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Endoscopic band ligation for non-variceal non-ulcer gastrointestinal hemorrhage
NEW METHODS & MATERIALS
Table 1. Characteristics and outcome of lesions treated by EBL Lesion No. of Site of type patients lesion
Endoscopic band ligation for non-variceal non-ulcer gastrointestinal hemorrhage David Abi-Hanna, MBBS, FRACP, BSc, PhD Stephen J. Williams, MBBS, FRACP, MD Peter E. Gillespie, MBBS, FRACP Michael J. Bourke, MBBS, FRACP
Background: There is no consensus as to the best treatment for non-variceal, non-ulcer gastrointestinal hemorrhage. Endoscopic band ligation is an inexpensive, readily available, and easily learned technique in contrast to conventional thermal methods of endoscopic hemostasis. We present the preliminary results of an open trial using endoscopic band ligation for non-variceal, non-ulcer bleeding in the gastrointestinal tract. Methods: Eighteen patients were treated by band ligation between June 1996 and November 1997. The lesions treated were: arteriovenous malformations in 10, Dieulafoy’s lesions in 4, Mallory-Weiss tear in 2, and post-colonic polypectomy bleeding in 2. Results: Endoscopic band ligation was successful in 17 of 18 cases, with a follow-up period ranging from 2 to 18 months. The remaining case, a duodenal Dieulafoy’s lesion, bled again at 24 hours but was successfully treated by adrenalin injection. Conclusions: Endoscopic band ligation is effective for non-variceal, non-ulcer bleeding. It has the advantage of ease of use and is relatively inexpensive. Endoscopic band ligation (EBL) is now a wellestablished therapeutic modality with documented efficacy and safety in the treatment of bleeding esophageal varices.1 Use of EBL for other causes of upper and lower gastrointestinal hemorrhage has been described in a few individual case reports2-5 and one small series of patients presented in abstract form.6 The place of this modality in the control of non-variceal, non-ulcer bleeding is not well
Received September 18, 1997. For revision January 13, 1998. Accepted June 3, 1998. From the Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, NSW, Australia. Reprint requests: M. J. Bourke, MBBS, FRACP, Suite 111, 151-155 Hawkesbury Rd., Westmead, NSW, 2145, Australia. Copyright © 1998 by the American Society for Gastrointestinal Endoscopy 0016-5107/98/$5.00 + 0 37/69/92183 510
GASTROINTESTINAL ENDOSCOPY
AVM DL MWT PP
10 4 2 2
9G/1D 3G/1D CEJ Sigmoid
Active bleed 4/10 4/4 2/2 2/2
EBL Previous F/U success Endo Rx (months) 10/10 3/4 2/2 2/2
4/10 0/10 1/2 1/2
6 8 7 14
D, Duodenal; G, gastric; CEJ, cardiaesophageal junction; AVM, arteriovenous malformation; DL, Dieulafoy’s lesion; MWT, Mallory-Weiss tear; PP, post-polypectomy.
