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Argon Plasma Coagulation for the Treatment of Radiation Induced Proctitis
Abstracts
(87%); in 15 patients the bleeding stopped completely, whereas in 11 patients symptoms improved significantly. All patients with mild and 9/11 (patients with moderate RP were successfully treated (mean 2.0 sessions). A mean of 3.5 sessions was required in 2/5 (40%) patients with severe RP in whom APC was proved successful; in one patient bleeding was controlled after 8 sessions. All APC sessions were well tolerated, and there were no cases of perforation. Conclusions: APC is a safe, effective, and well-tolerated treatment in patients with mild and moderate RP. However, in the presence of severe RP several sessions of APC are usually required and less than 50% of patients were treated successfully.
W1586 Evaluation of the Efficiency of Urgent Colonoscopy to Treat Bleeding from a Colorectal Diverticulum Hiroaki Suda, Sayo Itoh, Iruru Maetani Background: Bleeding from a colorectal diverticulum is the cause of about half of hemorrhages. Urgent colonoscopy is sometimes selected for diagnosis and treatment, but its efficiency is still unclear because it is often unable to detect the bleeding point and because diverticulum bleeding spontaneously stops in about 70 percent of cases. Recent improvements in a variety of endoscopic equipment and improved techniques allow us to detect the bleeding point more than ever, and in our hospital we detect it in about 70 percent of cases. Aim: We evaluated the efficiency of urgent colonoscopy in patients admitted within 24 hours for diagnosis and therapy for diverticulum bleeding. Methods: The study subjects included 37 patients with diverticulum bleeding admitted to our hospital between April 2006 and September 2007. Group S was defined as the patients diagnosed and treated successfully by the urgent endoscopy within 24 hours of admission, and Group U was defined as the other patients. Group U contained patients in whom the bleeding point was not detected by endoscopy or detected after 24 hours. Group S consisted of 11 men and 5 women. Group U consisted of 15 men and 6 women. In Group S, the bleeding segment was the cecum and ascending colon in 12 patients, the transverses colon in 2 patients, and the sigmoid colon in 2 patients. In Group U, the bleeding segment was the cecum and ascending colon in 14 patients, the transverses colon in 4 patients, and the sigmoid colon in 3 patients. There were no significant differences in age, sex or bleeding segment between the two groups. Data collected included Hb values before and after diverticulum bleeding, minimum Hb value, requirement for transfusions, total units of blood transfused, and period of hospital stay. Results: The median difference in Hb values before and after diverticulum bleeding was 1.9g/dl in Group S and 4.6g/dl in Group U (p Z 0.027). The median minimum Hb value was 12.1g/dl in Group S and 8.3g/dl in Group U (p Z 0.01). Transfusions were required in 5 patients (31.2%) in Group S and in 15 patients (71.4%) in Group U (p Z 0.035). The median total units of blood transfused was 0 units in Group S and 4 units in Group U (p Z 0.01). The median period of hospital stay was 9 days in Group S and 14 days in Group U. There was no significant difference between the groups. Conclusions: If we can find the bleeding point of the diverticulum institute treatment by urgent endoscopy in patients admitted within 24 hours, the chance of a transfusion being required and the units of blood transfused can be decreased.
