Aralık 2011

Aralık 2011 / (19 - 3)

Polipektomi sonrası kanamada endoskopik bant ligasyonunun kullanımı

Sayfa Numaraları
104-105
Yazarlar
Mehmet BEKTAŞ1, Onur KESKİN1, Esin KORKUT1, Yusuf ÜSTÜN1, Vikas GUPTA2, Hatice ANIKTAR1, Hülya ÇETİNKAYA1, Kadir BAHAR1, İrfan SOYKAN1
Kurumlar
Department of 1Gastroenterology, Ankara University, School of Medicine, Ankara
2University of Texas, School of Public Health, Houston, Texas, USA
Özet
Alt gastrointestinal kanama şüphesiyle kolonoskopi yapılan 61 yaşında kadın hastada sigmoid kolonda uzun saplı bir polip saptandı. Polipektomi yapılan hastada işlem sonrası ciddi arteriyel kanama olması üzerine işlem bölgesine acilen epinefrin ve sklerozan ajan uygulanarak kanama kontrolü sa¤landı. 3 saat sonra hastanın rektal kanamasının tekrarlaması üzerine kontrol kolonoskopide polip sapından kanamanın devam etti¤i gözlendi. Bunun üzerine polip sapına gastroskop ile endoskopik bant ligasyon uygulandı. Bu uygulama ile kanama başarılı bir şekilde durdurulabildi.
Anahtar Kelimeler
Bant ligasyon, polipektomi, hemoraji
Giriş
Endoscopic polypectomy is considered the standard of care for the treatment of colorectal polyps (1). The two most important complications of polypectomy are perforation and bleeding. Hemorrhage has been reported to occur after 1-6% of polypectomies, with clinically significant bleeding in only some 1% of the cases (1-4). In general, bleeding occurs during the transection of the polyp stalk. Delayed bleeding can occur after a few hours or even after a few days in 2% of the patients. Less than 50% occurs immediately after the procedure (1-3).

Bleeding prophylaxis can be attempted using several techniques, such as application of hemoclips, endoloops or injection of sclerosing solutions (5-9).
Olgu
Postpolypectomy bleeding can be mild mucosal oozing that ceases spontaneously or severe bleeding with resultant hypovolemia and hemodynamic instability. Antiplatelet agents (including aspirin, non-steroidal anti-inflammatory drugs [NSAIDs], ticlopidine, clopidogrel, and glycoprotein IIb/IIIa receptor antagonists) and anticoagulants may increase the risk of postpolypectomy bleeding (10-12). Our patient had a history of warfarin use, and her international normalized ratio (INR) level was very high. Hui et al. (13) performed polypectomy in 1657 patients. There were 37 cases of polypectomy- associated bleeding (2.2%); bleeding was immediate in 32 and delayed in 5. Multivariate analysis showed that warfarin use was an independent risk factor for bleeding. Anticoagulants, such as warfarin, should be stopped and the INR should be normalized before performing an elective colonoscopy in which therapeutic maneuvers are anticipated.

A postpolypectomy bleeding stalk has been conventionally treated with surgery or modalities like argon plasma coagulation, laser photocoagulation or bipolar electrocoagulation and hemoclip. EBL is an infrequently used modality for treatment of post polypectomy bleeding. Nijhawan et al. (14) reported the successful use of EBL for the management of postpolypectomy bleeding stalk. We report the successful use of this technique for the management of a postpolypectomy bleeding stalk with a gastroscope. The advantages of band ligation are its low cost, easy availability and ease of application.
Tartışma
Postpolypectomy bleeding can be mild mucosal oozing that ceases spontaneously or severe bleeding with resultant hypovolemia and hemodynamic instability. Antiplatelet agents (including aspirin, non-steroidal anti-inflammatory drugs [NSAIDs], ticlopidine, clopidogrel, and glycoprotein IIb/IIIa receptor antagonists) and anticoagulants may increase the risk of postpolypectomy bleeding (10-12). Our patient had a history of warfarin use, and her international normalized ratio (INR) level was very high. Hui et al. (13) performed polypectomy in 1657 patients. There were 37 cases of polypectomy- associated bleeding (2.2%); bleeding was immediate in 32 and delayed in 5. Multivariate analysis showed that warfarin use was an independent risk factor for bleeding. Anticoagulants, such as warfarin, should be stopped and the INR should be normalized before performing an elective colonoscopy in which therapeutic maneuvers are anticipated.

A postpolypectomy bleeding stalk has been conventionally treated with surgery or modalities like argon plasma coagulation, laser photocoagulation or bipolar electrocoagulation and hemoclip. EBL is an infrequently used modality for treatment of post polypectomy bleeding. Nijhawan et al. (14) reported the successful use of EBL for the management of postpolypectomy bleeding stalk. We report the successful use of this technique for the management of a postpolypectomy bleeding stalk with a gastroscope. The advantages of band ligation are its low cost, easy availability and ease of application.
Kaynaklar
1. Waye JD, Lewis BS, Yessayan S. Colonoscopy: a prospective report of complications. J Clin Gastroenterol 1992; 15: 347-51.

2. Macrae FA, Tan KG, Williams CB. Towards safer colonoscopy: a report of the complication of 5000 diagnostic or therapeutic colonoscopies. Gut 1983; 24: 376-83.

3. Rosen L, Bub DS, Reed JF III, et al. Hemorrhage following colonoscopic polypectomy. Dis Colon Rectum 1993; 36: 1126-31.

4. Gibbs DH, Opelka FG, Beck DE, et al. Postpolypectomy colonic hemorrhage. Dis Colon Rectum 1996; 39: 806-10.

5. Hachisu T, Yamada H, Satoh S, et al. Endoscopic clipping with a new rotable clip-device and a long clip. Dig Endosc 1996; 8: 127-33.

6. Pontecorvo C, Pesce G. The ?safety snare? -- a ligature-placing snare to prevent haemorrhage after transection of large pedunculated polyps. Endoscopy 1986; 18: 55-6.

7. Hachisu T. A new detachable snare for hemostasis in the removal of large polyps or other elevated lesions. Surg Endosc 1991; 5: 70-4.

8. Averbach M, Hashiba K, Corrê P, et al. Use of a homemade nylon loop for the prevention of postpolypectomy bleeding of large pedunculated polyps. Surg Laparosc Endosc Percutan Tech 2005; 15: 275-8.

9. Rohde H, Guenther MW, Budde R, et al. Randomized trial of prophylactic epinephrine-saline injection before snare polypectomy to prevent bleeding. Endoscopy 2000; 32: 1004-5.

10. Nakajima H, Takami H, Yamagata K, et al. Aspirin effects on colonic mucosal bleeding: implication on colonic biopsy and polypectomy. Dis Colon Rectum 1997; 40: 1484-8.

11. Basson MD, Panzini L, Palmer RH. Effect of nabumetone and aspirin on colonic mucosal bleeding time. Aliment Pharmacol Ther 2001; 15: 539- 42.

12. Timothy SK, Hicks TC, Opelka FG, et al. Colonoscopy in the patient requiring anticoagulation. Dis Colon Rectum 2001; 44: 1845-9.

13. Hui AJ, Wong RM, Ching JY, et al. Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases. Gastrointest Endosc 2004; 59: 44-8.

14. Nijhawan S, Kumar D, Joshi A, et al. Endoscopic band ligation for non variceal bleed. Indian J Gastroenterol 2004; 23: 186-7.
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