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Background Risk factors and outcomes of severe hematochezia from ischemic colitis compared with other colonic diagnoses have not been well studied. Objective Our purposes were (1) to compare demographics and outcomes of patients hospitalized with severe hematochezia from ischemic colitis compared with other colonic diagnoses, (2) to compare inpatient and outpatient start of bleeding from ischemic colitis, and (3) to describe potential risk factors. Design Prospective cohort study. Setting Tertiary referral academic centers. Patients Patients referred for gastroenterology consultation for severe hematochezia. Interventions Colonoscopic therapy was provided as indicated. Main Outcome Measurements Rebleeding, surgery, and length of hospital stay after colonoscopy. Results Of 550 patients in the past 12 years with severe hematochezia from colonic sources, the cause in 65 patients (11.8%) was ischemia. Ischemic colitis was found more often in females, in patients taking anticoagulant agents, in patients with severe lung disease, those with higher creatinine levels, those with higher glucose levels, and those with more fresh frozen plasma transfusions. Five patients with focal lesions had colonoscopic hemostasis. Major 30-day outcomes of ischemic colitis patients were significantly worse than patients with other colonic diagnoses. Patients with inpatient (vs outpatient) ischemic colitis had significantly more and more severe comorbidities at baseline and significantly higher rates of rebleeding, surgery, and more days spent in hospital and in the intensive care unit. Limitations Two-center study. Conclusions Major 30-day outcomes in ischemic colitis patients were significantly worse than in patients with other colonic diagnoses. Comparing outpatient and inpatient start of ischemic colitis, inpatients had significantly worse outcomes.

Background and Aims Few prospective reports describe the short-term natural history of colon diverticular hemorrhage based on stigmata of recent hemorrhage, and none include blood flow detection for risk stratification or as a guide to definitive hemostasis. Our purposes were to report the 30-day natural history of definitive diverticular hemorrhage based on stigmata and to describe Doppler probe blood flow detection as a guide to definitive hemostasis. Methods Different cohorts of patients with severe diverticular bleeding and stigmata on urgent colonoscopy are reported. For 30-day natural history, patients were treated medically. If severe rebleeding occurred, they had surgical or angiographic treatment. We report natural history with major stigmata (active bleeding, visible vessel, or adherent clot) and no stigmata or flat spots after clots were washed away. We also report Doppler probe detection of arterial blood flow underneath stigmata before and after hemostasis in a recent cohort. Results For natural history, patients with major stigmata treated medically had 65.8% (25/38) rebleeding rates, and 44.7% (17/38) had intervention for hemostasis. Patients with spots or clean bases had no rebleeding. A Doppler probe detected arterial blood flow in 92% of major stigmata—none after hemostasis—and there was no rebleeding. Conclusions (1) Patients with major stigmata treated medically had high rates of rebleeding and intervention for hemostasis. (2) Patients with clean diverticula or only flat spots had no rebleeding. (3) High rates of arterial blood flow were detected under major stigmata with a Doppler probe, but with obliteration by hemostasis no rebleeding occurred.

For more than 4 decades endoscopists have relied on ulcer stigmata for risk stratification and as a guide to hemostasis. None used arterial blood flow underneath stigmata to predict outcomes. For patients with severe peptic ulcer bleeding (PUB), we used a Doppler endoscopic probe (DEP) for (1) detection of blood flow underlying stigmata of recent hemorrhage (SRH), (2) quantitating rates of residual arterial blood flow under SRH after visually directed standard endoscopic treatment, and (3) comparing risks of rebleeding and actual 30-day rebleed rates for spurting arterial bleeding (Forrest [F] IA) and oozing bleeding (F IB).Prospective cohort study of 163 consecutive patients with severe PUB and different SRH.All blood flow detected by the DEP was arterial. Detection rates were 87.4% in major SRH-spurting arterial bleeding (F IA), non-bleeding visible vessel (F IIA), clot (F IIB)-and were significantly lower at 42.3% (P.0001) for an intermediate group of oozing bleeding (F IB) or flat spot (F IIC). For spurting bleeding (F IA) versus oozing (F IB), baseline DEP arterial flow was 100% versus 46.7%, residual blood flow detected after endoscopic hemostasis was 35.7% versus 0%, and 30-day rebleed rates were 28.6% versus 0% (all P.05).(1) For major SRH versus oozing or spot, the arterial blood flow detection rate by the DEP was significantly higher, indicating a higher rebleed risk. (2) Before and after endoscopic treatment, spurting (F IA) PUB had significantly higher rates of blood flow detection than oozing (F IB) PUB and a significantly higher 30-day rebleed rate. (3) The DEP is recommended as a new endoscopic guide with SRH to improve risk stratification and potentially definitive hemostasis for PUB.

