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Advanced Endoscopy: Gastrointestinal bleeding

Advances in technology have made endoscopy a “minimally invasive” option that is highly effective in diagnosing and treating diseases of the digestive tract. Here are some case studies to illustrate of the use of hemoclips in patients with life-threatening gastrointestinal bleeding. All procedures were performed by the author.

Severe bleeding from an esophagus ulcer in a child
A 2-year old girl who received a liver transplant developed feeding difficulties. One day she vomited blood and was admitted to hospital for emergency treatment and blood transfusions. Urgent gastroscopy was performed and identified multiple ulcers in the esophagus and stomach. Active bleeding was seen from a blood vessel sitting in a long ulcer in the esophagus. The cause of ulcer was thought to be due to cytomegalovirus infection. After injection of adrenaline, bleeding stopped but within 24 hours, bleeding recurred. Using a meticulous technique, 6 metallic hemoclips [A, B] were applied along the length of the esophageal ulcer, effectively closing the ulcer and stopping the bleeding. A chest X-ray confirmed the position of 6 metallic clips in the lower end of the esophagus [red ellipse, C]. Hemoclips are highly successful in the treatment of bleeding from the stomach, duodenum and colon. The clips fall off after a few days to weeks and pass out in the stool.

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Severe bleeding from duodenum ulcer
An 80-year man, a chronic smoker with advanced lung cancer passed black colored stools and vomited blood. After resuscitation and blood transfusion was instituted, he underwent emergency gastroscopy and a giant duodenum ulcer was found. A visible blood vessel was noted at the ulcer base [blue ellipse, D]. Using hemoclips, the vessel was “clipped” and bleeding was arrested [E]. Using high dose acid suppression medications, bleeding did not recur. A second gastroscopy 2 weeks later revealed the blood vessel had been obliterated and the ulcer base was clean [F]. The development of new endoscopic treatments have reduced the chance of patients dying from bleeding. It is particularly useful, in very sick patients who are at high risk for surgery.

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Esophagus tear after violent vomiting
A 40-year old man became air sick on a plane en route to Singapore and vomited fresh blood. He was evacuated to hospital on landing. After resuscitation with 4 units of blood, therapeutic gastroscopy with adrenaline injection managed to stop the bleeding temporarily. Within hours, massive bleeding recurred, requiring more blood transfusions. The patient was referred for further treatment. Using a cap-fitted technique developed by the author, a tear in the lower esophagus was readily identified with pulsatile bleeding from a small artery [green ellipse, G]. The artery was targeted and clipped with immediate arrest of bleeding [H]. The tear was closed with two additional clips [I].

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About the author. Dr Yap Chin Kong, is a leading Specialist and Senior Consultant in Gastroenterology, Liver Diseases and Endoscopy. He was awarded a Merit Scholarship to study Medicine at the National University of Singapore and graduated with a Bachelor of Medicine & Bachelor of Surgery degree in 1983. In 1988 he obtained his Masters degree in Medicine (Singapore) and became a Member of the Royal College of Physicians (United Kingdom). He became a Fellow of the Academy of Medicine (Singapore) in 1994 and a Fellow of the Royal College of Physicians (Edinburgh) in 2000. In 1992, he was awarded the Health Manpower Development Program Award by the Ministry of Health to pursue advanced training in therapeutic ERCP (Endoscopic Retrograde

Cholangio-Pancreatography) at the Academic Medical Centre in Amsterdam, The Netherlands. After a year of extensive experience he returned in 1993 to develop endoscopy further at the Singapore General Hospital until he left for private practice in 2004. He pioneered the use of endoscopic ultrasonography at SGH for a decade. During this time, he taught many generations of medical students and post-graduate doctors. In 2002, he continued to pursue his interest in early cancers of the stomach and colon and visited the Showa University Hospital in Yokohama, and the National Cancer Centre in Tsukiji, Tokyo. He lectured and taught at workshops locally and internationally, combining the best of Western and Eastern techniques. A Master endoscopist, he developed an innovative cap-fitted gastroscopy technique that is used to help countless patients worldwide. He was President of the Gastroenterological Society of Singapore (1999 to 2003) and was President of the Asia-Pacific Digestive Week in 2003. He is currently in private practice at Mount Elizabeth Medical Centre. His broad specialist experience include advanced endoscopy techniques such as ERCP treatment of bile duct stones and pancreas diseases, endoscopic ultrasound, treatment of esophagus, stomach, colon and liver cancers, viral hepatitis and inflammatory bowel disease. He is Visiting Consultant to the National University Hospital and Kandang Kerbau Womens’ & Childrens’ Hospital where he supervises gastroenterologists-in-training and performs endoscopy for sick children.
 
 
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