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Successful endoscopic clipping of rectal dieulafoy's lesion: Case report
Abstracts
PO.130 SMALL-BOWEL CARCINOID REVEALED BY CAPSULE ENDOSCOPY AFTER FANS GASTRIC BLEEDING M. Tebaldi, F. Bonfante, S. Pistoso, W. Piubello
Ospedale di Desenzano del Garda, Brescia Background and aim: A 30-year-old woman was referred to our hospital in June '05 for capsule endoscopy study because of chronic sideropenic anemia. Four mouths before, after FANS ingestion, she had an acute bleeding due to erosive gastritis; she was treated with blood transfusion and evaluated even with colonscopy with normal result; the patient was discharged but after two months detection of occult faecal blood was still positive without FANS use. Au upper endoscopy was carried out again but was normal and so she was referred to our hospital for capsule eudoscopy. Results: The investigation was performed with cleaning intestinal procedure and after 8 hour fasting; a jejunal bleeding polyp was detected and subsequently a double-balloon enteroscopy was carried out. It confirmed the presence of 4 cm jejunal polyp with irregular surface. After that the patient underwent to abdominal laparotomic surgery and minimal intestinal resection was performed. The histological exam revealed a carcinoid lesion confined to submucosa with no vascular involvement. The immunohystochemical investigation was positive for chromogranine A, serotonin, protein gene product 9.5 and NSE. A further octreo-scan examination was carried out but no other lesions were detected. The patients, after 3 months of follow-up, is fine with normalization of red blood count. Conclusions: A complete study of the entire gastrointestinal tract is mandatory in patient with persistent sideropenic anemia and occult faecal blood. After negative upper and lower endoscopy the subsequent approach is the capsule endoscopy which may direct to other more invasive procedures.
PO.13I SUCCESSFUL ENDOSCOPIC CLIPPING OF RECTAL DIEULAFOY'S LESION: CASE REPORT D. Berretti *, M. Marino, C. Macor, R. Maieron, S. Pevere, P. Rossitti, L. Zoratti, M. Zilli
SOC di Gastroenterologia AO S. Maria della Misericordia, Udine Background and aim: Dieulafoy's lesion is an uncommon but potentially life-threatening source of gastrointestinal bleeding. Although the original descriptions and early reports were of lesions in the proximal stomach, similar lesions have subsequently been reported in the oesophagns, dnodennm, jejunum, colon and rectum. We report a patient who presented with massive bleeding due to Dieulafoy's lesion in the rectum which was successfully treated with endoscopic hemostasis Material and methods: A 80-year-old woman was admitted to the hospital with acnte, massive, painless rectal bleeding. She had a history of chronic constipation, type II diabetes mellitus, ischaemic heart disease, cerebral vascular accident, cholecistectomy and hysterectomy. Four years ago the patients was admitted in a other hospital for gastrointestinal hemorrage of unknown origin. Her medications included ticlopidine 250 mg once daily. On initial examination she had a pulse of 130 beatslmin and a blood pressure snpine of 70150 mm Hg. Abdominal examination was normal and a digital rectal examination revealed bright red blood without palpable mass, hemorrhoids of fissure. His blood pressure fell from 120170 mmHg to 60/40 mmHg, and his hemoglobin level dropped from 12.6 gldl (hematocrit 38.5%) to 4.6 gldl (hematocrit 14.7%) in few honrs. Transfnsion of 9 nnits of packed red blood cells were reqnired. An emergency angiography of snperior and inferior mesentheric artery was negative. Then nrgent colonoscopy was performed and revealed large amounts of fresh blood in the rectum.
S211
Washing the clot identified a small mucosal punched-out lesion of the rectum, 4 cm proximal to the anal verge, with active arterial bleeding. There were no nlcers or erosions aronnd the lesion and the surronnding mucosa was otherwise normal. The bleeding site was treated with injection of 10 ml of 1:20000 epinephrine in saline solution (0.9% NaCl) delivered in an array around the lesion followed by application of four endoscopic hemoclips. The site ofthe lesion was tattooed with Indian Ink. Results: A colonoscopy 3 days later showed the lesion healed well. No further bleeding occnrred with a follow-up of 10 months. Conclusions: This case report suggest that therapeutic colonoscopy using hemoclips application should be considered as primary treatment for rectal Dieulafoy's lesion, avoiding emergency transanal surgery. The procednre is effective, safe, quick and has good long-term resnlts.