Background Our purposes were to (1) evaluate efficacy and safety of bipolar or heater probe endoscopic coagulation compared to prior medical therapy for bleeding radiation telangiectasia, and (2) consider the impact of treatments on patients' impression of their overall health and activity. Methods Twelve months of medical management had failed in 18 men and 3 women with chronic, recurrent hematochezia and anemia after radiation treatment of pelvic malignancies. Patients had multiple rectal telangiectasias coagulated with bipolar or heater probes in a randomized, prospective study. Results Rectal bleeding stopped within four treatment sessions. During 12 months of endoscopic versus medical therapy, severe bleeding episodes diminished significantly for bipolar probe versus 12 months of prior medical therapy (75% vs 33%) and heater probe (67% vs 11%); mean hematocrits rose significantly for patients undergoing bipolar (38.2 vs 31.9) and heater probe (37.6 vs 28.4) treatments, and their impression of overall health improved. During long-term follow-up, new telangiectasias or rectal bleeding were easily controlled. No major complications resulted. Conclusions (1) Bipolar or heater probes were safe and effective relative to medical therapy for palliation of patients with lower gastrointestinal bleeding from radiation telangiectasias, and (2) all patients improved in ability to travel and exercise and in their overall impression of their health.

The purpose of this study was to compare the relative efficacy and technical ease of use of eight different agents for endoscopic hemostasis and obliteration of bleeding gastric varices in a canine model, as no comparative data are available on gastric variceal sclerotherapy. Large bleeding gastric varices in 20 heparinized dogs were randomized to endoscopic injection treatment with one of the following agents: cyanoacrylate; a 1:1:1 mixture of sodium tetra-decyl sulfate 3%, ethanol 98%, and normal saline solution; ethanolamine oleate 5%; sodium morrhuate 5%; sodium tetradecyl sulfate 1.5%; polidocanol 1%; normal saline solution with epinephrine 1:10,000; or normal saline solution (control). The number and volume of injections and the time required to achieve complete hemostasis were evaluated; follow-up endoscopy was performed at 1 month to assess gastric variceal obliteration. Cyanoacrylate was the best agent overall in terms of immediate efficacy, low volume requirement, time required for initial hemostasis, and reduction of gastric variceal size. Cyanoacrylate, tetradecyl sulfate, and polidocanol were the most effective agents for reducing gastric variceal size. Epinephrine was effective for controlling induced or secondary bleeding caused by puncture of the gastric varices with the sclerotherapy needle during intravariceal injections. Ongoing studies are evaluating combinations of agents with different mechanisms of action, such as epinephrine (for vasoconstriction to minimize secondary bleeding) plus alcohol, and/or tetradecyl sulfate (for variceal thrombosis and sclerosis). In addition, different concentrations of alcohol as a single agent or combined with epinephrine should be evaluated because of the relatively low cost and wide availability of these substances. (Gastrointest Endosc 1995; 41:206-11.)

Background: Endoscopic diagnosis and treatment of hematochezia caused by rectal ulcers is poorly described. Methods: Consecutive patients hospitalized with severe hematochezia underwent urgent colonoscopy after purge. Those with rectal ulcers were divided into 2 groups based on the absence or presence of major stigmata of recent hemorrhage: active bleeding, visible vessel, or adherent clot. Major stigmata were treated with epinephrine injection and coagulation with a bipolar probe. The primary outcome endpoint was recurrent bleeding within 4 weeks of diagnosis Results: Rectal ulcers were identified in 23 of 285 (8%) patients. Twelve of 23 patients had major stigmata; these patients had an arithmetically greater decrease in hematocrit and required more blood transfusions than patients without major stigmata. Initial hemostasis was achieved in all, but bleeding recurred in 5 with stigmata. Four patients died of comorbid conditions. There was no recurrent bleeding or death in those without stigmata. Conclusions: Patients with rectal ulcers harboring major stigmata are at high risk for severe bleeding, recurrent bleeding, and death. For ulcers with major stigmata, endoscopic hemostasis is feasible but rates of recurrent bleeding are high

Background: There is a significant interest in combination therapy using endoscopic epinephrine injection and thermal coagulation for nonvariceal hemostasis. The purpose of the study was to compare the relative effectiveness, ease of use, and safety of new Injection Gold Probes to other hemostasis techniques in three randomized, controlled laboratory studies of bleeding canine gastric ulcers. Methods: Fifteen dogs with prehepatic portal hypertension were heparinized and bleeding gastric ulcers were induced with jumbo biopsy forceps. Three different prototypes of Injection Gold Probes were compared with monotherapy (thermal, electrocoagulation, or epinephrine injection alone), control, or combination therapy with separate injector and thermal probes. The treatment times, total number of pulses or injections, volume of epinephrine injected, and ease of applications were recorded. Gastric ulcer size, ulcer healing, and complications were evaluated at 1 and 4 weeks. Results: All endoscopic treatments were effective for acute hemostasis compared with control. Thermal coagulation alone was the fastest treatment to perform. The performance of the first Injection Gold Probe prototype was restricted by its small-gauge needle. The second and third Injection Gold Probe prototypes had a larger-gauge needle and irrigation channel which made them faster and easier to use than separate injection catheters and thermal probes. Conclusions: The advantages of Injection Gold Probes were the ability to irrigate, inject, and coagulate without probe removal. Combination therapy did not increase treatment-related complications compared with monotherapies. (Gastrointest Endosc 1998;48:598-605.)

