Endoscopic Therapy

The American Society for Gastrointestinal Endoscopy has provided guidelines for the management of lower GI bleeding (49). These guidelines state that "the first priority is to stabilize the patient with intravenous fluids and transfusions if necessary. The diagnostic evaluation can begin while these resuscitative efforts are under way or as soon as the patient is stable, depending on the urgency of the situation. The colon is cleansed, preferably by lavage with 3-4 L of electrolyte solution given orally or through a nasogastric tube. The delay required for preparation is rarely a significant disadvantage since other resuscitative measures may be carried out at the same time, and only rare patients bleed so rapidly that a delay of a few hours jeopardizes hemodynamic stability."

Colonoscopy can identify a bleeding lesion in 50-70% of patients examined and has the advantage that definitive treatment is possible during the emergent or subsequent elective colonoscopic procedure. Methods of treatment include fulguration with electrocautery, snare cautery, heater probe, injection therapy, argon plasma coagulation, or laser photocoagulation.

Diverticular Hemorrhage

When diverticulosis is the cause of lower GI bleeding, it is not usually possible to identify a visible vessel or clot within a particular source diverticulum at the time of colonoscopy, but finding these lesions is useful because it may denote those patients at high risk for persistent or recurrent diverticular bleeding (50). Pathologic examination of resected specimens may show erosion of an artery into either the dome or the orifice of the diverticulum. The lesion, if seen, can be treated by the usual methods: bipolar/multipolar electrocautery, heater probe, or epi-nephrine injection, independently or together, for control of bleeding. Endoscopic placement of metallic clips can also provide hemostasis (51). Colonoscopic treatment may prevent recurrent bleeding and reduce the need for hemicolectomy (52). Massive diverticular bleeding may not be amenable to endoscopic therapy because of poor visualization of the colon. Radiographic or surgical therapy should be considered for persistent or recurrent hemorrhage, but most cases stop bleeding with conservative management.

Angiodysplasia

Colonoscopic therapy for angiodysplasia is widely accepted and frequently successful. These lesions are also known as vascular ectasias or arteriovenous malformations and are acquired lesions most often found in the cecum and right colon. Treatment is successful in about 90% of cases using thermal cautery to coagulate and obliterate the vessels in the lesion (53). Lower power settings than those used for bleeding gastroduodenal ulcers may be recommended owing to the increased risk of perforation in the right colon (29,54). The periphery of the lesion should be treated before the center to obliterate the surrounding feeder vessels.

Radiation Colitis

Bleeding from multiple telangiectatic lesions in the distal colon produced by radiation therapy for prostate or gynecologic cancers (radiation proctitis or colitis) can be effectively treated with thermal contact probes, laser therapy, or newer noncontact modalities such as the argon plasma coagulator.

Polypectomy Site Bleeding

Postpolypectomy bleeding may occur immediately or weeks after the procedure. As for most other causes of lower GI bleeding, most polypectomy sites will stop bleeding spontaneously (55,56). A number of methods are available to treat persistent bleeding, including electrocautery with or without epinephrine injection, endoscopic band ligation of the polypectomy site, metallic clip placement, and the argon plasma coagulator. Surgical or radiologic intervention is only rarely necessary.

Hemorrhoidal Bleeding

Anorectal sources, usually enlarged hemorrhoidal veins, can be identified easily during colonoscopy and account for less than 10% of acute lower intestinal bleeding (57). Treatment by injection with epinephrine or a sclerosant, infrared coagulation, and band ligation of internal hemorrhoids is effective (58), although more proximal etiologies should also be carefully excluded.

Why Gluten Free

Why Gluten Free

What Is The Gluten Free Diet And What You Need To Know Before You Try It. You may have heard the term gluten free, and you may even have a general idea as to what it means to eat a gluten free diet. Most people believe this type of diet is a curse for those who simply cannot tolerate the protein known as gluten, as they will never be able to eat any food that contains wheat, rye, barley, malts, or triticale.

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