Gastrointestinal system (GIS) bleeding is a clinical condition that almost always indicates the presence of an organic disorder and requires careful treatment in terms of treatment. Since it is one of the disease groups that apply to the emergency services of hospitals most frequently, patients with GI bleeding should be questioned very well and undergo a good physical examination. Bleeding from the distal of the Treitz Lipament in the gastrointestinal tract is called lower GI bleeding.
Gastrointestinal tract bleedings; It constitutes a group of diseases with high mortality, high cost of diagnosis and treatment, often requiring hospitalization and monitoring in the intensive care unit, and difficulties in diagnosis and differential diagnosis from time to time. The approach to the patient with lower GI bleeding is a very important issue. Therefore, it sometimes requires multidisciplinary work.
GIS bleeding is one of the important causes of death and is seen in 100-150 per 100,000 people in the society. While the majority of bleeding is from the upper gastrointestinal tract
, 20% is from the lower GI tract. Although bleeding stops spontaneously in 80% of cases, it continues or recurs in 20%. In the group with ongoing bleeding, the need for surgical intervention increases up to 15-30%, especially in advanced ages. Mortality rates may increase up to 30-40% in advanced ages, especially in those with systemic disease. The high rate of death is also due to the delay in the emergency approach to the patient and the incorrect assessment of the amount and speed of bleeding.
Hematochezia is the best indicator of lower GI bleeding. The rectal discharge of blood without losing its physical properties is called hematochezia. Hematochezia can be bright red in color or mixed with stool and can be in the color of cherry rot.
The appearance of the blood becomes darker as it goes proximally. Hematochezia is usually seen in bleeding from the intestinal segments lower than the iliocecal valve. However, it should not be forgotten that only 80% of hemorrhages in the form of hematochezia originate from the colon. In 11% of the patients who applied to the doctor because of hematochezia, the bleeding originates from the upper GIS, while 3-9% of them originate from the small intestine. Because, in severe upper GI bleeding, intestinal perithaltism will increase a lot, and the blood can be expelled rectally without being digested, with a red color close to it. For this reason, in 11% of patients who apply to the doctor with severe hematochezia, the bleeding site is not the lower but the upper GI tract. In addition, 91% of patients with lower GI bleeding can define hematochezia, while approximately 9% can describe melena. Meckel’s diverticulum bleeding from the small intestine should be considered in the presence of red blood mixed with black stool, such as tar.
Patients with lower GIS bleeding may apply to the doctor in 3 different clinical forms: Hematochezia, positive stool occult blood, and rarely melena. In such cases, before these patients are treated, the upper GI/lower GI bleeding division must be done. (Table-1)
Table -1 Differentiation of upper and lower GI bleeding
Results Upper GI Bleeding Lower GIS Bleeding
Hematemesis present or absent
Melena present absent/rarely present
Hematochezia absent/rarely present present
Nasogastric fluid present absent
Bowel sounds increased usually normal
Bun/creatinine ratio increased usually normal
- GENERAL PRINCIPLES FOR THE TREATMENT OF LOWER GI BLEEDING
When taking anamnesis of patients with lower GI bleeding, the presence of diverticulosis, angiodysplasia, hemorrhoids, ulcers, varicose veins and inflammatory bowel disease should be sought. Because these diseases progress with recurrent bleeding attacks. The use of NSAIDs (non-steroidal anti-inflammatory drugs) is also important in lower GI bleeding. Especially in patients with a history of peptic ulcer, chronic liver disease and NSAID use, upper GI bleeding should be excluded by performing esophagogastro duodenoscopy, if necessary.
In patients with lower GI bleeding, hypovolemia should be corrected first. These patients should also be evaluated in terms of acute abdomen.
a- Detection of the cause of bleeding:
In patients with lower GI bleeding, the cause and, if possible, the location of the bleeding should be revealed in order for the treatment to be directed correctly and applied quickly.(Table-2)
Table -2 Most common causes of lower GI bleeding
Anatomical: Diverticulosis
Vascular: Angiodysplasia, radiation-induced telangiectasia,
Inflammatory: Infectious, ischemic, radiation inflammatory bowel disease, Colitis
Neoplastic: Polyp, carcinoma
Others: Hemorrhoids, fissure, rectal ulcer, after biopsy or polypectomy, parasitosis, rectal trauma, Enterobehçet’s disease, Dieulafoy’s lesion
Young- In the middle age group, acute infectious colitis, celiter rectal ulcer, inflammatory bowel diseases and anorectal diseases (hemorrhoids, anal fissure) are the most common causes of lower GI bleeding. In the childhood, invagination and Meckel’s diverticulum should always be kept in mind. However, especially in patients over 50 years of age, angiodysplasia, diverticulum, malignancies, ischemic bowel diseases and anorectal diseases should be investigated. Angiodysplasias and diverticula constitute 60% of major lower GI bleeding. Angiodysplasia is the most common cause of lower GI bleeding in patients over 65 years of age.