W1587 The Role of Flexible Sigmoidoscopy in Acute Lower GI Bleeding Rebecca Mckay, Deirdre Mcnamara Background: Acute lower gastrointestinal (LGI) bleeding is defined as brisk blood loss from a source distal to the Ligament of Treitz. Flexible sigmoidoscopy remains the initial endoscopic investigation of choice in many centres despite suggestions that colonoscopy hastens diagnosis. Aims and Methods: This study aimed to determine the role of flexible sigmoidoscopy as a first line investigation in acute LGI bleeding. All patients admitted to a high dependency bleeding unit between 1st January 2007 and 1st August 2007 with suspected LGI bleeding were included. A retrospective review of all endoscopy reports was performed. We recorded the bowel preparation, nature of procedure and diagnosis. Subsequent investigations were documented and findings noted. Results: 133 patients were included. 64 patients (49%) were over 70 years of age, 29(22%) being over 80 years. 7 (5%) were under 30 years of age. The commonest cause of bleeding was diverticular disease (31%) followed by colitis (9%). 12% had 2 or more diagnostic findings. Flexible sigmoidoscopy was the first line endoscopic investigation in 86 patients (65%). 62 (72%) of these were unprepared examinations. In 11 patients (13%) views were inadequate due to the presence of blood,9 of which were unprepared tests. A diagnosis was subsequently made at colonoscopy in 8 cases. 5 of the 7 patients under the age of 30 had an unprepared flexible sigmoidoscopy, with a diagnosis being made in all instances. 31 (36%) patients had further imaging: 25 (80%) proceeded to colonoscopy and 6 (19%) had a barium enema. In the patients who had both a flexible sigmoidoscopy and a colonoscopy (n Z 25) an additional diagnosis was made in 19 patients (76%). Colonoscopy was the first line endoscopic procedure for 22 patients (17%). 4 of these were performed without preparation although 2 subsequently had the procedure repeated with preparation. 23 patients had no lower GI endoscopic procedures. Of interest, 47 of the 120 patients aged 3080 years underwent a colonoscopy within 6 months of their admission (39%). Conclusion: Flexible sigmoidoscopy was the investigation of choice for 65% of patients in this audit. Of these, 87% were complete studies and just over a third required further imaging. Of the 25 who had subsequent colonoscopy, only 7 were
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for inadequate views obtained with unprepared sigmoidoscopies. Just 47 patients (35%) underwent colonoscopy. This audit suggests flexible sigmoidoscopy remains a useful investigation for LGI bleeding, and that age as well as other clinical factors may be useful in selecting patients who would benefit from direct colonoscopy. Further prospective studies will be required to assess the benefits of such a model.
W1588 Argon Plasma Coagulation for the Treatment of Radiation Induced Proctitis ´ Mez, Marı´a Laura Gonzalez, Marina Cariello, Carlos Alberto Macı´As Go Fernando Van Domselaar, Jorge R. Da´Volos Introduction: Radiation-induced proctitis (RIP) is a relative common complication of pelvic radiation therapy. Medical treatment generally fails in control bleeding. Argon Plasma Coagulation (APC) is established as an alternative effective therapeutic method. However, APC usefulness and safety have not been studied in our Country. Aims: To asses the usefulness and safety of APC in the management of patients with (RIP). Patients and methods: We analized the clinical records of fourteen patients with radiation proctitis derived to our Endoscopic Unit for APC treatment from July 2004 through March 2007. Indication for radiation therapy, onset of symptoms after the procedure, APC related complications and post treatment clinical evolution were analyzed retrospectively. Diagnosis of radiation proctitis was made based on endoscopic findings in rectal or sigmoideal mucosa. Such us single or multiple telangiectasias and/or friability or contact bleeding in patients with previous pelvic radiotherapy without any other bleeding source. Clinical outcome was classified as completely response: no recurrence of bleeding, partial response: intermittent slight bleeding or no response: without improvement or worsen of bleeding. We used ERBE (Tubigen, Germany) APC 300 system with a 3,2 mm probe in all patients. The gas flow was 2 l/min. and the power setting used was 40 W in 2 seconds pulses. Results: Fourteen consecutive patients, (M/F: 12/2, mean age 74 (61-84 years) were retrospectively included. Male patients received RT due to prostate cancer and females for uterine cancer. Onset of symptoms after RTwas 23 months (0-108). The follow up was 15 months (2-34). All patients had overt bleeding, 6 of them had anemia (3 were transfused). Only one patient received previous medical treatment and endoscopic sclerosis. Eleven patients (79%) responded to APC treatment. Six in the first session and four required two sessions for complete response. One patient had a partial response and refused a second session. Three patients had no response. One underwent only one session, other received palliative management and the last one died from no related procedure causes. Anemia improved in all patients, no transfusions were required and no complication occurred. Conclusion: APC was useful and safe in our patients for RIP treatment and should be recommended as an avilable therapeutic tool in our country.
