Retroflexed View Rectum

Endoscopie Rectite Radique Apr Plasma

Fig. 13.37 Bleeding from a visible vessel of a resected polyp. b a Visible vessel, protruding from the remaining stalk of a resected c polyp in the sigmoid colon, causing massive rebleeding.

Fig. 13.37 Bleeding from a visible vessel of a resected polyp. b a Visible vessel, protruding from the remaining stalk of a resected c polyp in the sigmoid colon, causing massive rebleeding.

Epinephrine injection (1:10000) at the resection site.

Afterward the visible vessel is clipped and closed with two hemoclips

(Olympus).

Fig. 13.39 Visible vessel at the site of an excisional biopsy of the colon mucosa. The mucosa is slightly elevated around the biopsy site as a result of submucosal bleeding.

Sigmoid Colon Srs Visible
Fig. 13.38 Small visible vessel at the site of an excisional biopsy of the colon mucosa.

Fig. 13.39 Visible vessel at the site of an excisional biopsy of the colon mucosa. The mucosa is slightly elevated around the biopsy site as a result of submucosal bleeding.

Fig. 13.40 Bloodsoaked anal fissure.

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Hemorrhoids. Hemorrhoids are the source in 2-9% of patients with acute lower gastrointestinal bleeding (overview in 64). In particular, among patients with HIV they seem to be a not uncommon cause of bleeding (12).

Endoscopic therapy

► Hemorrhoid management long belonged to the domain of surgical intervention. In recent years, however, endoscopic alternatives have established themselves in the treatment of symptomatic internal hemorrhoids and hemorrhoidal bleeding. Ligation of internal hemorrhoids has proved an especially effective and easy-to-learn method for treating internal hemorrhoid bleeding.

► Jensen (29) compared BICAP (bipolar coagulation) and heater probe therapies of bleeding internal hemorrhoids. Pain was more often reported with heater probe use, yet the success of therapy compared with BICAP was more evident and appeared more quickly.

According to our own clinical files, acute hemorrhoidal bleeding occurs less frequently than bleeding following ligation of internal hemorrhoids (0 13.8a-c). Rebleeding after hemorrhoid operation is also seen on occasion (013.8f, g). Mechanical hemostasis using hemoclips has proved effective.

Anal fissures. Though anal fissures (Fig. 13.40) often cause bloody stools, acute bleeding is rare. Fissures are relatively easily diagnosed by inspecting the anus. The patient typically has severe pain upon spreading the anus, but the lesion can be carefully and painlessly inspected after injecting a few milliliters of local anesthesia. Bleeding from fissures usually ceases spontaneously. If bleeding is detectable at the time of examination, however, hemostasis can be attempted with injection of an epinephrine solution. Hemostasis can also be attempted with a swab soaked in epinephrine placed in the anus.

|T] 13.8 Rebleeding after ligation or surgical intervention for hemorrhoids

|T] 13.8 Rebleeding after ligation or surgical intervention for hemorrhoids

Sigmoid Fissure Pain

a-c Bleeding after ligation of an internal hemorrhoid. A bloodsoaked polypoid form is visible with a slight ring around the base where it was ligated (a). Following removal of the elevated tissue, hemorrhagic oozing ensued (b), and bleeding was stopped mechanically using three hemoclips (Olympus) (c).

c a-c Bleeding after ligation of an internal hemorrhoid. A bloodsoaked polypoid form is visible with a slight ring around the base where it was ligated (a). Following removal of the elevated tissue, hemorrhagic oozing ensued (b), and bleeding was stopped mechanically using three hemoclips (Olympus) (c).

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e d Diffuse bleeding from an anorectal ulcer which formed after a ligated internal hemorrhoid fell off. The image was taken with a retroflexed colonoscope. e Thick visible vessel protruding from the resection site (band ligation) of an internal hemorrhoid at the upper border of the anal canal. The ligated hemorrhoid fell off. The image was taken with a retroflexed instrument.

Taken Out Hemorrhoid

Rebleeding from an operative wound four days after hemorrhoidectomy. A clip has already been applied, but cannot stem the flow of arterial bleeding. Hemostasis was not achieved until two further hemoclips (Olympus) were applied. The image was taken with a retroflexed colonoscope in the rectum-view from above to the upper edge of the anus.

