Antiplatelet therapy and uremic toxins can impair platelet function and hinder hemostasis during gastrointestinal bleeding. In this case report, we applied EBL method to treat a bleeding gastric polyp in a uremic patient who took ticlopidine for cardiovascular prophylaxis. Hemostasis was successfully achieved by banding ligation. Follow-up endoscopy showed that both the ligated polyp and the rubber band had disappeared spontaneously. The findings suggest that EBL is a safe and effective technique for the treatment of bleeding gastrointestinnal polyps in patients with bleeding tendency.
Our banding ligation method can be employed for both bleeding sessile or pedunculated gastric polyps. Sessile polyps are often difficult to be captured by traditional electrocautery polypectomy. Although endoscopic mucosal resection with cap-fitted panendoscopy may capture the lesions by suction, bleeding is a possible serious complication following the procedure (Inoue et al. 1993), especially in patients with bleeding tendency. In this situation, banding ligation of the lesions is possibly a good choice because it is easy to aspirate the polyps by suction, and the avoidance of resection procedure might decrease the risk of bleeding. In this reported case, 3 ml of distilled water was injected into the base of the bleeding polyp to lift the lesion off the muscle layer. Additionally, submucosal injection before banding ligation could compress the vessels in the submucosal layer and was possibly beneficial for preventing bleeding.
Conventional snare polypectomy encounters difficulties in effectively and efficiently controlling lesions located in the lesser curvature side, posterior wall and cardia of the stomach. Our previous study (Lo et al. 2003) showed that it was easily to capture a lesion into the hood of EVL, even the lesion was situated tangentially. Therefore, banding ligation method also can be applied for the treatment of bleeding gastric polyps located in some difficult approach areas.
In this reported case, the polyp immediately stopped bleeding following strangulation with the rubber band, and developed cyanotic change approximately 4 min later. It disappeared at follow-up endoscopy. The finding suggested that the ligated polyp would develop avascular necrosis following banding ligation. Therefore, our banding ligation could not only stop bleeding from polyp but also could bloodlessly transect the polyp. Since the bleeding polyp was not biopsied or resected following ligation, its nature was unknown. However, we have taken biopsies to assess the histology of some non-bleeding gastric polyps after banding ligation recently. No polyps bleeding occurred following biopsies because blood supply of those polyps was blocked by banding ligation. Therefore, it is possibly safe to take biopsy for bleeding polyps following banding ligation in patients with bleeding tendency.
The indication of banding ligation of gastrointestinal polyps include (1) treatment for bleeding polyps in patients with bleeding tendency, and (2) treatment for sessile or pedunculated hyperplastic polyps less than 1 cm. Because the distal attached hood of the pneumoactivated ligation device is 1 cm in diameter, it is difficult to capture a polyp greater than 1.5 cm by banding ligation. If the size of this polyp is greater than 1.5 cm, endoscopic detachable snare ligation method can be employed to ligate the polyps (Hsu et al. 2001). However, banding ligation technique is not suitable for treating a non-bleeding gastric adenoma, which carries a risk of carcinomatous conversion.