Revista de Gastroenterología de México Revista de Gastroenterología de México
DOI: 10.1016/j.rgmxen.2017.07.007
CLINICAL IMAGE IN GASTROENTEROLOGY
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
U.G. Rossia,, , 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

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 responsibilitiesProtection of persons and animals

The authors declare that no experiments on humans or animals were carried out in relation to this study.

Data confidentiality

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.

Conflict of interest

The authors declare that there is no conflict of interest.

References
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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. http://dx.doi.org/10.1016/j.rgmx.2017.01.007

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. (U.G. Rossi urossi76@hotmail.com)
Copyright © 2017. Asociación Mexicana de Gastroenterología
DOI: 10.1016/j.rgmxen.2017.07.007