Ulcer with visible vessel on the outer margin of the anus, causing anal bleeding. A hemorrhoid operation was performed fourteen days prior. The patient was known to suffer from Crohn disease.

Ulcer Anal Cleft Biopsied
Fig. 13.41 Solitary rectal ulcer.
Retroflexed View Rectum

Fig. 13.43 Relatively large, rectal ulcer with fibrinous exudate of uncertain genesis.

Fig. 13.42 Solitary rectal ulcer in a patient who complained of low-grade anal rebleeding. He was previously treated with rectopexy to relieve severe rectal constipation.

Fig. 13.43 Relatively large, rectal ulcer with fibrinous exudate of uncertain genesis.

Solitary rectal ulcer. Local ischemia appears to play a role in the pathogenesis of solitary rectal ulcers (Figs. 13.41-13.43). Intussusception (internal rectal prolapse) causes excessive straining which, through repeated compression of the anorectal mucosa leads to necrosis and ulceration. The ulcer usually becomes symptomatic with pain and a layer of blood on the stool. Heavy bleeding is rare.

Ectasies Vasculaires Antrales

Fig. 13.44 Injury to the rectal wall and hematochezia.

a Injury from a transrectal prostate biopsy. b Bleeding source closed with two hemo-clips (Olympus).

Fig. 13.44 Injury to the rectal wall and hematochezia.

a Injury from a transrectal prostate biopsy. b Bleeding source closed with two hemo-clips (Olympus).

Arterial Bleeding

Fig. 13.47 Arterial bleeding from a rectal stump from a Hartmann procedure. Bleeding occurred some time after operative intervention for carcinoma. The patient was treated preoperatively with neoadjuvant chemoradiotherapy. Bleeding could not be controlled using hemoclips and did not stop until after injection of acrylic glue.

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Colon Wall Injected With Ink

Fig. 13.46 Submucosal rectal wall bleeding from anticoagulation with Marcumar.

The patient presented with massive hematochezia. Prior to endoscopy, coagulation was normalized by administering clotting factors.

Fig. 13.45 Transmural laceration (perforation) of the rectal wall. The lesion was caused by balloon inflation during a proc-tometrogram (to determine rectal sensation) as part of anal manometry. Injury to the wall manifested clinically with anal bleeding immediately after examination. The lesion healed with conservative therapy and without any further problems.

Fig. 13.46 Submucosal rectal wall bleeding from anticoagulation with Marcumar.

The patient presented with massive hematochezia. Prior to endoscopy, coagulation was normalized by administering clotting factors.

Fig. 13.47 Arterial bleeding from a rectal stump from a Hartmann procedure. Bleeding occurred some time after operative intervention for carcinoma. The patient was treated preoperatively with neoadjuvant chemoradiotherapy. Bleeding could not be controlled using hemoclips and did not stop until after injection of acrylic glue.

Endoscopic therapy

► There are no comparative studies on optimal endoscopic therapy. Hemoclips can be applied or local injection of epinephrine solution may be used for circumscribed bleeding sources.

► Thermocoagulation (APC) can be attempted for diffuse bleeding.

Mechanical lesions of the rectal mucosa. Such lesions are not an entirely rare cause of acute lower gastrointestinal bleeding. Rectal manipulation on the part of the patient can cause quite serious damage to the mucosa. Injuries from thermometer use are less frequent nowadays as rectal temperature measurement is no longer common. Treatment principles are analogous to those for other circumscribed bleeding sources.

Rectal bleeding following diagnostic procedures such as transected prostate biopsy (Fig. 13.44) or functional diagnostic investigations (Fig. 13.45) is rare. Rectal wall hemorrhage due to anticoagulation drugs (Fig. 13.46) is uncommon. The treatment of choice is to correct clotting. Postoperative rectal bleeding (Fig. 13.47) is not particularly uncommon, especially if the mucosa has been damaged by prior radiation therapy.

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  • efrem
    What is a retroflexed view of the colon?
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    What is the retroflexed view of the rectum?
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