Angiodysplasias, which are the most common vascular lesions of the gastrointestinal tract, are also called vascular ectasia or arterivenous malformations. They are most commonly found in the cecum and ascending colon. It is usually subacute and recurrent, and massive bleeding occurs in 15% of cases. Bleeding stops spontaneously in 90% of cases. Cardiac disease accompanies half of the patients and aortic stenosis in 25%.
b- Evaluation of the body’s response to bleeding: The loss of more than 35% of the total blood volume in a patient is fetal. The body’s response to bleeding often depends on the rate and amount of blood lost. In the acute loss of 15% of the blood volume in a healthy person, the interstitial fluid moves into the capillaries from the first hour and this fluid passage may take 36-40 hours. While the intravascular volume deficit is repaired with this transcapillary passage, interstitial fluid deficit develops. In the second stage after bleeding, the renin-angiotensin system is activated due to blood volume deficit and renal sodium retention begins.
The main purpose of fluid therapy in mild and subacute hemorrhages, that is, in those with less than 20% volume loss, is to fill the fluid deficit in the interstitial space rather than the intravascular space. Na-rich fluids such as physiological saline and ringer’s lactate allow rapid filling of the interstitial space. If the bleeding is light, these fluids containing electrolytes are preferred and sufficient. In severe hemorrhages in which volume loss is more than 20%, faster expansion of the intravascular space takes priority, and in such cases, colloidal fluids (fluids such as Dextran-40 and reomacrodex) should be administered.
Advanced age, diabetes mellitus, renal failure, patients taking beta-blockers and vasodilators should be more careful because the early compensatory response of the body may be delayed.
c- Determination of the severity of bleeding: The most important step is to determine the blood volume lost in a patient with active GI bleeding. The most useful method in evaluating bleeding is rapid examination of the patient. As a general rule, if the systolic blood pressure is less than 100 MMHg and the pulse rate is greater than 100 per minute, the volume loss is greater than 20%. The pallor of the skin and the disappearance of the redness of the lines on the palm support this idea. A positive Tilt Test, which is characterized by a decrease in systolic blood pressure of more than 15 mmHg or an increase in pulse rate of 20 per minute as a result of placing the patient in the supine position into a sitting position at a 45º angle, again indicates that the patient has more than 20% blood loss. If the volume loss is more than 20%, the patient should be evaluated quickly regardless of the location and cause of the bleeding. (Table-3)
d- Correction of the general condition of the patient:
The general condition of the patients with lower GI bleeding should be evaluated rapidly. needs to be corrected. If there are signs of deterioration in hemodynamics such as shock, orthostatic hypotension, and a decrease of more than 6% with hematoxygen, or if there is active hematochezia, the patient should be hospitalized, if possible, in the intensive care unit, and close follow-up with arterial blood pressure, ECG monitoring and pulse oximetry.
Table -3 Principles of approach to patients with lower GI bleeding
The cause of bleeding is investigated.
The severity of bleeding is determined
- Orthostatic tachycardia = less than 20% loss
- Orthostatic hypotension = 20-25% loss
- Hypotension in lying position = 25-35% loss
- Cardiovascular collapse = more than 35% loss
Volume deficit is calculated
- Normal blood volume estimate:
- Male = 70 ml/kg or 3.2 l/m²
- Female = 60 ml/kg or 2.9 l/m²
- Volume loss percent
- Replacement requirement = Normal blood volume – % loss
Volume deficit is closed
- Whole blood = 1.0 x volume deficit
- Colloid = 1.0 x volume deficit
- Crystalloid= 3.0 x volume deficit
acute bleeding successive mortality is highest in the first few hours. Therefore, fluid infusion should be done as early as possible and in sufficient quantity. Crystalloid fluids have a faster infusion rate than colloid fluids. For this reason, crystalloid fluids are more effective than whole blood when there is a need for rapid volume replenishment. Correction of hypovolemia and low cardiac output is the first goal in acute bleeding, and correction of anemia is the second goal. The first fluid to be chosen should be the fluid that will increase cardiac output. Colloid fluids are the fluids that best increase cardiac output. Since 20-30% of the crystalloid fluids will remain in the intravascular bed, infusion of crystalloid fluid up to 3 times the volume deficit is required. Crystalloid fluids are the first choice fluids for mild bleeding.
