Post written by Yasutoshi Shiratori, MD, from the Division of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan.
Our video describes a case of colonic diverticular bleeding (CDB) in which Doppler probe ultrasonography (DOP) was used, with new systems for effective identification of stigmata of recent hemorrhage (SRH). An 89-year-old man was admitted for treatment of hemorrhage. Contrast-enhanced computed tomography revealed extravasation from the ascending colon. Although the patient had already undergone colonoscopy 3 times in the preceding week, the bleeding source had not yet been identified and rebleeding was observed. To identify the source of the bleeding, we prepared a DOP system (16 MHz, Compumedics, DWL, Germany), which has been accepted in the field of vascular surgery, and performed colonoscopy again. Although there was no sign of active bleeding, we checked each diverticulum near the extravasation using DOP. During the procedure, we detected the DOP-positive artery in one diverticulum. The Doppler wave shifts depending on the speed and direction of the blood flow relative to the Doppler probe. We identified the diverticulum as the origin of the CDB. Endoscopic band ligation was performed on the DOP-positive diverticula, and the disappearance of the Doppler wave was confirmed. The DOP examination took 12 minutes. There was no rebleeding for 6 months thereafter.
CDB is the most common cause of acute lower gastrointestinal bleeding. The diagnosis of CDB is made through detection of the SRH. Hitherto, to increase the rate of SRH identification, bowel preparation, water-jet scope, and transparent hood have been recommended. Despite the use of the above methods, the rate of SRH identification is only 15-40%. Even if blood or blood clots are present in the diverticulum, it is not always the source of bleeding, as there are cases where blood from the bleeding diverticulum flows into it. To identify the source of bleeding, detailed observation using the washing tube of each diverticulum is required; however, this is a time-consuming procedure, and it is not always possible to evaluate the interior of the diverticulum.
DOP detects blood flow that feeds potential sources of bleeding. The usefulness of DOP in increasing the detection rate of SRH of diverticular hemorrhage has not been proposed. Because DOP detects blood flow toward the probe, we hypothesized that it would be easier to detect blood flow when the vertical artery in the diverticulum collapses.
This DOP method has the potential to increase the rate of identification of the bleeding source of CDB. This new system has been adopted in the field of vascular surgery, not endoscopy. The use of this DOP system is our idea, and we have obtained the approval of the ethics committee of our hospital and the informed consent of the patient in using it.
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