PO.132 ENDOSCOPIC RESECTION OF A "GIANT" COLONIC LIPOMA. CASE REPORT M. Nuti *, G. Ciancio, M. Campaioli, G. DiFiore, A. Soldi, A. Candidi Tommasi
Ospedale Misericordia e Dolce, Prato Background and aim: Lipoma are benign nonepithelia tumors that occur throughout the GI tract predominantly in the colon. They occur in bowel wall, usually in submucosal location Small colonic lipomas are asymptomatic and may be detected incidentally at the time of colonoscopy. Large lipomas can canse symptoms: constipation, abdominal pain or rectal bleeding. The routine endoscopic removal of lipomas is controversial. Endoscopic removal of lipomas 3 cm or greater in size has been associated with a higher risk of perforation. However, there are a number of reports about the safe endoscopic removal of colonic lipomas with standard electrosurgical methods. Whereas others stndy have suggested that the technique of injection-assisted polypectomy has reduced the risk of perforation. Injection of saline solutions into the submucosa beneath the lesion creates a "cushion" between the lesion and the muscolaris propia, thereby reducing the risk of perforation. Material and methods: Case Report: We reporter the case of a 58year-old man presented as an emergency with abdominal pain and six moth history of intermittent constipation. He had recent episodic rectal bleeding also. A colonoscopy revealed a large polypoid sessile lesion in the sigma. The mass appeared like a benign lesion: soft, with intact mucosal, cherry-red in colour and approximately 5 cm size. We decided to treat the sessile lesion whit endoscopic method. Removal of the lesion was preceded to submucosal injection of dilute hyalnronate acid plus 10 cc of adrenaline and circumferential incision ontside the lesion with pre-cnt. Then electrocantery snare resection completed the cut. This technique reduced the risk of perforation. Results: Any complication developed in our patient. The histology showed the polyp to be a submucosal lipoma Conclusions: The size of our lesion and the absence of the pedicle has been associated with a greater risk of perforation. The techniqne of pre-snbmucosal injection and then circnmferential incision outside the lesion before resection using a electrocautery snare appears to be safe and reduced the risk of perforetion (7)
PO.133 SHORT BOWEL NON-HAEMORRAGIC PATHOLOGY; USEFULNESS OF CAPSULE ENDOSCOPY F. Bonfante *, M. Tebaldi, S. Pistoso, W. Piubello
Ospedale di Desenzano del Garda, Brescia Background and aim: The stndy of the small bowel diseases is the first indication for wireless capsule endoscopy. Occult gastrointestinal
PO.130 SMALL-BOWEL CARCINOID REVEALED BY CAPSULE ENDOSCOPY AFTER FANS GASTRIC BLEEDING M. Tebaldi, F. Bonfante, S. Pistoso, W. Piubello
Ospedale di Desenzano del Garda, Brescia Background and aim: A 30-year-old woman was referred to our hospital in June '05 for capsule endoscopy study because of chronic sideropenic anemia. Four mouths before, after FANS ingestion, she had an acute bleeding due to erosive gastritis; she was treated with blood transfusion and evaluated even with colonscopy with normal result; the patient was discharged but after two months detection of occult faecal blood was still positive without FANS use. Au upper endoscopy was carried out again but was normal and so she was referred to our hospital for capsule eudoscopy. Results: The investigation was performed with cleaning intestinal procedure and after 8 hour fasting; a jejunal bleeding polyp was detected and subsequently a double-balloon enteroscopy was carried out. It confirmed the presence of 4 cm jejunal polyp with irregular surface. After that the patient underwent to abdominal laparotomic surgery and minimal intestinal resection was performed. The histological exam revealed a carcinoid lesion confined to submucosa with no vascular involvement. The immunohystochemical investigation was positive for chromogranine A, serotonin, protein gene product 9.5 and NSE. A further octreo-scan examination was carried out but no other lesions were detected. The patients, after 3 months of follow-up, is fine with normalization of red blood count. Conclusions: A complete study of the entire gastrointestinal tract is mandatory in patient with persistent sideropenic anemia and occult faecal blood. After negative upper and lower endoscopy the subsequent approach is the capsule endoscopy which may direct to other more invasive procedures.