established. In this article, we describe the use of this technique for the treatment of 18 patients with gastrointestinal hemorrhage of various causes and discuss the role of band ligation in these situations. PATIENTS AND METHODS During the period June 1996 to November 1997, 18 patients were treated with EBL who had gastrointestinal hemorrhage caused by the following: 10 with arteriovenous malformations (AVM), 4 with Dieulafoy’s lesion (DL), 2 with Mallory-Weiss tear (MWT), and 2 with post-polypectomy hemorrhage. Active bleeding was present at the therapeutic procedure in 4 of 10 AVM patients and in all of the remaining patients (Table 1). In all cases informed consent was obtained from the patient and/or relatives. All patients with an upper gastrointestinal lesion were placed on acid suppression (omeprazole 20 mg bid) for a minimum of 4 weeks. The Stiegmann-Goff clearview band ligation device (Bard International Products, Billerica, Mass.) was used for all lesions. An overtube was not used. Illustrative case reports are presented below. Arteriovenous malformations A 75-year-old man presented with melena of 2 days’ duration and hematemesis of 2 hours’ duration. Panendoscopy showed an AVM oozing blood in the first part of the duodenum. It was injected with 2 mL of 1:10,000 adrenalin, but despite this, it began to bleed actively. A band was placed around the AVM with immediate cessation of bleeding. Four days later at repeat endoscopy a superficial ulcer was seen at the site of the AVM, with the band being no longer present. The patient was discharged the next day, having had no further bleeding. Six weeks later, endoscopy revealed an ulcer scar; the AVM was not visible. There was no further bleeding during 6 months of follow-up. A 75-year-old man with a documented 8 mm AVM on the greater curvature of the stomach was referred for definitive therapy. He had a history of five episodes of significant upper gastrointestinal bleeding requiring transfusion of a total of 20 units of packed cells over 2 years. The last two episodes had occurred in the preceding month. The AVM was treated by band ligation (Fig. 1A and B). There has been no further bleeding during 6 months of follow-up. VOLUME 48, NO. 5, 1998
Endoscopic band ligation for non-variceal non-ulcer GI hemorrhage
A
B Figure 1. A, Gastric arteriovenous malformation. B, Arteriovenous malformation after band ligation. Note that the AVM is wholly included within the banded mucosa. Dielufoy’s lesion A 75-year-old man presented after two episodes of hematemesis and melena, the second episode being associated with collapse, hemodynamic instability, and anemia (hemoglobin 7.5 gm/dL). Panendoscopy showed a bleeding DL on the proximal lesser curve of the stomach. A band was placed around the lesion with immediate cessation of bleeding (Fig. 2A and B). He was discharged 4 days later, having had no further evidence of bleeding. Endoscopy 4 weeks later disclosed a shallow 6 mm ulcer at the site of the DL. At telephone interview 12 months later, there had been no further bleeding. A 69-year-old man with multiple medical problems was transferred to our hospital because of severe pneumonia, unstable blood sugars, and acute renal failure. Melena was noted on the day of transfer. Panendoscopy showed a bleeding DL in the first part of the duodenum. The duodenal cap appeared scarred but no ulcer was present. Band ligation was performed. The patient was free of bleeding for 24 hours, after which there was a recurrence of melena. Repeat endoscopy revealed a shallow ulcer at the site of VOLUME 48, NO. 5, 1998
D Abi-Hanna, S Williams, P Gillespie, et al.
A
B Figure 2. A, Bleeding gastric Dieulafoy’s lesion. B, Dieulafoy’s lesion after band ligation. Note protruding vessel visible at top of banded mucosa banding with an overlying fresh clot. The band was no longer present. A total of 9 mL of 1:10,000 adrenalin was injected into and around the ulcer with blanching of the area. Over the next 2 weeks there was no further bleeding and the patient’s general condition improved. He was discharged back to his referring hospital. A telephone followup disclosed no further bleeding at 12 months. Mallory-Weiss tear A 72-year-old man was admitted after 2 days of diarrhea and vomiting which was followed by three episodes of hematemesis and later three episodes of melena. The patient was receiving coumadin for a metallic cardiac valve prosthesis. Because of the risk of thromboembolism, his anticoagulation was not reversed, but no further coumadin was administered until bleeding was controlled. Panendoscopy on the day of admission showed a MWT with active bleeding and a visible vessel. The area was injected with 10 mL of 1:10,000 adrenalin with cessation of bleeding. Twelve hours later he had a further large hematemesis and repeat endoscopy showed recurrence of active bleeding at the same site. The vessel and surroundGASTROINTESTINAL ENDOSCOPY
511
D Abi-Hanna, S Williams, P Gillespie, et al.
ing mucosa were banded with immediate hemostasis. No further bleeding was noted and the patient was discharged on day five. At 12-month telephone follow-up there had been no recurrence of bleeding. A 62-year-old man suffered an acute myocardial infarction and was given morphine for pain relief and a thrombolytic agent (recombinant tissue plasminogen activator). Soon after, he began to vomit, initially, undigested food then frank blood. With repeated hematemesis he became hemodynamically compromised (hemoglobin of 6.0 mg/dL). At urgent endoscopy a large MWT was seen with an actively bleeding visible vessel. A band was applied with immediate hemostasis. There was no further bleeding during the following week of hospitalization and the ensuing 3 months. Post-polypectomy A 54-year-old man presented with rectal bleeding 4 days after polypectomy at another hospital. Sigmoidoscopy revealed a polyp stalk oozing blood at 15 cm from the anal verge. A band was applied with immediate cessation of bleeding (Fig. 3A and B). The patient was discharged the next day with no further bleeding. Telephone interview at 12 months confirmed that there had been no further bleeding.
