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Vasopressin in postpotypectomy bleeding
2. Fromm D. Gastrojejunocolic fistula. In: Dietschy JM, series ed. Complications of gastric surgery. Clinical gastroenterology monograph series. New York: John Wiley & Sons, 1977:150-4. 3. Cody JH, Di Vincenti FC, Cowick DR, et al. Gastrocolic and gastrojejunocolic fistulae. Ann Surg 1975;181:376-80.
Vasopressin in postpolypectomy bleeding To the Editor: Colonoscopic removal has become the preferred treatment for polyps of the colon, particularly those that are pedunculated. 1 The overall complication rate is low but may include significant hemorrhage. 2 In reviewing the literature, only two cases of postpolypectomy hemorrhage treated by vasopressin infusion were found. 2,3 In both of these patients, the infusion was intraarterial. My case, treated by intravenous vasopressin infusion, may be of interest to your readers. A 72-year-old woman was found to have three positive stool hemoccults on routine physical evaluation. She denied gastrointestinal symptomatology. Her diagnoses included arteriosclerotic heart disease, congestive heart failure, chronic obstructive lung disease, and hypocalciuric hypercalcemia. Physical examination revealed an irregular heart rhythm, distant breath sounds, and decreased respiratory excursion with expiratory wheezing. Colonoscopy was performed revealing sigmoid diverticulosis and a 1.5-cm pedunculated polyp at approximately 30 em as well as an area of erythema in the cecum, which was biopsied. The biopsy exhibited chronic inflammation. The following day after PTT, protime, bleeding time, and platelet count were obtained and found to be normal, the patient underwent a flexible sigmoidoscopy. During this procedure, the pedunculated polyp was removed by snare and cautery. Following the polypectomy, there was oozing of blood from the polyp stalk, making additional cauterization difficult. Over a subsequent period of 3lf2 hours, the bleeding increased and the patient began passing much blood and clots per rectum. At one point, she became hypotensive with a blood pressure of 80/60 mm Hg. The patient received a total of three units of packed cells, returning her hemoglobin to approximately the preoperative level. After the 31/2 hours of continued active bleeding, it was elected to begin an intravenous infusion of vasopressin at the rate of 0.2 units/min. Within 45 min, there was cessation of visible bleeding, and the patient's vital signs remained stable thereafter. The patient developed nausea and retching shortly after the infusion was begun, and she was treated with nasogastric intubation. The vasopressin infusion was tapered and discontinued within approximately 20 hours of its initiation. The bleeding did not recur. Pathologic examination revealed an adenomatous polyp with a focus of well differentiated superficially invasive adenocarcinoma and superficial invasion of the stalk. The patient refused surgery, and repeat flexible sigmoidoscopy 10 months later revealed a small sessile polyp near the site of the polypectomy. This was a benign adenoma on biopsy. Hemorrhage requiring transfusion is uncommon following colonoscopic polypectomy. In one combined series of 11,066 polypectomies, only seven cases (0.6%) required transfusion or surgery.2 When such hemorrhage does occur, it may be VOLUME 33, NO.5, 1987
quite difficult to stop even with additional cauterization of the polyp stalk. 2 Carlyle and Goldstein 2 reported a case of hemorrhage following colonoscopic polypectomy which continued after attempted further stalk cauterization and which required a transfusion of three units of blood.The patient underwent an inferior mesenteric arteriogram revealing the bleeding site at the polypectomy location. Vasopressin was then infused intraarterially at a rate of 0.4 units/min, resulting in rapid cessation of the bleeding. A similar case was presented by Athanasoulas et al. 3 Intravenous vasopressin infusion has been used successfully in treating gastrointestinal hemorrhage from various sources. 4 - 6 This prompted its use in our postpolypectomy patient who had a 3-unit loss of blood and stopped bleeding with intravenous infusion of vasopressin. James E. Dill, MD, FACP Roanoke, Virginia REFERENCES 1. Williams CB, Riddell RH. Colonic polyps and polypectomy. In:
Schiller KFR, Salmon PR, eds. Modern topics in gastrointestinal endoscopy. Chicago: Year Book Publishers, 1976:273. 2. Carlyle DR, Goldstein HM. Angiographic management of bleeding following transcolonoscopic polypectomy. Dig Dis 1975;20:1196-200.