PO.13I SUCCESSFUL ENDOSCOPIC CLIPPING OF RECTAL DIEULAFOY'S LESION: CASE REPORT D. Berretti *, M. Marino, C. Macor, R. Maieron, S. Pevere, P. Rossitti, L. Zoratti, M. Zilli
SOC di Gastroenterologia AO S. Maria della Misericordia, Udine Background and aim: Dieulafoy's lesion is an uncommon but potentially life-threatening source of gastrointestinal bleeding. Although the original descriptions and early reports were of lesions in the proximal stomach, similar lesions have subsequently been reported in the oesophagns, dnodennm, jejunum, colon and rectum. We report a patient who presented with massive bleeding due to Dieulafoy's lesion in the rectum which was successfully treated with endoscopic hemostasis Material and methods: A 80-year-old woman was admitted to the hospital with acnte, massive, painless rectal bleeding. She had a history of chronic constipation, type II diabetes mellitus, ischaemic heart disease, cerebral vascular accident, cholecistectomy and hysterectomy. Four years ago the patients was admitted in a other hospital for gastrointestinal hemorrage of unknown origin. Her medications included ticlopidine 250 mg once daily. On initial examination she had a pulse of 130 beatslmin and a blood pressure snpine of 70150 mm Hg. Abdominal examination was normal and a digital rectal examination revealed bright red blood without palpable mass, hemorrhoids of fissure. His blood pressure fell from 120170 mmHg to 60/40 mmHg, and his hemoglobin level dropped from 12.6 gldl (hematocrit 38.5%) to 4.6 gldl (hematocrit 14.7%) in few honrs. Transfnsion of 9 nnits of packed red blood cells were reqnired. An emergency angiography of snperior and inferior mesentheric artery was negative. Then nrgent colonoscopy was performed and revealed large amounts of fresh blood in the rectum.
S211
Washing the clot identified a small mucosal punched-out lesion of the rectum, 4 cm proximal to the anal verge, with active arterial bleeding. There were no nlcers or erosions aronnd the lesion and the surronnding mucosa was otherwise normal. The bleeding site was treated with injection of 10 ml of 1:20000 epinephrine in saline solution (0.9% NaCl) delivered in an array around the lesion followed by application of four endoscopic hemoclips. The site ofthe lesion was tattooed with Indian Ink. Results: A colonoscopy 3 days later showed the lesion healed well. No further bleeding occnrred with a follow-up of 10 months. Conclusions: This case report suggest that therapeutic colonoscopy using hemoclips application should be considered as primary treatment for rectal Dieulafoy's lesion, avoiding emergency transanal surgery. The procednre is effective, safe, quick and has good long-term resnlts.
PO.132 ENDOSCOPIC RESECTION OF A "GIANT" COLONIC LIPOMA. CASE REPORT M. Nuti *, G. Ciancio, M. Campaioli, G. DiFiore, A. Soldi, A. Candidi Tommasi
Ospedale Misericordia e Dolce, Prato Background and aim: Lipoma are benign nonepithelia tumors that occur throughout the GI tract predominantly in the colon. They occur in bowel wall, usually in submucosal location Small colonic lipomas are asymptomatic and may be detected incidentally at the time of colonoscopy. Large lipomas can canse symptoms: constipation, abdominal pain or rectal bleeding. The routine endoscopic removal of lipomas is controversial. Endoscopic removal of lipomas 3 cm or greater in size has been associated with a higher risk of perforation. However, there are a number of reports about the safe endoscopic removal of colonic lipomas with standard electrosurgical methods. Whereas others stndy have suggested that the technique of injection-assisted polypectomy has reduced the risk of perforation. Injection of saline solutions into the submucosa beneath the lesion creates a "cushion" between the lesion and the muscolaris propia, thereby reducing the risk of perforation. Material and methods: Case Report: We reporter the case of a 58year-old man presented as an emergency with abdominal pain and six moth history of intermittent constipation. He had recent episodic rectal bleeding also. A colonoscopy revealed a large polypoid sessile lesion in the sigma. The mass appeared like a benign lesion: soft, with intact mucosal, cherry-red in colour and approximately 5 cm size. We decided to treat the sessile lesion whit endoscopic method. Removal of the lesion was preceded to submucosal injection of dilute hyalnronate acid plus 10 cc of adrenaline and circumferential incision ontside the lesion with pre-cnt. Then electrocantery snare resection completed the cut. This technique reduced the risk of perforation. Results: Any complication developed in our patient. The histology showed the polyp to be a submucosal lipoma Conclusions: The size of our lesion and the absence of the pedicle has been associated with a greater risk of perforation. The techniqne of pre-snbmucosal injection and then circnmferential incision outside the lesion before resection using a electrocautery snare appears to be safe and reduced the risk of perforetion (7)
PO.133 SHORT BOWEL NON-HAEMORRAGIC PATHOLOGY; USEFULNESS OF CAPSULE ENDOSCOPY F. Bonfante *, M. Tebaldi, S. Pistoso, W. Piubello
Ospedale di Desenzano del Garda, Brescia Background and aim: The stndy of the small bowel diseases is the first indication for wireless capsule endoscopy. Occult gastrointestinal