Utility of the gel immersion method for treating massive colonic diverticular bleeding. These are my courses. These are our disclosures. These are keywords. It has been reported that the gel immersion method using OS1 jelly in endoscopy for gastrointestinal bleeding is effective. In our case series, we focus on the efficacy of the gel immersion method in patients with massive right-sided colonic diverticular bleeding. Stigmata of recent hemorrhage requires endoscopic treatment, as it has been reported that the re-bleeding occurs in about 50% of cases of untreated SRH. However, the identification rate of SRH is reported to range from 17 to 42%. Moreover, the identification rate of SRH that is extravasation negative on CT scan is as low as 20%. There are two major reasons for the difficulty in identifying the source of bleeding. First, diverticular bleeding is intermittent. Identification of active bleeding is not that difficult, but in about 75% of cases, the bleeding stops spontaneously, making it difficult to identify the cause. The second reason is that massive bleeding make it difficult to maintain a visual field. In Japan, 68 to 76% of diverticular bleeding cases were right-sided. Since massive bleeding is particularly problematic in right-sided colonic diverticular bleeding, detecting small SRH hidden under accumulated blood clots is particularly challenging. SRH distributed equally, and 65% of SRH are non-bleeding visible vessel and adherent clots. Therefore, improvement of non-bleeding visible vessel and AC detection rate is a key for the colonic diverticular bleeding management. The use of water jet scope is an independent predictive factor of SRH. However, in patient with massive bleeding, the injected water rapidly mixes with fresh blood in the lumen, compromising the clear endoscopic view and complicating the identification of the bleeding source. Here is a case of massive bleeding with a large number of clots had accumulated within the colon, interfering with the clear view and obstructing the identification of SRH. Even underwent bowel preparation, massive bleeding blocks the view, so the water jet was used. However, injected water rapidly mixes with fresh blood in the lumen, compromising the clear endoscopic view and complicating the identification of the bleeding source. The gel-emergent method was first reported by Yano in 2016. They injected OS-1 jelly instead of water. The gel-emergent method was reported to be effective for 17 patients with several types of GI bleeding. Previous studies has included 3 patients with right-sided diverticular bleeding. However, the efficacy of OS-1 jelly in detecting small non-bleeding visible vessel and AC in these patients was unclear. That we focus on the efficacy of the gel-emergent method in CDB patients, especially in detecting non-bleeding visible vessel and AC observed in patients with massive right-sided diverticular bleeding. All patients with diverticular bleeding who underwent gel-emergent method were included during this study period. The video shows a coronoscopic view after using OS-1 jelly. Blood clots were successfully washed out, and the viscosity of the gel prevented its rapid mixing with blood. Contributing to improvement in the visual field that enabled the detection of an AC in the diverticulum. We used a catheter as a washing tube, gently peeling off the clot in the diverticulum. Non-bleeding visible vessel was exposed after gently peeling off the AC. A total of 9 patients underwent gel-emergent method were included in this study. The bleeding source identification and hemostatic treatment rate was 66.7%. Moreover, in terms of right-sided diverticular bleeding, effective hemostasis was obtained in 85.7% of patients. Within all patients with extravasation from right-sided diverticular bleeding, effective hemostasis was obtained. Even when extravasation was absent from right-sided diverticular bleeding, effective hemostasis was obtained in 75% of patients. In the case of active bleeding, fresh blood and massive clots obstruct a clear endoscopic view. And in the case of non-bleeding visible vessel and AC, accumulated blood clots interfere the detection of small SRH. Viscosity of the gel prevented rapid mixing with blood, contributing to skewer a clear visual field during treatment of patient with massive bleeding. Moreover, OS-1 jelly can wash out massive blood clots. This enabled to detect small non-bleeding visible vessel and AC hidden under massive clots. For these reasons, high SRH identification rate were achieved. The gel immersion method to be efficient for patient with right-sided diverticular bleeding, increasing the detection rate of not only active bleeding, but also non-bleeding visible vessel and AC.

gel immersion method

colonic diverticular bleeding

OS1 jelly

endoscopy

gastrointestinal bleeding