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Bizarre ulcer in the cecum with blood-covered borders.

f d Flat ulcer on a haustrum in the ascending colon; the surrounding area shows no reaction. The patient was using Diclo-fenac.

e Bizarre ulceration on the Bauhin valve.

Bizarre ulcer in the cecum with blood-covered borders.

g Depressed linear ulceration with swollen margins.

h Larger, flat ulcer on the Bauhin valve, with a visible vessel on its margin.

Large ulcer with swollen borders in the descending colon.

g Depressed linear ulceration with swollen margins.

h Larger, flat ulcer on the Bauhin valve, with a visible vessel on its margin.

Large ulcer with swollen borders in the descending colon.

Fig. 13.30 Hemorrhagic and erosive defects in swollen colon mucosa. The patient was using nonsteroidal antiinflammatory drugs.

Neoplasias (see also Chapter 10)

Carcinomas. Carcinomas were cited in one study in 21 % of patients as the source of hematochezia (45). More probable figures range from 2-9% (14, 34, 36, 40, 43, 52, 57).

Bleeding from a carcinoma (Figs. 13.31-13.35) is the result of erosions and ulcerations on the surface of the tumor, which can be exacerbated by use of anti-inflammatory drugs. Carcinomas in the sigmoid colon often lead to early rectal bleeding. In the right hemicolon, in contrast, they do not manifest with rectal bleeding until after they are clearly ulcerated.

Endoscopic therapy

► Endoscopic therapy must be determined on an individual basis. Based on our experience, injection therapy and mechanical hemostasis using hemoclips have proved to be effective methods ( E 13.5 b, c).

Endoscopic therapy

► Both laser and APC methods allow endoscopic hemosta-sis of the usually superficially bleeding carcinomas by means of noncontact thermocoagulation. APC has proved especially effective based on individual reports (50,11) and also in our own experience.

Rectal Erosion

Fig. 13.31 Polyp in the rectum with erosion of the tip and a small visible vessel.

Histology revealed an adenocarcinoma.

Fig. 13.31 Polyp in the rectum with erosion of the tip and a small visible vessel.

Histology revealed an adenocarcinoma.

Fig. 13.32 Rectal carcinoma with hemor-rhagic oozing.

Fig. 13.33 Ulcerated rectal carcinoma with hemorrhagic oozing.

Fig. 13.34 Bleeding caused by a bladder carcinoma protruding into the rectum.

Fig. 13.35 Polyp at rectosigmoid junction with eroded and bleeding surface. The polyp was already transforming into an adenocarci-

Fig. 13.36 Stalked polyp covered with a layer of blood.

► Thermocoagulation using contact methods is less suitable because tearing of tissue after completing coagulation can cause hemorrhagic oozing.

► Injection of absolute alcohol into a tumor has reportedly been successful in achieving hemostasis (5).

► In circumscribed bleeding sources, especially with visible vessels, mechanical methods such as hemoclipping can also be used.

gastrointestinal bleeding from benign polyps is polypectomy (0 13.6, 13.7, Fig. 13.37). Bleeding may occur immediately after resection (0 13.6, Fig. 13.37), though the time between polypectomy and bleeding can vary, and can occasionally be a few days (0 13.7).

Colon polyps. Colon polyps are cited in 5-11 % of patients as the source of acute lower gastrointestinal bleeding (overview in 64). However, polyps are more commonly involved in chronic intermittent bleeding.

Generally, it is larger polyps with a diameter greater than 1 cm that bleed (Fig. 13.36). The polyp surface demonstrates lesions of uncertain genesis, though they could be caused by hardened waste eroding the vulnerable polyp surface. Anti-inflammatory drugs or acetylsalicylic acid probably play a role. The most common cause of lower

Endoscopic therapy

► Bleeding can generally be controlled endoscopically. Preferred methods of hemostasis include epinephrine injection or hemoclip application (0 13.6,13.7 a-c), or a combination of the two (Fig. 13.37).

► Therapy with hemoclips seems to be the more reliable method based on our own experience in that they guarantee mechanical closure of the vessel if applied correctly.

- |T] 13.6 Bleeding after resection of colon polyps, hemostasis with clips -

Lar -n j a b c a-c Bleeding after partial resection of a large, broad-based polyp at the rectosigmoid junction (a). Visible vessel can be seen after irrigation (b) at the base of the resection wound. Bleeding was definitively controlled by application of three hemoclips (Olympus) (c).

d, e Broad-based sessile polyp (histology: tubular adenoma) (d). After resection, spurting bleeding stopped with two hemo-clips (Olympus) (e).

Colon Tubular Adenoma

d, e Broad-based sessile polyp (histology: tubular adenoma) (d). After resection, spurting bleeding stopped with two hemo-clips (Olympus) (e).

Sessile Polyp The Sigmoid

f, g Broad-based, sessile polyp (opposite the Bauhin valve) (f). After polypectomy by means of mucosectomy, bleeding occurred from a vessel. The visible vessel on the edge of the resection site was closed with two hemoclips (Olympus) (g).

Although it does not belong to the topic of polyps, rebleeding after forceps biopsy (Figs. 13.38,13.39) should be mentioned here. Not infrequently, the cause of rebleeding lies in anticoagulant use, which is resumed too soon or not discontinued before the biopsy.

Anorectal Diseases

Anorectal causes of acute lower gastrointestinal bleeding can be detected in fewer than 10% of patients, whereby hemorrhoids and anal fissures are the main sources of bleeding. The exact prevalence is difficult to determine, as some studies of acute lower gastrointestinal bleeding do not include anorectal causes.

- [F| 13.7 Rebleeding after polypectomy, hemostasis with clips

- [F| 13.7 Rebleeding after polypectomy, hemostasis with clips

Fissures Sigmoid Colon

c a-c Polypectomy site in the ascending colon. A visible vessel can be seen on the upper edge of the resection defect (a), which led to massive rebleeding. Hemostasis is attempted with a single hemoclip (Olympus) (b). An additional clip is used to definitively compress and close the visible vessel (c).

Adherent clot on the resection site; rebleeding after polypectomy in the sigmoid colon.

Visible vessel protruding from the remaining stalk of a resected polyp in the sigmoid colon.

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