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Vol. 82. Num. 4.October - December 2017
Pages 275-364
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Vol. 82. Num. 4.October - December 2017
Pages 275-364
CLINICAL IMAGE IN GASTROENTEROLOGY
DOI: 10.1016/j.rgmxen.2017.07.007
Acute intestinal bleeding after endoscopic polypectomy: Super-selective endovascular embolization in a clinically unstable patient
Hemorragia intestinal aguda después de polipectomía endoscópica: embolización superselectiva en un paciente clínicamente inestable
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U.G. Rossia,
Corresponding author
urossi76@hotmail.com

Corresponding author. Unidad de Radiología y Radiología Intervencionista, Departamento de Ciencias Diagnósticas, ASST Santi Paolo y Carlo-Hospital San Carlo Borromeo, Via Pio II 3, 20153 Milan, Italy. Tel.: +39 02 40222465; fax: ++39 02 40222465.
, G. Rubis-Passonib, P. Torciaa, M. Cariatia
a Interventional Radiology and Radiology Unit, Department of Diagnostic Sciences ASST Santi Paolo y Carlo-Hospital San Carlo Borromeo, Milan, Italy
b Interventional Endoscopy and Diagnostic Unit, Department of Gastroenterology ASST Santi Paolo and Carlo-Hospital San Carlo Borromeo, Milan, Italy
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A 70-year-old man underwent endoscopy that revealed an adenomatous polyp in the ascending colon (fig. 1). It was removed in the same session through the placement of four endoscopic clips (fig. 2). Six hours after the endoscopic polypectomy, the patient presented with severe intermittent lower intestinal bleeding with an initial hemodynamically unstable status: heart rate > 80 bpm and systolic blood pressure <100mmHg. After multidisciplinary agreement, the patient underwent urgent selective digital subtraction angiography of the superior mesenteric artery that showed the presence of active bleeding in the ascending colon in the area of the previous endoscopic polypectomy (fig. 3A). Super-selective transarterial embolization of the active bleeding was performed with success (fig. 3 B and C). Lower intestinal bleeding disappeared and the patient was hemodynamically stable immediately after the transarterial embolization. The patient did not need a bowel resection.

Figure 1.
(0.17MB).

Ascending colon endoscopy showing an adenomatous polyp (arrowheads).

Figure 2.
(0.18MB).

Final endoscopic control after polypectomy with the placement of four endoscopic clips (arrows).

Figure 3.
(0.27MB).

A) Selective digital subtraction angiography of the superior mesenteric artery that shows the presence of contrast extravasation (arrowhead) from the vasa recta of a distal arcade of the right colic artery, next to the only remaining endoscopic clip (arrow). B) Super-selective catheterization of the distal arcades of the right colic artery with contrast extravasation from the vasa recta (arrowhead) near the endoscopic clip (arrow). C) Final selective digital subtraction angiography of the superior mesenteric artery that shows the complete exclusion of the vasa recta of a distal arcade of the right colic artery embolized by n-butyl cyanoacrylate with the absence of contrast extravasation (arrowhead) near the endoscopic clip (arrow).

Lower intestinal bleeding after endoscopic polypectomy can be seen up to 2 weeks after the procedure. However, acute post-polypectomy bleeding is due to: insufficient hemostasis of the vessels, or sloughing of the surface coagulum1. Despite advances in medical management, acute lower intestinal bleeding after endoscopic polypectomy remains a major complication with high morbidity and mortality. Interventional endoscopy and angiography are the fastest and least invasive therapies for controlling this major complication2,3. Nevertheless, endovascular embolization is the preferred therapy when there is massive hemorrhage or in clinically unstable patients3.

Ethical disclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that no patient data appear in this article.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Financial disclosure

No financial support was received in relation to this article.

Conflict of interest

The authors declare that there is no conflict of interest.

References
[1]
D.T. Weldon,S.J. Burke,S. Sun
Interventional management of lower gastrointestinal bleeding
Eur Radiol, 18 (2008), pp. 857-867 http://dx.doi.org/10.1007/s00330-007-0844-2
[2]
O.R. Busch,O.M. van Delden,D.J. Gouma
Therapeutic options for endoscopic haemostatic failures: The place of the surgeon and radiologist in gastrointestinal tract bleeding
Best Pract Res Clin Gastroenterol, 22 (2008), pp. 341-354 http://dx.doi.org/10.1016/j.bpg.2007.10.018
[3]
M.S. Cappell,M. Abdullah
Management of gastrointestinal bleeding induced by gastrointestinal endoscopy
Gastroenterol Clin North Am, 29 (2000), pp. 125-167

Please cite this article as: Rossi UG, Rubis-Passoni G, Torcia P, Cariati M. Hemorragia intestinal aguda después de polipectomía endoscópica: embolización superselectiva en un paciente clínicamente inestable. Revista de Gastroenterología de México. 2017;82:341–343.

Copyright © 2017. Asociación Mexicana de Gastroenterología
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