After cardiac output is corrected, anemia should be corrected and sufficient blood should be prepared immediately for this purpose. Since the initial hematocrit value may not accurately reflect the amount of blood loss, it is possible to correctly interpret the hemoglobin and hematocrit values at the end of the 12-24 hour compensatory period. The amount of blood needed; Viral findings are determined by measurable loss, central vein pressure and, if necessary, pulmonary capillary wedge pressure measurements.
During the initial evaluation of the patient, complete blood count, urinalysis, serum electrolytes, BUN/creatinine ratio should be studied. An increased BUN value while creatinine is normal indicates that there is a large amount of blood in the GI tract.
Especially the elderly, those with other serious diseases, patients with coronary disease or cirrhosis constitute the patient group at high risk for bleeding.
In these patients, one should try to keep the hematocrit above 30%. In patients with active bleeding, in the presence of coagulopathy (in the presence of prolonged PT2 with an INR above 1.5) or in the presence of low platelet count (< 50,000/ml), patients should receive fresh frozen plasma. and platelet transfusion.
e-Detection of bleeding:
Endoscopy: In patients with lower GI bleeding, rectosigmoidodcopy should be considered as part of the physical examination and should be performed immediately. With this procedure, diseases such as hemorrhoids, anal fissures, ulcers, angiodysplasia, malignancies, amebiasis, inflammatory bowel diseases, shigellosis can be easily recognized and specific treatments can be started.
In lower GI bleeding that cannot be diagnosed by colonoscopy, erythrocyte scintigraphy marked with Technicium 99 m, angiography and, if necessary, small bowel X-ray should be taken. Mesenteric angiography easily shows the majority of vascular lesions and some tumors. Selective superior mesenteric artery (SMA) angiography shows the entire small intestine and the entire right colon. 50-80% of diverticulum hemorrhages and almost all of vascular ectasia are the areas where the SMA is supplied with blood. If SMA angiography is negative, inferior mesenteric artery and, if necessary, celiac angiography should be performed. Bleeding 0.5-1.0 ml/minute and above is detected by angiography.
Radionuclide imaging: Hemorrhages at a rate of 0.1-0.5 ml/min can be detected by scintigraphic methods. It is more sensitive than angiography. However, it is less specific than endoscopy and angiography. It can be done in two ways: Active bleeding can be detected at a rate of 0.05 -0.1 ml/min with Tc 99 m sulfur colloid, and 0.35-1.25 ml/minute in blood pool studies with marked erythrocytes. Since images will be taken for 24-36 hours, this method is superior in intermittent hemorrhages.
Angiographic imaging: If bleeding at a rate of 0.5-1 ml/min can be detected in selective SMA angiography, bleeding at a rate of 1-1.5 ml/min is generally detected with angiographic examination. It is 100% specific. However, the sensitivity is very variable. The rate of negative arteriograms can be reduced by scintigraphy. The advantages of angiography are that there is no need for colon preparation and the localization is precise. It allows treatments such as angiography, catheterized vasopressin infusion and embolization. There is a risk of intestinal infarction up to 20% in embolization. For this reason, distal embolization should be performed as much as possible, using superselective catheterization techniques and temporary occlusive agents. Contrast-induced renal failure, arterial dissection and occlusion, intestinal infarction and vasepressin-induced myocardial infarction are the most important complications. For this reason, it should be preferred in cases of persistent or recurrent bleeding, in which angiography endoscopy cannot be performed or cannot be diagnosed.
- TREATMENT METHODS APPLIED TO LOWER GI BLEEDING
I Endoscopic treatments
II Medical treatments
III Radiological Interventions (Angiographic Treatments)
IV Surgical Treatment
I. Endoscopic Treatment Methods: These are the most frequently used treatment methods today and their success rates have been increasing in recent years. Emergency colonoscopic examination is a reliable, well tolerated and clinically effective method in acute lower GI bleeding. With colonoscopy, 89.1% of lower GI bleedings originating from the colon are diagnosed and in a significant part of them, simultaneous treatment is possible.
The advantages of colonoscopy in lower GIS bleeding are the detection of the exact localization of the bleeding area, the possibility of taking biopsy and treatment in the same session.