3. Athanasoulis CA, Waltman AC, Ring EJ, Smith JC Jr, Vaus S. Angiographic management of postoperative bleeding. Radiology 1974;113:37-42.
4. Merigan TC Jr, Plotkin GR, Davidson CS. Effect of intravenously administered posterior pituitary extract on hemorrhage from bleeding esophageal varices. A controlled evaluation. N Engl J Med 1962;266:134-5. 5. Semb BKH, Schjonsby H, Solhaug JH. Intravenous infusion of vasopressin in the treatment of bleeding from severe hemorrhagic gastritis. Acta Chir Scand 1983;149:579-83. 6. Dill JE, Wells RF. Use of vasopressin in the Mallory-Weiss syndrome (letter). N Engl J Med 1971;284:852-3.
Balloon dilation of recurrent terminal ileal Crohn's stricture To the Editor: The balloon catheter has been employed in the management of a variety of strictures in the gastrointestinal tract. I - 3 Intraluminal balloon dilation can successfully treat strictures in lieu of more extensive procedures. Recently, the utility of balloon dilation of a terminal ileal stricture has been described. 4 We report a successful dilation of the terminal ileum in a patient with recurrent Crohn's disease. A 48-year-old man underwent resection of the terminal ileum 15 years ago for active Crohn's disease and extensive hemorrhaging. The patient had been treated with sulfasalazine (2 g daily) and prednisone (20 mg/day). Efforts to increase the dosage of sulfasalazine induced side effects. On several occasions prednisone was withdrawn with subsequent exacerbation of symptoms of small bowel obstruction. During these episodes the patient complained of abdominal bloating accompanied by nausea and vomiting. He required hospitalization on eight occasions in 2 years. Dilated loops of small intestine with air fluid levels were noted on abdominal films. A barium enema revealed active disease in the 399
Vasopressin in postpolypectomy bleeding To the Editor: Colonoscopic removal has become the preferred treatment for polyps of the colon, particularly those that are pedunculated. 1 The overall complication rate is low but may include significant hemorrhage. 2 In reviewing the literature, only two cases of postpolypectomy hemorrhage treated by vasopressin infusion were found. 2,3 In both of these patients, the infusion was intraarterial. My case, treated by intravenous vasopressin infusion, may be of interest to your readers. A 72-year-old woman was found to have three positive stool hemoccults on routine physical evaluation. She denied gastrointestinal symptomatology. Her diagnoses included arteriosclerotic heart disease, congestive heart failure, chronic obstructive lung disease, and hypocalciuric hypercalcemia. Physical examination revealed an irregular heart rhythm, distant breath sounds, and decreased respiratory excursion with expiratory wheezing. Colonoscopy was performed revealing sigmoid diverticulosis and a 1.5-cm pedunculated polyp at approximately 30 em as well as an area of erythema in the cecum, which was biopsied. The biopsy exhibited chronic inflammation. The following day after PTT, protime, bleeding time, and platelet count were obtained and found to be normal, the patient underwent a flexible sigmoidoscopy. During this procedure, the pedunculated polyp was removed by snare and cautery. Following the polypectomy, there was oozing of blood from the polyp stalk, making additional cauterization difficult. Over a subsequent period of 3lf2 hours, the bleeding increased and the patient began passing much blood and clots per rectum. At one point, she became hypotensive with a blood pressure of 80/60 mm Hg. The patient received a total of three units of packed cells, returning her hemoglobin to approximately the preoperative level. After the 31/2 hours of continued active bleeding, it was elected to begin an intravenous infusion of vasopressin at the rate of 0.2 units/min. Within 45 min, there was cessation of visible bleeding, and the patient's vital signs