RESULTS Endoscopic band ligation was successful in 17 of 18 cases, with a follow-up period ranging from 2 to 18 months. The remaining case, a duodenal Dieulafoy’s lesion, bled again at 24 hours but was successfully treated by adrenalin injection. DISCUSSION The endoscopic approach to the more frequent causes of gastrointestinal hemorrhage, peptic ulcer disease and esophageal varices, is now reasonably well defined as a consequence of randomized controlled trials and meta-analysis of these trials.1,7 In contrast non-variceal, non-ulcer gastrointestinal hemorrhage is uncommon and there is no clear consensus on best method of endoscopic treatment. Endoscopic band ligation has now emerged as the method of choice for treatment (both acute and interval) of esophageal variceal bleeding.1 In contrast to thermal methods of endoscopic hemostasis, EBL does not involve initial tissue destruction, but rather the controlled ligation of the bleeding source, analogous to tying a suture around a bleeding vessel. In addition, EBL offers rapid “single shot,” mechanical, hemostasis if the elastic band is applied directly over the bleeding source. The procedure is relatively simple to learn and the equipment required readily available and inexpensive. These factors have made the application of this modality to various causes of gastrointestinal bleeding attrac512
GASTROINTESTINAL ENDOSCOPY
Endoscopic band ligation for non-variceal non-ulcer GI hemorrhage
tive. However, EBL can only be considered for pliable, non-fibrotic lesions because the lesion and surrounding tissue must be aspirated into the friction fit chamber at the endoscope tip for successful ligation. This limitation precludes the use of EBL for lesions with associated fibrosis, such as visible vessels within peptic ulcers. The first case reports of EBL for post-polypectomy and bleeding of DL appeared in 1994.2-4 A series of 10 patients (DL 5, AVM 4, and post-gastric polypectomy 1) was also reported in 1994 in abstract form.6 Successful banding of a bleeding AVM was reported in 1996.5 Our series of 18 patients extends these observations and includes the first two reported cases of EBL for actively bleeding MWTs. AVMs are an uncommon cause of upper gastrointestinal hemorrhage, accounting for between 1% and 5% of cases of bleeding in various series.8 Including our 10 cases, a total of 15 cases of EBL in AVM have been reported; therapy was successful in all cases. A superficial ulcer invariably develops at the site of EBL (Fig. 4), but in our experience and that of others, this heals quickly with acid suppression, without pain or bleeding.9 Treatment-induced bleeding is common with thermal methods of AVM ablation and occasionally this may create technical difficulties. In contrast, if bleeding occurs with EBL it is usually of short duration and confined to the suction phase of band application. DL is also an infrequent cause of gastrointestinal hemorrhage, accounting for 0.3% to 6.7% of cases.8 Including our 4 cases, there have been 10 cases reported of treatment of DL with EBL. Hemostasis was achieved in all cases, but in our patient with a duodenal DL (all other reported cases are gastric DL), bleeding recurred 24 hours later and was associated with a shallow ulcer at the site of banding with an adherent fresh clot. The area was injected with adrenalin with cessation of bleeding. It is possible that the band slipped off early in this patient because of the presence of scarring and fibrosis. A retrospective analysis of 31 patients with bleeding DL revealed that lesions managed by injection alone were more likely to bleed again. Band ligation and contact thermal methods were both 100% effective.10 Again, thermal methods carry a risk of treatment induced bleeding in contrast to precisely targeted EBL. Given the infrequency of DL, a randomized trial comparing one modality with another will probably not be possible. However this report extends the observations of others that attest to the safety and efficacy of EBL in this condition. MWT accounts for 5% to 15% of cases of upper gastrointestinal hemorrhage.8 Endoscopic band ligation has not been reported in the treatment of VOLUME 48, NO. 5, 1998
Endoscopic band ligation for non-variceal non-ulcer GI hemorrhage
D Abi-Hanna, S Williams, P Gillespie, et al.