W1589 Colonoscope Position Detecting System’s Impact On Patient-Based Comfort and Efficiency of Colonoscopy in Difficult-to-Insert Cases Morio Takahashi, Yasumi Katayama, Hajime Kuwayama A magnetic imaging system of colonoscope (Unit of Position Detection: UPD, Olympus Optical Co., Ltd.) provides a new facility for viewing of the position of the colonoscope during examination, without exposing patients or medical staff to radiation. We previously compare UPD system with routine colonoscopy and got the impression that UPD system is more useful in comparatively difficult cases. In order to confirm this, we assigned the patients into three groups according to the insertion time to the cecum of previously performed colonoscopy with ordinary colonoscope (First colonoscopy). Then we performed second colonoscopy with UPD colonoscope. We compared the insertion time between the first (ordinary colonoscope) and second colonoscopy (UPD) in each group. Methods: From Jan. 2005 to August 2007, consecutive 3721 patients undergoing colonoscopy with ordinary colonoscope were assigned into three groups according to the insertion time of first colonoscopy, A group; 7 minute or less, B group; 15 minutes or more, and C group; unable to reach the cecum. Patients of insertion time from 8 to 14 min were excluded. Of these patients, 310 patients underwent second colonoscopy with UPD and were enrolled in the study. One experienced endoscopist (experienced more than 10,000 colonoscopies) performed colonoscopy in this study. Parameters used in this study were the insertion time to the cecum, visual analog scale of patients discomfort (0 cm, no pain; 10 cm, worst pain of life). Results: 1. Of 310 patients enrolled in the study, 200 patients were assigned to be in A group (! 7 min.), 98 in B group (O 15 min.) and 12 in C (unable to reach cecum). 2. In group A, there was no difference in insertion time between first and second colonoscopy (260þ/-88 seconds vs. 248þ/-58). In group B, the insertion time of second colonoscopy is significantly shorter than that of first colonoscopy (1266þ/-582 vs. 523þ/-123). In group C, the total colonoscopies were performed in 10 out of 12 patients (788þ/-235) with UPD. 3. There was no difference in pain of patients in group A (1.67þ/-0.97 vs. 1.72þ/-0.93). There is a trend toward less pain in second colonoscopy (UPD) in group B (3.02þ/-1.41 vs. 2.65þ/-1.13). There was no difference in pain of patients in group C (3.32þ/-2.11 vs. 3.17þ/-2.23). Conclusion: These results indicated that UPD system is useful only in difficult cases and total colonoscopy to the cecum can be obtained with UPD in cases where it is not obtained with ordinary colonoscope.
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB321
(87%); in 15 patients the bleeding stopped completely, whereas in 11 patients symptoms improved significantly. All patients with mild and 9/11 (patients with moderate RP were successfully treated (mean 2.0 sessions). A mean of 3.5 sessions was required in 2/5 (40%) patients with severe RP in whom APC was proved successful; in one patient bleeding was controlled after 8 sessions. All APC sessions were well tolerated, and there were no cases of perforation. Conclusions: APC is a safe, effective, and well-tolerated treatment in patients with mild and moderate RP. However, in the presence of severe RP several sessions of APC are usually required and less than 50% of patients were treated successfully.
W1586 Evaluation of the Efficiency of Urgent Colonoscopy to Treat Bleeding from a Colorectal Diverticulum Hiroaki Suda, Sayo Itoh, Iruru Maetani Background: Bleeding from a colorectal diverticulum is the cause of about half of hemorrhages. Urgent colonoscopy is sometimes selected for diagnosis and treatment, but its efficiency is still unclear because it is often unable to detect the bleeding point and because diverticulum bleeding spontaneously stops in about 70 percent of cases. Recent improvements in a variety of endoscopic equipment and improved techniques allow us to detect the bleeding point more than ever, and in our hospital we detect it in about 70 percent of cases. Aim: We evaluated the efficiency of urgent colonoscopy in patients admitted within 24 hours for diagnosis and therapy for diverticulum bleeding. Methods: The study subjects included 37 patients with diverticulum bleeding admitted to our hospital between April 2006 and September 2007. Group S was defined as the patients diagnosed and treated successfully by the urgent endoscopy within 24 hours of admission, and Group U was defined as the other patients. Group U contained patients in whom the bleeding point was not detected by endoscopy or detected after 24 hours. Group S consisted of 11 men and 5 women. Group U consisted of 15 men and 6 women. In Group S, the bleeding segment was the cecum and ascending colon in 12 patients, the transverses colon in 2 patients, and the sigmoid colon in 2 patients. In Group U, the bleeding segment was the cecum and ascending colon in 14 patients, the transverses colon in 4 patients, and the sigmoid colon in 3 patients. There were no significant differences in age, sex or bleeding segment between the two groups. Data collected included Hb values before and after diverticulum bleeding, minimum Hb value, requirement for transfusions, total units of blood transfused, and period of hospital stay. Results: The median difference in Hb values before and after diverticulum bleeding was 1.9g/dl in Group S and 4.6g/dl in Group U (p Z 0.027). The median minimum Hb value was 12.1g/dl in Group S and 8.3g/dl in Group U (p Z 0.01). Transfusions were required in 5 patients (31.2%) in Group S and in 15 patients (71.4%) in Group U (p Z 0.035). The median total units of blood transfused was 0 units in Group S and 4 units in Group U (p Z 0.01). The median period of hospital stay was 9 days in Group S and 14 days in Group U. There was no significant difference between the groups. Conclusions: If we can find the bleeding point of the diverticulum institute treatment by urgent endoscopy in patients admitted within 24 hours, the chance of a transfusion being required and the units of blood transfused can be decreased.
