Hemostatic Clipping
Hemoclips have been used to treat a variety of upper GI bleeding conditions including: peptic ulcers, Mallory-Weiss tears, Dieulafoy lesions, gastric angiectasias, gastric tumors, and following polypectomy, sphincterotomy, and biopsy. Hemoclips have been used to treat a variety of lower GI bleeding conditions including: diverticula, hemorroids, solitary rectal ulcers, and following polypectomy and biopsy.
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In the past few years, studies have been published relating to the safety and effectiveness of using clips to treat GI bleeding. According to those studies, clips may not only provide a lower rebleeding rate, but also may cause less tissue reaction, potentially reducing the risk of tissue necrosis and perforation as compared to injection and thermal treatments.1
In a study comparing the use of hemoclips and heater probes in preventing early recurrent bleeding from peptic ulcers, patients treated with hemoclips showed a 1.8% (p<0.002; n=1) chance of rebleeding compared to 21% for those (n=12) treated with heater probes.1
Multiple Band Ligation
Band ligation is an endoscopic technique involving ligation of esophageal varices and anorectal hemorroids. The multiple band ligator consists of preloaded elastic bands and is designed to overcome the inefficiencies of the single band system. Once the target tissue is identified, the ligating unit is pressed against it. When the ligating unit is completely around the varix, suction is applied, drawing the varix into the ligating unit. The band is deployed by rotating the handle unit hearing a click. Tissue results with subsequent necrosis and sloughing.
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In a study comparing band ligation with sclerotherapy for the treatment of esophageal variceal bleeding, rebleeding (odds ratio, 0.52 [95% Cl, 0.37 to 0.74]), mortality (odds ratio, 0.67 [Cl, 0.46 to 0.98]), complications (odds ratio, 0.49 [Cl, 0.24 to 0.996]), and the need for fewer endoscopic treatments resulted when treated with ligation. Esophageal strictures occurred less frequently with ligation (odds ratio, 0.10 [Cl, 0.03 to 0.29]).3
Injection Therapy
Injection therapy (or endoscopic sclerotherapy) is intended for non-variceal and variceal bleeding.
4 This technique involves injection of liquid agents, including a sclerosing agent, either into the varix or gastrointestinal mucosa surrounding the bleeding site.
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Endoscopic sclerotherapy generally stops bleeding in 80 to 90% of patients with acute variceal hemorrhage. Its low cost, ease of use, and ability to establish control of bleeding are some of the main advantages of this technique. However there may be complications such as perforation, ulceration, and stricture.4
Thermal Electrohemostasis
Thermal electrohemostasis is an endoscopic technique involving passage of high frequency, low voltage alternating current through tissue at a bleeding site to achieve a controlled, thermally induced coagulation effect. In this technique, an electrohemostasis catheter is held against the bleeding site and used to pass the electrical current through the tissue. Because of its electrolyte and water composition, the tissue conducts the current. Physiologically, this generates thermal energy within the cells, which can produce a coagulation effect.
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Generally bipolar electrohemostasis catheters are designed with paired electrodes at the tip that generate heat directly to the tissue site. The design of the bipolar catheter is intended to enhance the safety and effectiveness of electrohemostasis techniques. First, there is rapid completion of the narrow circuit, limiting the depth of tissue effect. Secondly, vaporization of tissue water at approximately 100°C produces a markedly increased resistance to electrical current. Therefore, when the target tissue temperature reaches 100°C, the thermal effect is more likely to be confined to therapeutic hemostasis, lessening the risk of tissue damage.2
Combination Therapy
Combination endoscopic hemostasis therapy is defined as preliminary injection therapy and subsequent thermal electrohemostasis. It has been found that use of both techniques in sequence can enhance procedural efficiency.
6 Specifically, the local effect produced by injection therapy helps create a favorable environment for application of thermal energy. Adrenaline injection prior to thermal electrohemostasis during adherent clot removal may lessen the risk of rebleeding as the clot is removed by irrigation or snare technique.
6 Because of the effect this combination hemostasis treatment has on tissue, this approach can provide highly effective, long-term hemostasis for patients presenting with GI bleeding.
A study of 96 patients with peptic ulcer bleeding compared the use of Boston Scientific’s Gold Probe™ and Injection Gold Probe™ Catheters, and adrenaline alone for treatment. The combined therapy of Boston Scientific’s Injection Gold Probe Catheter provided greater prevention in rebleeding (2/30, 6.7%) and a decreased need for blood transfusions (491mL vs 1548mL in the adrenaline group).6
The Injection Gold Probe Catheter incorporates a multifunctional design, which allows implementation of injection therapy and thermal hemostasis with a single catheter. This probe has been found to be “faster and more convenient for hemostasis of severe active bleeding from non-variceal lesions than use of separate catheters.”7
References
- Cipolletta. Endoclips versus heater probe in preventing early recurrent bleeding from peptic ulcer: a prospective and randomized trial. Gastrointestinal Endoscopy 2001; 53:147-51.
- American Society of Gastrointestinal Endoscopy. www.asge.org/nspages/practice/patientcare/technology/hemostatdevices.cfm. Accessed 7/6/2005.
- Loren Laine, MD and Deborah Cook, MD. Endoscopic Ligation Compared with Sclerotherapy for Treatment of Esophageal Variceal Bleeding. Annals of Internal Medicine, Vol. 123; No. 4, 15 August 1995:p. 280-287.
- Sharara MD, Ala I., and Don C. Rockey, MD. Medical Progress: Gastroesophageal Variceal Hemorrhage. New England Journal of Medicine, Vol. 345:669-681, August 2001.
- Lee, Yuk Tong, et. al. Dieulafoy’s lesion. Gastrointestinal Endoscopy 2003:58:236-243.
- H-J Lin, et. al. Comparison of adrenaline injection and bipolar electrocoagulation for the arrest of peptic ulcer bleeding. Gut 1999;44:715-719.
- Dennis M. Jensen, MD. Thermal Probe or Combination Therapy for Nonvariceal Upper Gastrointestinal Hemorrhage. Techniques in Gastrointestinal Endoscopy, Vol 1, No 3, July 1999:p. 107-114.