Background : Our purpose was to compare the efficacy, complications, failure rates, and crossovers of heater and bipolar probe treatments of chronically bleeding internal hemorrhoids. Methods : Eighty-one patients (31 female, 50 male) with mean age of 53 years had large (grade 2 to 3) internal hemorrhoids with bleeding for a mean of 12 years, had failed medical management, and were randomized in a prospective study of anoscopic treatments to heater versus bipolar probes. Failure was defined as a major complication or failure to reduce the size of all internal hemorrhoids with three or more treatments. Results : With similar background variables and no difference in treatment times, rectal bleeding and other symptoms were controlled in a shorter time with the heater probe than with the bipolar probe (77 versus 121 days). Five complications (fissures, bleeding, or rectal spasm) occurred with the bipolar probe, and two occurred with the heater probe. The heater probe caused more pain during treatments but had significantly fewer failures and crossovers. Conclusions : For patients who had failed medical management of chronically bleeding internal hemorrhoids, the techniques and complications of heater and bipolar probes were similar, but pain was more common, failures and crossovers were less frequent, and the time to symptom relief was shorter with the heater probe than with the bipolar probe. (Gastrointest Endosc 1997;46:435-43.)

Background: There are no published, detailed assessments of the direct costs of endoscopic hemostasis for actively bleeding peptic ulcers. We compared the direct costs of care for patients with active ulcer hemorrhage treated with endoscopic or medical-surgical therapies and correlated these costs with patient outcomes. Methods: In a prospective, randomized, controlled trial, 31 patients with active ulcer hemorrhage at emergency endoscopy were randomly assigned to heater probe, injection, or medical-surgical treatment. For further ulcer bleeding, heater probe and injection patients were re-treated endoscopically and medical-surgical patients were referred for surgery. Direct costs were estimated using fixed and variable costs for resources consumed and Medicare reimbursement rates for physician fees. Results: Compared to medical-surgical treatment, the heater probe and injection groups had significantly higher primary hemostasis rates (100% and 90% vs 8%) and lower rates of emergency surgery (0% and 10% vs 75%), blood transfusions, and median direct costs per patient ($4153 and $5247 vs $11,149). Furthermore, compared to medical-surgical treatment, the heater probe group had a significantly lower incidence of severe ulcer rebleeding (11% vs 75%). Conclusions: Heater probe and injection sclerosis are similarly efficacious treatments for active ulcer hemorrhage, and both treatments yield significantly lower direct costs of medical care and cost savings. (Gastrointest Endosc 1997;46:105-12.)

Background: Monopolar hot biopsy forceps (HBF), bipolar HBF, and cold biopsy forceps (CBF) followed by bipolar electrocoagulation are used clinically to simultaneously perform a biopsy and coagulate diminutive colon polyps and angiomata. Our purpose was to conduct a randomized, controlled study to evaluate the safety of these different techniques in the canine right colon. Methods: After right colotomy in 8 mongrel dogs, colonic mucosa was grasped en face, tented, and biopsy performed in randomized order. The dogs were sacrificed after nine days and the biopsy sites were identified and histologically examined. Results: Monopolar HBF caused an overall mean rate of acute serosal whitening of 29% compared with 0% for bipolar HBF and CBF and 6% for CBF/bipolar probe. Histologically confirmed transmural injury 9 days after biopsy occurred in 44% of monopolar HBF compared with 5% of bipolar HBF, 0% of CBF, and 50% of CBF/bipolar probe. Conclusions: Monopolar HBF had significantly higher rates of acute serosal whitening and histologic transmural damage than bipolar HBF or cold biopsy alone. On the basis of these results, monopolar HBF should be avoided for coagulation of small or flat right colon lesions such as diminutive polyps or angiomata. (Gastrointest Endosc 1995;42:573-8.)

The purpose of this randomized, nonblinded study was to compare the effectiveness, safety, and technical ease of three different endoscopic techniques for the treatment of bleeding gastric varices in a canine model. Twenty dogs with large, bleeding gastric varices underwent endoscopic hemostasis with rubber band ligation, sclerotherapy, and cyanoacrylate injection. The time and number of attempts required to achieve definitive hemostasis were evaluated for each technique, and each method was assessed for ease of use. Ulceration rates, ulcer size and depth, and stigmata of ulcer hemorrhage were assessed at 1 week. Intravariceal sclerotherapy was the fastest and easiest to perform. Rubber band ligation was intermediate in technical ease, but it caused the largest and deepest ulcers and had the highest rates of stigmata of ulcer hemorrhage and secondary bleeding. Cyanoacrylate injection was the most cumbersome endoscopic method to perform. All three treatments were effective for controlling gastric variceal bleeding. Intravariceal sclerotherapy had the most favorable results overall because of its technical ease, efficacy, and modest complication rates.