Hemostatic bitherapy for spurting bleeding

Konstantinos H. Katsanos, Dimitrios E. Sigounas, Dimitrios K. Christodoulou,
Epameinondas V. Tsianos

University Hospital of Ioannina, Greece

1^st Department of Internal Medicine & Hepato-Gastroenterology Unit, University Hospital of Ioannina, Greece

Conflict of Interest: None

Correspondence to: Prof. Epameinondas V. Tsianos, MD, PhD, AGAF, Professor of Internal Medicine, Department of Internal Medicine, Medical School, University of Ioannina, Leoforos Panepistimiou, 45 110 Ioannina, Greece
Tel:+30-26510-07501, Fax:+30-26510-07016,
e-mail: etsianos@uoi.gr

Received 7 December 2011; accepted 2 January 2012

Endoscopic clipping is an easy and effective technique for the treatment of various bleeding lesions in the upper and lower gastrointestinal tract. Several studies have shown comparable efficacy between clipping and contact thermal therapy for hemostasis of non-variceal upper gastrointestinal hemorrhage. Proficiency in clip application and endoscopic identification of lesions that are amenable to clipping are basic determinants of successful hemostasis [1]. In recent years, endoscopic hemostatic bitherapy (adrenaline injection plus clipping or bipolar coagulation) replaced monotherapy with injection of adrenaline for hemostasis [2].

The patient presented herein was scoped on emergency due to massive hematemesis. Patient had a history of Billroth type II operation 20 years ago and no obvious triggering factor for this acute bleeding. On endoscopy a blood jet was identified at the gastrointestinal anastomosis. The bleeding jet was successfully treated with adrenaline injection and clipping (Fig. 1) and the patient recovered smoothly with no need of further intervention.

In spurting bleedings clinical experience shows that multiple clips are frequently necessary and hemostasis may require up to 6 clips for each bleeding location. Various types of hemostatic clips are available. In a study with a reloadable clipping device, on average 5 clips (range 1-6) were used. Sequential application of multiple hemoclips had an increasing effect. Of interest, the number of hemoclips applied correlated inversely, but not significantly, with the endoscopist´s experience [3].

A meta-analysis of more than 1,000 patients in 15 studies showed that successful application of hemoclips is superior to injection alone but comparable to thermocoagulation in producing definitive hemostasis. There was no difference in all-cause mortality irrespective of the modalities of endoscopic treatment [4].

References

1. Anastassiades CP, Baron TH, Wong Kee Song LM. Endoscopic clipping for the management of gastrointestinal bleeding. Nat Clin Pract Gastroenterol Hepatol 2008;5:559-568.

2. Sporea I, Lazăr D, Popescu A, et al. Peptic upper gastrointestinal bleeding: diagnosis and treatment. A monocentric experience on a 5 years period. Rom J Intern Med 2009;47:347-354.

3. Ende A, Zopf Y, Heide R, et al. Hemodynamic efficacy of sequential hemoclip application using the Olympus HX-110/610 reloadable clipping device in spurting bleedings. Med Sci Monit 2011;17:1-6

4. Sung JJY, Tsoi KKF, Lai LH, Wu JCY, Lau JYW. Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis Gut 2007;56:1364-1373.