A Figure 4. Typical ulcer 4 weeks after EBL of a gastric AVM. All patients in our series were placed on acid suppression for a minimum of 4 weeks.
B Figure 3. A, Oozing sigmoid polypectomy site 4 days after polypectomy. B, Bleeding polypectomy site after band ligation. Note visible stalk vessel which is included within banded mucosa.
actively bleeding MWT; our two cases are the first to the best of our knowledge. Because MWT is actually a mucosal tear, EBL may be an ideal treatment because the band ligates mucosa and submucosa,9 effectively closing the tear. Fortunately, the majority of MWTs resolve spontaneously, but 1% to 3% require intervention.8 In our two cases, it is clear that the bleeding was unlikely to stop spontaneously. Injection therapy had already failed in one patient and both patients had a coagulopathy. Intuitively, thermal methods of hemostasis which require some degree of tissue destruction are unlikely to be effective with patients with coagulopathies. Endoscopic band ligation provides mechanical hemostasis that is largely independent of blood clotting. Post-polypectomy hemorrhage occurs in 0.5% to 2.2% of cases of endoscopic polypectomy and may be delayed.11,12 Our two cases bring the total reported VOLUME 48, NO. 5, 1998
to 5 cases of EBL for post-polypectomy bleeding (4 colonic, 1 gastric). The procedure is highly effective but was used mainly (4 of 5 cases) after failure of other modalities. Endoscopic band ligation is uniquely suited to the treatment of bleeding from a protuberant residual polyp stalk. However, the necessity to “carry” the ligation apparatus, which attenuates the endoscopic view, to the bleeding source adds complexity to the treatment of right sided colonic lesions. The utilization of EBL for non-variceal, non-ulcer bleeding has mainly been described in small series and case reports where other modalities have failed. This accumulated evidence and our own results confirm the safety and efficacy of this technique. Greater experience in prospective trials is required to transform the conceptual appeal of EBL for nonvariceal, non-ulcer bleeding into a standard, widely practiced endoscopic technique. REFERENCES 1. Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 1995;123:280-7. 2. Slivka A, Parsons WG, Carr-Locke DL. Endoscopic band ligation for treatment of post-polypectomy haemorrhage. Gastrointest Endosc 1994;40:230-2. 3. Smith RE, Doull J. Treatment of colonic post-polypectomy bleeding site by endoscopic band ligation. Gastrointest Endosc 1994;40:499-500. 4. Brown GR, Harford WV, Jones WF. Endoscopic band ligation of an actively bleeding Dieulafoy lesion. Gastrointest Endosc 1994;40:501-3. 5. Baniukiewicz A, Sklodowskiej MC. An endoscopic treatment for gastric angiodysplasia, using an endoscopic ligating device designed to treat esophageal varices [letter]. Endoscopy 1996;28:787. GASTROINTESTINAL ENDOSCOPY
513
6. Jones WF, Khandelwal M, Akerman P, Garcia-Rebull M, Kandel G, Kortan P, et al. Endoscopic band ligation (EBL) for acute non-variceal/non-ulcer upper gastrointestinal haemorrhage (NVNU-UGIH) [abstract]. Gastrointest Endosc 1994; 40:P25. 7. Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med 1994;331:717-27. 8. Katz PO, Salas L. Less frequent causes of upper gastrointestinal bleeding. Gastroenterol Clin North Am 1993;22:875-89. 9. Stiegmann GV, Sun H, Hammond WS. Results of experimental endoscopic esophageal varix ligation. Am Surg 1988; 54:105-8.