Endoscopic treatment can be successfully applied in directicular, angiodysplasia, hemorrhoids, polyps and radiation-induced telangiectasias.
The disadvantages of colonoscopy are the poor visualization of the colon if the patient is not well prepared and the risk of sedation in acute excessive bleeding.
A pediatric colonoscope can also be used, if necessary, in cases of abdominal surgery or in cases of tortous sigmoid with prominent diverticulum.
Other endoscopic treatment methods used today;
- Thermal coagulation methods:
- Contact applied:
- Monopolar/bipolar/multipolar coagulations
- Heater probe coagulation
2- Those applied without contact:
a) Argon plasma coagulation
b) Nd-YAG laser therapy
c) Microwave coagulation
Lesion In thermal coagulation methods applied by providing contact, physical compression and application of tamponade to the vessels are essential. Many bleedings can be successfully stopped with these procedures.
Argon plasma coagulation (APC); It is a thermal coagulation method that is applied more and more frequently and successfully. It is more effective in superficial bleeding. Maximum coagulation depth should be 2-3 mm to minimize transmural damage. For this, the gas flow rate should be 0.5 liters/minute and the electric power should be 40-60 W. It is applied without contact. It is most commonly applied in hemorrhagic radiation proctitis, angiodysplasias and bleeding tumors.
Advantages: Being portable, inexpensive, not requiring much equipment and not having much adhesion effect.
Disadvantages: There is a risk of perforation and cavitation in the cecum, especially in those who are given excess gas. Although it is a non-contact method, tissue damage may increase upon contact because the patient moves. There is also a risk of perforation in cases that are not taken care of.
Nd-YAG laser therapy: It can be applied in acute lower GI bleeding. The success rate is high. However, it is not widely used due to its cost, non-portability and high complications.
- Injection treatments: They can be applied alone or together with endoscopic thermal treatment methods. They are reliable, inexpensive and effective treatment methods. The most used substances; epinephrine, cyanoacrylate, polydocanol, alcohol, ethanolamine, thrombin, fibrin, hypertonic saline or hypertonic saline + epinephrine combination. When applied, they have local tamponade, sclerotherapy or local tamponade + local vasoconstriction effects.
In some lesions, especially lesions in the cecum, the success of the treatment can be increased by slightly elevating the lesion from the mucosa by diluting epinephrine injection before thermal coagulation methods.
- Mechanical Treatment Methods:
1-Metallic Clips: They are easy to apply and have high success rates. When applied to the bleeding vein, bleeding can be stopped immediately. Success rates are higher than injection treatments. The probability of recurrence of bleeding is 8.3% in patients with metallic clips and 33.3% in injection treatments. The success rate in Dieulafoy’s lesions is 91.7%.
2-Band ligation: It has also been found useful in stopping bleeding in lower GIS bleeding. Multiple bands are applied. Successful results were obtained especially in arteriovenous malformations, polypectomy and diverticulum bleeding.
3-Removable snare: It stops bleeding to a large extent, especially when applied to the bleeding site in postpolypectomy hemorrhages.
The use of endoscopic treatments for lower GI bleeding has increased in the last few years. There is no significant difference between injection treatments and thermal treatments. One of the endoscopic treatment methods may be preferred according to the available facilities in the health institution, the experience of the endoscopist and the condition of the lesion.
II Medical Treatments:
- Non-specific treatments: Correction of coagulation and platelet abnormalities, blood and fresh frozen plasma transfusions, and iron replacement can be applied when necessary.
- Combined hormone therapy: Ethinyl estradiol (0.035-0.05 mg) and norethisterone (1 mg) combination therapy was found to be beneficial, especially in the treatment of recurrent angiodysplastic hemorrhages.
- Vasopressin infusion treatments: Intravenous and intraarterial vasopressin infusion treatments can also be applied in lower GI bleeding.
III. Radiological Interventions (Angiographic treatments)
Especially superselective embolization therapy can be successfully applied in severe lower GI bleeding. The main agents used in this method are gel foami, polyvinyl alcohol, Ethiblock, microcoil and their combinations. The success rate in stopping bleeding is 66-93%. The recurrence rate of bleeding in angiodysplastic lesions is 17%, while it is only 5% in diverticula. The development of ischemia is the most important disadvantage and is seen at a rate of 0-33%.
With this method, vasopressin therapy can also be applied to patients who need it.
