Endoscopic Treatment of Small Intestinal Bleeding

Various methods of endoscopic hemostasis have been developed for successful treatment of a variety of bleeding lesions in the gastrointestinal tract, including a peptic ulcer in the stomach and duodenum and angiodysplasia and diverticular hemorrhage in the large intestine. These successful endoscopic treatments obviate surgery in many patients, and endo-scopic hemostasis is one of the great achievements of therapeutic endoscopy. A variety of hemostatic techniques, including injection of ethanol or hypertonic saline, cauterization with an argon plasma coagulator (APC) or a heat probe, and hemostasis with a clip have been developed and put to practical use. They have led to the establishment of therapeutics involving the selection, indications, and techniques of treatments based on the pathological condition of the bleeding lesions. Although the principle of insertion differs between the double-balloon endoscope and conventional endoscopes, all hemostatic techniques used for conventional upper and lower endoscopy are applicable to treatment using the double-balloon endoscope. However, endoscopic hemostasis with the double-balloon endoscope requires consideration of three factors.

The first factor is the anatomical characteristics of the small intestine, and the second is the pathophysiology of the bleeding lesion(s) in the small intestine. The third factor is the limitation intrinsic to the endoscopic system, such as the EN-450P5 with a working length of 200 cm and a forceps channel diameter of 2.2 mm. This problem has been resolved by the treatment-type endoscope EN-450T5 with a 2.8-mm forceps channel.

Anatomically, the intestinal wall is thin. Particularly when thermocoagulation is chosen for hemostasis, then, the risk of perforation increases as coagulation depth increases. Because of limitations on the therapeutic devices that can be used with the EN-450P5, we used the tip of a snare to perform coagulation and hemostasis for the treatment of many bleeding lesions. In cases of bleeding from the center of tumors such as the gastrointestinal stromal tumor (GIST), adequate cauterization can be achieved with less consideration of coagulation depth. In cases of bleeding from angiodysplasia, saline is injected submucosal-ly under lesions to provide substantial mucosal elevation, and then hemostasis is performed with due attention given to the coagulation depth.

The second consideration is the pathophysiology of bleeding lesions in the small intestine. The usefulness of identifying an exposed vessel and the technique for accurate hemo-stasis of the exposed vessel have been demonstrated for peptic ulcers in the stomach and the duodenal bulb. Various conditions, such as Crohn's disease, Behcet's disease, and nonsteroidal antiinflammatory drug (NSAID) use, may induce ulceration in the small intestine. We rarely have identified and treated exposed vessels in patients with intestinal ulcers associated with these pathological conditions. However, intestinal Behcet's disease is often associated with deep ulcers, which can result in massive bleeding that necessitates emergency surgery. Similarly, Crohn's disease may lead to massive bleeding. Thus, treatment of ulcerative lesions requires the establishment of diagnostics to evaluate the depth and appearance of ulcers and to assess the bleeding risk, as well as therapeutic techniques for visible vessels if identified. Angiodysplasia tends to occur at multiple sites, and active bleeding found on examination is regarded as the source of bleeding. Otherwise, it cannot be determined whether the identified lesion is responsible for the bleeding. In those cases, lesions with or without active bleeding are cauterized when possible. Thus, it is necessary to establish safe, reliable therapeutic techniques taking into consideration the thinness of the small-intestinal wall, as described above. An APC probe is compatible with EN-450T5, and cauterization by APC can go mainstream as in the stomach and the large intestine. Bleeding lesions in the small intestine often occur at multiple sites, and well-planned enteroscopy is often needed to examine the entire small intestine.

The third consideration comprises the limitations intrinsic to the system, such as the EN-450P5 with a working length of 200 cm and a forceps channel diameter of 2.2 mm. We previously used the tip of a snare as a thermocoagulation device, but the development of APC probes has increased our options on therapeutic devices. The treatment-type endoscope EN-450T5 with a 2.8-mm forceps channel is now commercially available and allows the use of clips and hemostatic forceps. We take into consideration the risk of tissue injury and do not use ethanol or hypertonic saline in principle.


Tips for Tattooing with an Endoscope

Successful submucosal injection is difficult because an injection needle easily penetrates the muscle layer of the thin small-intestinal wall. If the India ink used for tattooing leaks into the lumen, visibility worsens. These problems may be solved by the following strategies. First, the injection needle is filled with physiological saline instead of India ink. After J physiological saline is injected to elevate the mucosa and the needle tip is securely placed in the submucosal layer, the syringe is replaced with another syringe filled with India ink, and the ink is then injected with the same needle tip. The injection needle is removed while slight negative pressure is applied to prevent leakage of India ink.

Saline injection and subsequent coagulation and hemostasis for the treatment of active bleeding from angiodysplasia in the small intestine (Figs. 11.2.1, 11.2.2).

Hemostatsis And Treatment
Fig. 11.2.1. Active bleeding from angiodysplasia Fig. 11.2.2. Hemostasis for angiodysplasia

Coagulation and hemostasis for the treatment of bleeding from a small-intestinal tumor (Figs. 11.2.3, 11.2.4).

Balloon Endoscopy
Fig. 11.2.3. Active bleeding from a small-intestin- Fig. 11.2.4. Hemostasis for the treatment of al tumor bleeding from a small-intestinal tumor

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