514
GASTROINTESTINAL ENDOSCOPY
10. Scheider DM, Bourke MJ, Ghanbari A, Kandel G, Kortan P, Marcon N, Haber GB. Dieulafoy’s disease: clinical features and endoscopic predictors of rebleeding [abstract]. Gastrointest Endosc 1995;41:370. 11. Rex D, Lewis B, Waye J. Colonoscopy and endoscopic therapy for delayed post-polypectomy haemorrhage. Gastrointest Endosc 1992;38:127-9. 12. Gilbert DA, Hallstrom AP, Shaneyfelt SL, Mahler AK, Silverstein FE. The National ASGE Colonoscopy Survey— Complications of colonoscopy [abstract]. Gastrointest Endosc 1984;30:156.
VOLUME 48, NO. 5, 1998
Table 1. Characteristics and outcome of lesions treated by EBL Lesion No. of Site of type patients lesion
Endoscopic band ligation for non-variceal non-ulcer gastrointestinal hemorrhage David Abi-Hanna, MBBS, FRACP, BSc, PhD Stephen J. Williams, MBBS, FRACP, MD Peter E. Gillespie, MBBS, FRACP Michael J. Bourke, MBBS, FRACP
Background: There is no consensus as to the best treatment for non-variceal, non-ulcer gastrointestinal hemorrhage. Endoscopic band ligation is an inexpensive, readily available, and easily learned technique in contrast to conventional thermal methods of endoscopic hemostasis. We present the preliminary results of an open trial using endoscopic band ligation for non-variceal, non-ulcer bleeding in the gastrointestinal tract. Methods: Eighteen patients were treated by band ligation between June 1996 and November 1997. The lesions treated were: arteriovenous malformations in 10, Dieulafoy’s lesions in 4, Mallory-Weiss tear in 2, and post-colonic polypectomy bleeding in 2. Results: Endoscopic band ligation was successful in 17 of 18 cases, with a follow-up period ranging from 2 to 18 months. The remaining case, a duodenal Dieulafoy’s lesion, bled again at 24 hours but was successfully treated by adrenalin injection. Conclusions: Endoscopic band ligation is effective for non-variceal, non-ulcer bleeding. It has the advantage of ease of use and is relatively inexpensive. Endoscopic band ligation (EBL) is now a wellestablished therapeutic modality with documented efficacy and safety in the treatment of bleeding esophageal varices.1 Use of EBL for other causes of upper and lower gastrointestinal hemorrhage has been described in a few individual case reports2-5 and one small series of patients presented in abstract form.6 The place of this modality in the control of non-variceal, non-ulcer bleeding is not well
Received September 18, 1997. For revision January 13, 1998. Accepted June 3, 1998. From the Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, NSW, Australia. Reprint requests: M. J. Bourke, MBBS, FRACP, Suite 111, 151-155 Hawkesbury Rd., Westmead, NSW, 2145, Australia. Copyright © 1998 by the American Society for Gastrointestinal Endoscopy 0016-5107/98/$5.00 + 0 37/69/92183 510
GASTROINTESTINAL ENDOSCOPY
AVM DL MWT PP
10 4 2 2
9G/1D 3G/1D CEJ Sigmoid
Active bleed 4/10 4/4 2/2 2/2
EBL Previous F/U success Endo Rx (months) 10/10 3/4 2/2 2/2
4/10 0/10 1/2 1/2
6 8 7 14
D, Duodenal; G, gastric; CEJ, cardiaesophageal junction; AVM, arteriovenous malformation; DL, Dieulafoy’s lesion; MWT, Mallory-Weiss tear; PP, post-polypectomy.