C- SOME SPECIFIC TREATMENT METHODS APPLIED TO LOWER GI BLEEDING
Most of the bleeding due to diverticulum and angiodysplasia, which constitutes 60% of lower GI bleeding, stops spontaneously after a few days, continuing intermittently. Because of its high mortality and morbidity, emergency surgery should be avoided except in mandatory situations. Although surgery may be needed in severe, persistent lower GI bleeding, conservative treatment should be insisted on. Most diverticula do not bleed again and are discharged without surgical treatment.
1- Angiodysplasias:
They are lesions of 1-10 mm in diameter, which are often localized in the colon region close to the ileocecal, increase in advanced age, and mostly develop later. However, it can also be seen in other parts of the colon, stomach, duodenum, jejunum and ileum. Although they usually bleed subacute and recurrently, they can cause massive bleeding in 15% of cases. About 90% of bleeding cases stop spontaneously. Bleeding angiodysplasia is accompanied by heart disease in 50% and aortic sterosis in 25%. In cases where aortic valve replacement is indicated and endoscopic treatment is not successful, valve replacement should be performed first and then endoscopic treatment should be repeated.
First of all, acute bleeding is controlled and the patient’s hemodynamics is tried to be corrected. In the second stage, colonoscopic treatment is applied. Colonoscopic treatment should be the first choice in specific treatment. Colonoscope should be carefully advanced during the procedure, biopsy should not be taken as it is not diagnostic. Since these lesions are affected by blood pressure and volume deficit, endoscopic intervention should be performed after adequate fluid therapy in the bleeding patient.
Heater probe and biopolar electrocoagulation methods are most commonly used in colonoscopic treatment. It is controversial whether to treat non-bleeding vascular lesions that are incidentally detected on colonoscopy.
Right hemicolectomy should be performed when a lesion is detected in colonoscopy, if the endoscopist has no treatment experience, or if endoscopic treatment is unsuccessful, or if endoscopic intervention cannot be performed because the lesion is large. However, if bleeding continues, subtotal colectomy can be performed if angiography is completely normal and colonoscopy and small bowel radiography are not diagnostic.
Endoscopic treatments for angiodysplasia are often successful. These patients often have superficial lesions in the cecum and right colon. Most bleeding usually stops spontaneously. In some cases, intermittent bleeding occurs. Some may also experience severe acute bleeding and anemia requiring transfusion.
Injection therapy or one of the Thermal Coagulation methods (Monopolose electrocoagulation, Bipolar electrocoagulation, Heatre probe, Argon plasma coagulation and Nd-OIL laser therapy) can be applied in the treatment.
However, the first choice should be Thermal treatment methods. The success rate in these is about 50-87%. There is a 5% risk of severe delayed bleeding in bipolar coagulation treatment.
In addition, there are no prospective randomized studies of these treatments. Since there is a risk of performation, lower power is used compared to upper gastroduonel hemorrhages.
Column distension should be kept to a minimum because of the risk of perforation.
Injection therapy usually stops active bleeding and leakage. It should be the second choice in treatment. Injection of sclerosing and other irritant substances is less preferred in injection therapy.
2- Colon diverticulum:
Pseudodiverticula are seen, the frequency of which increases with age, and mostly does not include all layers of the colon wall. They are usually localized in the distal colon and only 3-5% of patients with colonic diverticula develop bleeding. Bleeding can be controlled in 90% of cases by administering a vasoconstrictor agent through the angiography catheter. 80% of right colon diverticulum bleeding is controlled with vasopressin infusion given during angio. If the bleeding focus is in the left colon, intravenous vasopressin infusion is as effective as intraarterial infusion.
It can be successfully applied in colonoscopic treatments for diverticulum hemorrhages. The risk of re-bleeding is also less after colonoscopic treatments compared to conservative treatments.
The use of endoscopic treatments for bleeding from colon diverticulum has increased recently. Injection therapy, thermal coagulation treatments and mechanical treatments can be applied in these patients. The most frequently recommended method is Thermal coagulation methods, in which direct tissue contact is achieved.
Recurrent bleeding due to visible vessel lesions in the diverticulum can be easily prevented with treatment, and the rate of patients to undergo surgical treatment can be reduced. However, since the colonic mucosa is thin, low electrical energy should be used due to the risk of perforation.
In the bleeding visible vessel, Epinephrine (at 1:20,000 dilution) is applied to all 4 quadrants. Bipolar coagulation (10-15 W power) is more preferred in non-bleeding visible vessel lesions.