remained stable thereafter. The patient developed nausea and retching shortly after the infusion was begun, and she was treated with nasogastric intubation. The vasopressin infusion was tapered and discontinued within approximately 20 hours of its initiation. The bleeding did not recur. Pathologic examination revealed an adenomatous polyp with a focus of well differentiated superficially invasive adenocarcinoma and superficial invasion of the stalk. The patient refused surgery, and repeat flexible sigmoidoscopy 10 months later revealed a small sessile polyp near the site of the polypectomy. This was a benign adenoma on biopsy. Hemorrhage requiring transfusion is uncommon following colonoscopic polypectomy. In one combined series of 11,066 polypectomies, only seven cases (0.6%) required transfusion or surgery.2 When such hemorrhage does occur, it may be VOLUME 33, NO.5, 1987
quite difficult to stop even with additional cauterization of the polyp stalk. 2 Carlyle and Goldstein 2 reported a case of hemorrhage following colonoscopic polypectomy which continued after attempted further stalk cauterization and which required a transfusion of three units of blood.The patient underwent an inferior mesenteric arteriogram revealing the bleeding site at the polypectomy location. Vasopressin was then infused intraarterially at a rate of 0.4 units/min, resulting in rapid cessation of the bleeding. A similar case was presented by Athanasoulas et al. 3 Intravenous vasopressin infusion has been used successfully in treating gastrointestinal hemorrhage from various sources. 4 - 6 This prompted its use in our postpolypectomy patient who had a 3-unit loss of blood and stopped bleeding with intravenous infusion of vasopressin. James E. Dill, MD, FACP Roanoke, Virginia REFERENCES 1. Williams CB, Riddell RH. Colonic polyps and polypectomy. In:
Schiller KFR, Salmon PR, eds. Modern topics in gastrointestinal endoscopy. Chicago: Year Book Publishers, 1976:273. 2. Carlyle DR, Goldstein HM. Angiographic management of bleeding following transcolonoscopic polypectomy. Dig Dis 1975;20:1196-200.
3. Athanasoulis CA, Waltman AC, Ring EJ, Smith JC Jr, Vaus S. Angiographic management of postoperative bleeding. Radiology 1974;113:37-42.
4. Merigan TC Jr, Plotkin GR, Davidson CS. Effect of intravenously administered posterior pituitary extract on hemorrhage from bleeding esophageal varices. A controlled evaluation. N Engl J Med 1962;266:134-5. 5. Semb BKH, Schjonsby H, Solhaug JH. Intravenous infusion of vasopressin in the treatment of bleeding from severe hemorrhagic gastritis. Acta Chir Scand 1983;149:579-83. 6. Dill JE, Wells RF. Use of vasopressin in the Mallory-Weiss syndrome (letter). N Engl J Med 1971;284:852-3.
Balloon dilation of recurrent terminal ileal Crohn's stricture To the Editor: The balloon catheter has been employed in the management of a variety of strictures in the gastrointestinal tract. I - 3 Intraluminal balloon dilation can successfully treat strictures in lieu of more extensive procedures. Recently, the utility of balloon dilation of a terminal ileal stricture has been described. 4 We report a successful dilation of the terminal ileum in a patient with recurrent Crohn's disease. A 48-year-old man underwent resection of the terminal ileum 15 years ago for active Crohn's disease and extensive hemorrhaging. The patient had been treated with sulfasalazine (2 g daily) and prednisone (20 mg/day). Efforts to increase the dosage of sulfasalazine induced side effects. On several occasions prednisone was withdrawn with subsequent exacerbation of symptoms of small bowel obstruction. During these episodes the patient complained of abdominal bloating accompanied by nausea and vomiting. He required hospitalization on eight occasions in 2 years. Dilated loops of small intestine with air fluid levels were noted on abdominal films. A barium enema revealed active disease in the 399