established. In this article, we describe the use of this technique for the treatment of 18 patients with gastrointestinal hemorrhage of various causes and discuss the role of band ligation in these situations. PATIENTS AND METHODS During the period June 1996 to November 1997, 18 patients were treated with EBL who had gastrointestinal hemorrhage caused by the following: 10 with arteriovenous malformations (AVM), 4 with Dieulafoy’s lesion (DL), 2 with Mallory-Weiss tear (MWT), and 2 with post-polypectomy hemorrhage. Active bleeding was present at the therapeutic procedure in 4 of 10 AVM patients and in all of the remaining patients (Table 1). In all cases informed consent was obtained from the patient and/or relatives. All patients with an upper gastrointestinal lesion were placed on acid suppression (omeprazole 20 mg bid) for a minimum of 4 weeks. The Stiegmann-Goff clearview band ligation device (Bard International Products, Billerica, Mass.) was used for all lesions. An overtube was not used. Illustrative case reports are presented below. Arteriovenous malformations A 75-year-old man presented with melena of 2 days’ duration and hematemesis of 2 hours’ duration. Panendoscopy showed an AVM oozing blood in the first part of the duodenum. It was injected with 2 mL of 1:10,000 adrenalin, but despite this, it began to bleed actively. A band was placed around the AVM with immediate cessation of bleeding. Four days later at repeat endoscopy a superficial ulcer was seen at the site of the AVM, with the band being no longer present. The patient was discharged the next day, having had no further bleeding. Six weeks later, endoscopy revealed an ulcer scar; the AVM was not visible. There was no further bleeding during 6 months of follow-up. A 75-year-old man with a documented 8 mm AVM on the greater curvature of the stomach was referred for definitive therapy. He had a history of five episodes of significant upper gastrointestinal bleeding requiring transfusion of a total of 20 units of packed cells over 2 years. The last two episodes had occurred in the preceding month. The AVM was treated by band ligation (Fig. 1A and B). There has been no further bleeding during 6 months of follow-up. VOLUME 48, NO. 5, 1998
Endoscopic band ligation for non-variceal non-ulcer GI hemorrhage
A
B Figure 1. A, Gastric arteriovenous malformation. B, Arteriovenous malformation after band ligation. Note that the AVM is wholly included within the banded mucosa. Dielufoy’s lesion A 75-year-old man presented after two episodes of hematemesis and melena, the second episode being associated with collapse, hemodynamic instability, and anemia (hemoglobin 7.5 gm/dL). Panendoscopy showed a bleeding DL on the proximal lesser curve of the stomach. A band was placed around the lesion with immediate cessation of bleeding (Fig. 2A and B). He was discharged 4 days later, having had no further evidence of bleeding. Endoscopy 4 weeks later disclosed a shallow 6 mm ulcer at the site of the DL. At telephone interview 12 months later, there had been no further bleeding. A 69-year-old man with multiple medical problems was transferred to our hospital because of severe pneumonia, unstable blood sugars, and acute renal failure. Melena was noted on the day of transfer. Panendoscopy showed a bleeding DL in the first part of the duodenum. The duodenal cap appeared scarred but no ulcer was present. Band ligation was performed. The patient was free of bleeding for 24 hours, after which there was a recurrence of melena. Repeat endoscopy revealed a shallow ulcer at the site of VOLUME 48, NO. 5, 1998
D Abi-Hanna, S Williams, P Gillespie, et al.
A
B Figure 2. A, Bleeding gastric Dieulafoy’s lesion. B, Dieulafoy’s lesion after band ligation. Note protruding vessel visible at top of banded mucosa banding with an overlying fresh clot. The band was no longer present. A total of 9 mL of 1:10,000 adrenalin was injected into and around the ulcer with blanching of the area. Over the next 2 weeks there was no further bleeding and the patient’s general condition improved. He was discharged back to his referring hospital. A telephone followup disclosed no further bleeding at 12 months. Mallory-Weiss tear A 72-year-old man was admitted after 2 days of diarrhea and vomiting which was followed by three episodes of hematemesis and later three episodes of melena. The patient was receiving coumadin for a metallic cardiac valve prosthesis. Because of the risk of thromboembolism, his anticoagulation was not reversed, but no further coumadin was administered until bleeding was controlled. Panendoscopy on the day of admission showed a MWT with active bleeding and a visible vessel. The area was injected with 10 mL of 1:10,000 adrenalin with cessation of bleeding. Twelve hours later he had a further large hematemesis and repeat endoscopy showed recurrence of active bleeding at the same site. The vessel and surroundGASTROINTESTINAL ENDOSCOPY
511
D Abi-Hanna, S Williams, P Gillespie, et al.
