonly because of superior vena cava (SVC) obstruction. They are named based on their cephalad-to-caudal direction of blood flow. The incidence of downhill varices is low (0.5%), and they account for 0.4% to 10% of all acute esophageal variceal bleeding.Hemostasis of an actively bleeding lesion at the ileocecal valve by low-pressure endoscopy using the gel immersion technique
In emergency endoscopy for GI bleeding or colonoscopy without preparation, the visual field can become obscured. The water immersion method is often used, but it is difficult to secure the visual field because the injected water rapidly mixes with blood or stool. Excessive insufflation, especially in the large intestine, may make insertion of the endoscope difficult. In such a situation, gel immersion endoscopy is very effective (Video 1, available online at www.VideoGIE.org ).1Red dichromatic imaging in peroral endoscopic myotomy: a novel image-enhancing technique
A 40-year-old man presented with a 1-year history of difficulty in swallowing liquids and solids. His Eckhart’s score was 6 of 12. EGD showed dilated esophagus with liquid stasis and mild resistance noted across the gastroesophageal junction. Esophageal manometry showed elevated integrated relaxation pressure with panesophageal pressurization (achalasia cardia type II). Peroral endoscopic myotomy (POEM) was planned and was performed using the novel Evis X1 endoscopy (Olympus Corporation, Tokyo, Japan) system.EUS-guided coiling and cyanoacrylate injection of ectopic duodenal varices
Duodenal varices due to significant portal hypertension are considered ectopic and are less common than esophageal or gastric varices. Duodenal variceal bleeding is a rare cause of upper GI bleeding and carries a mortality rate of up to 40%.1,2 Current treatment methods include transjugular intrahepatic portosystemic shunt (TIPS) placement, balloon-occluded retrograde transvenous obliteration, and endoscopic interventions including band ligation or sclerotherapy. Coil embolization and cyanoacrylate injection via EUS have been previously reported for the treatment of ectopic varices.Endoscopic tamponade using a fully covered self-expandable metallic stent for massive biliary bleeding from a pseudoaneurysm rupture during metallic stent removal
Hemobilia is a rare but life-threatening adverse event related to pancreatobiliary diseases, transhepatic percutaneous intervention, or endoscopic procedures including ERCP and interventional EUS.1,2 The rupture of the pseudoaneurysm after plastic stent or self-expandable metallic stent (SEMS) insertion has been reported to induce massive hemobilia, which requires prompt transcatheter arterial embolization (TAE) for hemostasis.2,3 In addition, hemobilia has occurred after plastic stent removal, according to several previous reports.Hemostatic forceps used as a scissor-type knife in combination with the transanal-traction method for assisted endoscopic submucosal dissection in the area of the dentate line
Endoscopic submucosal dissection (ESD) of rectal lesions extending to the dentate line is technically challenging. Eastern experts have demonstrated the feasibility of polyp resection in this region using a traditional ESD technique that makes use of the tip-cutting knife.1 The scissor-type knife has also been demonstrated as an effective instrument to perform ESD on lesions in the anal region.2 ESD by hydrodissection is an effective treatment for colorectal polyps.3,4 The water-jet hydrodissection technique also has been shown to be effective in overcoming various difficult situations.A spiraling journey into the small bowel: a case series of novel motorized power spiral enteroscopies
The small bowel has, to date, remained a difficult area to access via endoscopy. The novel motorized power spiral enteroscopy, recently introduced, has more depth of insertion and is of shorter duration. Presented here is a case series of motorized spiral enteroscopies.
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