If blood is coming from the diverticulum, 5-10 ml of epinephrine (at 1:20,000 dilution) is injected into the diverticulum from all directions. If there is a clot, epinephrine is injected at a 1:20,000 dilution around and below the clot.
It should be kept in mind that most bleeding in diverticula can stop spontaneously. In addition, colonoscopy should be performed carefully, especially if there is a mutapil diverticulum.
3-Tumor hemorrhages:
The best treatment method in tumor hemorrhages is argon plasma (APC) coagulation. APC is an effective method in the coagulation of the bleeding tissue with limited penetration and no contact with the tissue. Pure ethanol can also be used for intratumoral injection. However, contact thermal ablation methods and injection treatments have not been found to be very successful.
4-Radiation damage: Although radiation colitis and multiple telangiectasias can be seen in any part of the colon, they are most commonly seen in the distal colon and ectum. In the treatment of bleeding due to these lesions, multipolar electrocoagulation and APC and Nd-YAG laser treatment without tissue contact are generally preferred. Potassium Titanyl Phospate Laser Treatment (2 sessions, 4-10 W power), which has been used in recent years, has been found to be very useful in bleeding due to radiation. However, with this treatment, the risk of developing rectal ulcers is high.
If rectal radiation colitis has extended to the anal canal, nerve blockade with a local anesthetic agent or general anesthesia is recommended before treatment.
These patients are at risk of developing stenosis after their treatment. (Table-4)
Table – 4 Indications for endoscopic treatment in radiation colitis
- Development of chronic hematochezia after radiation
- after 6 months Anemia requiring prolonged transfusion
- Bleeding unresponsive to medical treatment
- Absence of recument tumor, fistula and stricture
5-Post Polypectomy hemorrhage: Bleeding starts immediately after polypectomy or biopsy . Or late bleeding occurs after 2 weeks.
Most bleeding stops spontaneously. No blood transfusion or endoscopic procedure is required.
If bleeding continues or is severe, endoscopic injection therapy, thermal methods or combined treatments can be applied. In addition, endoscopic band ligation and endoscopic metallic hemoclip have also been found useful.
6-Colonic varices: They are usually seen in portal hypertension. Its incidence is 1-8%. Although bleeding is rare, it is massive and may be fetal. It is common in the cecum and rectum.
Endoscopic varicose ligation and sclerotherapy can be applied in the treatment. Care should be taken in terms of necrosis and performance. N-butyl-2-cyanoacrylate can also be used in the treatment of colonic varicose veins. Cyanoacrylate is used undiluted or diluted 1: 1 with lipiodal. As the lipiodal concentration increases, the risk of embolization increases.
7-Anorektal orjinli gasrtointestinal kanamalar:
Akut alt gastrointestinal sistem kanamalarının yaklaşık % 10’unu oluşturur. Hemoroidler ve anal fissürler en sık görülenlerdir. Endoskopik hemoroidal ligasyon, internal hemoroidlerde etkili ve emniyetli bir yöntemdir Hemoroidlerde bipolar elektrokoagulasyon ve heater prota tedavileri de uygulanabilir. Kronik kanayan internal hemoroidlerde heater probe ve bipolar koagulasyonun komplikasyonları benzer bulunmuştur. Fakat heater probe ile yapılan tedavide başarı oranı yüksek ve semptomlar daha kısa sürede düzelmesine rağmen, ağrı da daha fazla görülür. Anal fissür gelişmesi, işleme bağlı kanama ve rektal spazm gibi komplikasyonlar ise bipolar elektrokoagulasyonda yaklaşık 2 kat daha fazladır.
İnce Barsakların değerlendirilmesi
Üst GİS kanamalarının ekarte edildiği ve kolonoskopinin negatif olduğu hastalarda ince barsaklar da değerlendirilmelidir. Push entereskopi ile jejenumun 60 cm distaline kadar olan bölge gösterilebilir. İnce barsak grafisi ve enteroklizis ile ince barsak tümörleri, ülserleri ve Crohn hastalığı tesbit edilebilir. Gerekli durumlarda selektif SMA anjiografisi ve sintigrafik yöntemlerle de kanama yeri tayin edilebilir. Endoskopik yöntemlerle saptanan kanama odakları uygunsa heater probe, laser veya elektrokoagulasyonla tedavi edilebilir. Seçilmiş olgularda, özellikle anjiodisplazik kanamalarda vazopressin infüzyonları ve selektif embolizasyon tedavi yöntemleri uygulanabilir.