ing mucosa were banded with immediate hemostasis. No further bleeding was noted and the patient was discharged on day five. At 12-month telephone follow-up there had been no recurrence of bleeding. A 62-year-old man suffered an acute myocardial infarction and was given morphine for pain relief and a thrombolytic agent (recombinant tissue plasminogen activator). Soon after, he began to vomit, initially, undigested food then frank blood. With repeated hematemesis he became hemodynamically compromised (hemoglobin of 6.0 mg/dL). At urgent endoscopy a large MWT was seen with an actively bleeding visible vessel. A band was applied with immediate hemostasis. There was no further bleeding during the following week of hospitalization and the ensuing 3 months. Post-polypectomy A 54-year-old man presented with rectal bleeding 4 days after polypectomy at another hospital. Sigmoidoscopy revealed a polyp stalk oozing blood at 15 cm from the anal verge. A band was applied with immediate cessation of bleeding (Fig. 3A and B). The patient was discharged the next day with no further bleeding. Telephone interview at 12 months confirmed that there had been no further bleeding.
RESULTS Endoscopic band ligation was successful in 17 of 18 cases, with a follow-up period ranging from 2 to 18 months. The remaining case, a duodenal Dieulafoy’s lesion, bled again at 24 hours but was successfully treated by adrenalin injection. DISCUSSION The endoscopic approach to the more frequent causes of gastrointestinal hemorrhage, peptic ulcer disease and esophageal varices, is now reasonably well defined as a consequence of randomized controlled trials and meta-analysis of these trials.1,7 In contrast non-variceal, non-ulcer gastrointestinal hemorrhage is uncommon and there is no clear consensus on best method of endoscopic treatment. Endoscopic band ligation has now emerged as the method of choice for treatment (both acute and interval) of esophageal variceal bleeding.1 In contrast to thermal methods of endoscopic hemostasis, EBL does not involve initial tissue destruction, but rather the controlled ligation of the bleeding source, analogous to tying a suture around a bleeding vessel. In addition, EBL offers rapid “single shot,” mechanical, hemostasis if the elastic band is applied directly over the bleeding source. The procedure is relatively simple to learn and the equipment required readily available and inexpensive. These factors have made the application of this modality to various causes of gastrointestinal bleeding attrac512
GASTROINTESTINAL ENDOSCOPY
Endoscopic band ligation for non-variceal non-ulcer GI hemorrhage
tive. However, EBL can only be considered for pliable, non-fibrotic lesions because the lesion and surrounding tissue must be aspirated into the friction fit chamber at the endoscope tip for successful ligation. This limitation precludes the use of EBL for lesions with associated fibrosis, such as visible vessels within peptic ulcers. The first case reports of EBL for post-polypectomy and bleeding of DL appeared in 1994.2-4 A series of 10 patients (DL 5, AVM 4, and post-gastric polypectomy 1) was also reported in 1994 in abstract form.6 Successful banding of a bleeding AVM was reported in 1996.5 Our series of 18 patients extends these observations and includes the first two reported cases of EBL for actively bleeding MWTs. AVMs are an uncommon cause of upper gastrointestinal hemorrhage, accounting for between 1% and 5% of cases of bleeding in various series.8 Including our 10 cases, a total of 15 cases of EBL in AVM have been reported; therapy was successful in all cases. A superficial ulcer invariably develops at the site of EBL (Fig. 4), but in our experience and that of others, this heals quickly with acid suppression, without pain or bleeding.9 Treatment-induced bleeding is common with thermal methods of AVM ablation and occasionally this may create technical difficulties. In contrast, if bleeding occurs with EBL it is usually of short duration and confined to the suction phase of band application. DL is also an infrequent cause of gastrointestinal hemorrhage, accounting for 0.3% to 6.7% of cases.8 Including our 4 cases, there have been 10 cases reported of treatment of DL with EBL. Hemostasis was achieved in all cases, but in our patient with a duodenal DL (all other reported cases are gastric DL), bleeding recurred 24 hours later and was associated with a shallow ulcer at the site of banding with an adherent fresh clot. The area was injected with adrenalin with cessation of bleeding. It is possible that the band slipped off early in this patient because of the presence of scarring and fibrosis. A retrospective analysis of 31 patients with bleeding DL revealed that lesions managed by injection alone were more likely to bleed again. Band ligation and contact thermal methods were both 100% effective.10 Again, thermal methods carry a risk of treatment induced bleeding in contrast to precisely targeted EBL. Given the infrequency of DL, a randomized trial comparing one modality with another will probably not be possible. However this report extends the observations of others that attest to the safety and efficacy of EBL in this condition. MWT accounts for 5% to 15% of cases of upper gastrointestinal hemorrhage.8 Endoscopic band ligation has not been reported in the treatment of VOLUME 48, NO. 5, 1998
Endoscopic band ligation for non-variceal non-ulcer GI hemorrhage
D Abi-Hanna, S Williams, P Gillespie, et al.