W1587 The Role of Flexible Sigmoidoscopy in Acute Lower GI Bleeding Rebecca Mckay, Deirdre Mcnamara Background: Acute lower gastrointestinal (LGI) bleeding is defined as brisk blood loss from a source distal to the Ligament of Treitz. Flexible sigmoidoscopy remains the initial endoscopic investigation of choice in many centres despite suggestions that colonoscopy hastens diagnosis. Aims and Methods: This study aimed to determine the role of flexible sigmoidoscopy as a first line investigation in acute LGI bleeding. All patients admitted to a high dependency bleeding unit between 1st January 2007 and 1st August 2007 with suspected LGI bleeding were included. A retrospective review of all endoscopy reports was performed. We recorded the bowel preparation, nature of procedure and diagnosis. Subsequent investigations were documented and findings noted. Results: 133 patients were included. 64 patients (49%) were over 70 years of age, 29(22%) being over 80 years. 7 (5%) were under 30 years of age. The commonest cause of bleeding was diverticular disease (31%) followed by colitis (9%). 12% had 2 or more diagnostic findings. Flexible sigmoidoscopy was the first line endoscopic investigation in 86 patients (65%). 62 (72%) of these were unprepared examinations. In 11 patients (13%) views were inadequate due to the presence of blood,9 of which were unprepared tests. A diagnosis was subsequently made at colonoscopy in 8 cases. 5 of the 7 patients under the age of 30 had an unprepared flexible sigmoidoscopy, with a diagnosis being made in all instances. 31 (36%) patients had further imaging: 25 (80%) proceeded to colonoscopy and 6 (19%) had a barium enema. In the patients who had both a flexible sigmoidoscopy and a colonoscopy (n Z 25) an additional diagnosis was made in 19 patients (76%). Colonoscopy was the first line endoscopic procedure for 22 patients (17%). 4 of these were performed without preparation although 2 subsequently had the procedure repeated with preparation. 23 patients had no lower GI endoscopic procedures. Of interest, 47 of the 120 patients aged 3080 years underwent a colonoscopy within 6 months of their admission (39%). Conclusion: Flexible sigmoidoscopy was the investigation of choice for 65% of patients in this audit. Of these, 87% were complete studies and just over a third required further imaging. Of the 25 who had subsequent colonoscopy, only 7 were
www.giejournal.org
for inadequate views obtained with unprepared sigmoidoscopies. Just 47 patients (35%) underwent colonoscopy. This audit suggests flexible sigmoidoscopy remains a useful investigation for LGI bleeding, and that age as well as other clinical factors may be useful in selecting patients who would benefit from direct colonoscopy. Further prospective studies will be required to assess the benefits of such a model.