A Figure 4. Typical ulcer 4 weeks after EBL of a gastric AVM. All patients in our series were placed on acid suppression for a minimum of 4 weeks.
B Figure 3. A, Oozing sigmoid polypectomy site 4 days after polypectomy. B, Bleeding polypectomy site after band ligation. Note visible stalk vessel which is included within banded mucosa.
actively bleeding MWT; our two cases are the first to the best of our knowledge. Because MWT is actually a mucosal tear, EBL may be an ideal treatment because the band ligates mucosa and submucosa,9 effectively closing the tear. Fortunately, the majority of MWTs resolve spontaneously, but 1% to 3% require intervention.8 In our two cases, it is clear that the bleeding was unlikely to stop spontaneously. Injection therapy had already failed in one patient and both patients had a coagulopathy. Intuitively, thermal methods of hemostasis which require some degree of tissue destruction are unlikely to be effective with patients with coagulopathies. Endoscopic band ligation provides mechanical hemostasis that is largely independent of blood clotting. Post-polypectomy hemorrhage occurs in 0.5% to 2.2% of cases of endoscopic polypectomy and may be delayed.11,12 Our two cases bring the total reported VOLUME 48, NO. 5, 1998
to 5 cases of EBL for post-polypectomy bleeding (4 colonic, 1 gastric). The procedure is highly effective but was used mainly (4 of 5 cases) after failure of other modalities. Endoscopic band ligation is uniquely suited to the treatment of bleeding from a protuberant residual polyp stalk. However, the necessity to “carry” the ligation apparatus, which attenuates the endoscopic view, to the bleeding source adds complexity to the treatment of right sided colonic lesions. The utilization of EBL for non-variceal, non-ulcer bleeding has mainly been described in small series and case reports where other modalities have failed. This accumulated evidence and our own results confirm the safety and efficacy of this technique. Greater experience in prospective trials is required to transform the conceptual appeal of EBL for nonvariceal, non-ulcer bleeding into a standard, widely practiced endoscopic technique. REFERENCES 1. Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 1995;123:280-7. 2. Slivka A, Parsons WG, Carr-Locke DL. Endoscopic band ligation for treatment of post-polypectomy haemorrhage. Gastrointest Endosc 1994;40:230-2. 3. Smith RE, Doull J. Treatment of colonic post-polypectomy bleeding site by endoscopic band ligation. Gastrointest Endosc 1994;40:499-500. 4. Brown GR, Harford WV, Jones WF. Endoscopic band ligation of an actively bleeding Dieulafoy lesion. Gastrointest Endosc 1994;40:501-3. 5. Baniukiewicz A, Sklodowskiej MC. An endoscopic treatment for gastric angiodysplasia, using an endoscopic ligating device designed to treat esophageal varices [letter]. Endoscopy 1996;28:787. GASTROINTESTINAL ENDOSCOPY
513
6. Jones WF, Khandelwal M, Akerman P, Garcia-Rebull M, Kandel G, Kortan P, et al. Endoscopic band ligation (EBL) for acute non-variceal/non-ulcer upper gastrointestinal haemorrhage (NVNU-UGIH) [abstract]. Gastrointest Endosc 1994; 40:P25. 7. Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med 1994;331:717-27. 8. Katz PO, Salas L. Less frequent causes of upper gastrointestinal bleeding. Gastroenterol Clin North Am 1993;22:875-89. 9. Stiegmann GV, Sun H, Hammond WS. Results of experimental endoscopic esophageal varix ligation. Am Surg 1988; 54:105-8.
514
GASTROINTESTINAL ENDOSCOPY
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