W1588 Argon Plasma Coagulation for the Treatment of Radiation Induced Proctitis ´ Mez, Marı´a Laura Gonzalez, Marina Cariello, Carlos Alberto Macı´As Go Fernando Van Domselaar, Jorge R. Da´Volos Introduction: Radiation-induced proctitis (RIP) is a relative common complication of pelvic radiation therapy. Medical treatment generally fails in control bleeding. Argon Plasma Coagulation (APC) is established as an alternative effective therapeutic method. However, APC usefulness and safety have not been studied in our Country. Aims: To asses the usefulness and safety of APC in the management of patients with (RIP). Patients and methods: We analized the clinical records of fourteen patients with radiation proctitis derived to our Endoscopic Unit for APC treatment from July 2004 through March 2007. Indication for radiation therapy, onset of symptoms after the procedure, APC related complications and post treatment clinical evolution were analyzed retrospectively. Diagnosis of radiation proctitis was made based on endoscopic findings in rectal or sigmoideal mucosa. Such us single or multiple telangiectasias and/or friability or contact bleeding in patients with previous pelvic radiotherapy without any other bleeding source. Clinical outcome was classified as completely response: no recurrence of bleeding, partial response: intermittent slight bleeding or no response: without improvement or worsen of bleeding. We used ERBE (Tubigen, Germany) APC 300 system with a 3,2 mm probe in all patients. The gas flow was 2 l/min. and the power setting used was 40 W in 2 seconds pulses. Results: Fourteen consecutive patients, (M/F: 12/2, mean age 74 (61-84 years) were retrospectively included. Male patients received RT due to prostate cancer and females for uterine cancer. Onset of symptoms after RTwas 23 months (0-108). The follow up was 15 months (2-34). All patients had overt bleeding, 6 of them had anemia (3 were transfused). Only one patient received previous medical treatment and endoscopic sclerosis. Eleven patients (79%) responded to APC treatment. Six in the first session and four required two sessions for complete response. One patient had a partial response and refused a second session. Three patients had no response. One underwent only one session, other received palliative management and the last one died from no related procedure causes. Anemia improved in all patients, no transfusions were required and no complication occurred. Conclusion: APC was useful and safe in our patients for RIP treatment and should be recommended as an avilable therapeutic tool in our country.
W1589 Colonoscope Position Detecting System’s Impact On Patient-Based Comfort and Efficiency of Colonoscopy in Difficult-to-Insert Cases Morio Takahashi, Yasumi Katayama, Hajime Kuwayama A magnetic imaging system of colonoscope (Unit of Position Detection: UPD, Olympus Optical Co., Ltd.) provides a new facility for viewing of the position of the colonoscope during examination, without exposing patients or medical staff to radiation. We previously compare UPD system with routine colonoscopy and got the impression that UPD system is more useful in comparatively difficult cases. In order to confirm this, we assigned the patients into three groups according to the insertion time to the cecum of previously performed colonoscopy with ordinary colonoscope (First colonoscopy). Then we performed second colonoscopy with UPD colonoscope. We compared the insertion time between the first (ordinary colonoscope) and second colonoscopy (UPD) in each group. Methods: From Jan. 2005 to August 2007, consecutive 3721 patients undergoing colonoscopy with ordinary colonoscope were assigned into three groups according to the insertion time of first colonoscopy, A group; 7 minute or less, B group; 15 minutes or more, and C group; unable to reach the cecum. Patients of insertion time from 8 to 14 min were excluded. Of these patients, 310 patients underwent second colonoscopy with UPD and were enrolled in the study. One experienced endoscopist (experienced more than 10,000 colonoscopies) performed colonoscopy in this study. Parameters used in this study were the insertion time to the cecum, visual analog scale of patients discomfort (0 cm, no pain; 10 cm, worst pain of life). Results: 1. Of 310 patients enrolled in the study, 200 patients were assigned to be in A group (! 7 min.), 98 in B group (O 15 min.) and 12 in C (unable to reach cecum). 2. In group A, there was no difference in insertion time between first and second colonoscopy (260þ/-88 seconds vs. 248þ/-58). In group B, the insertion time of second colonoscopy is significantly shorter than that of first colonoscopy (1266þ/-582 vs. 523þ/-123). In group C, the total colonoscopies were performed in 10 out of 12 patients (788þ/-235) with UPD. 3. There was no difference in pain of patients in group A (1.67þ/-0.97 vs. 1.72þ/-0.93). There is a trend toward less pain in second colonoscopy (UPD) in group B (3.02þ/-1.41 vs. 2.65þ/-1.13). There was no difference in pain of patients in group C (3.32þ/-2.11 vs. 3.17þ/-2.23). Conclusion: These results indicated that UPD system is useful only in difficult cases and total colonoscopy to the cecum can be obtained with UPD in cases where it is not obtained with ordinary colonoscope.
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB321