Improved Visualization With Cap Fitted Colonoscopy in Lower GI Bleeding

Abstract

Lower gastrointestinal bleeding is one of the most frequently encountered conditions by gastroenterologists. Locating a treatable source can be difficult due to the time required for bowel preparation and cessation of bleeding, intermittent nature of bleeding, as well as poor visibility in the setting of active bleeding. We present a case illustrating the use of endoscopic cap to improve visualization and aid in treatment of an actively bleeding cecal Dieulafoy lesion. An eighty-two-year-old female with a past medical history of end stage renal disease, coronary artery disease on aspirin, and diabetes mellitus. She presented to the emergency department with fatigue, shortness of breath, pallor, and melena. Initial laboratory results were significant for a hemoglobin of 4.1. The patient was admitted to the hospital and underwent an EGD. The EGD was significant for a 2cm antral erosion, which was not felt to be the source of bleeding to account for the patient's anemia and so colonoscopy was performed. There was a large amount of blood that repeatedly obscured the lens of the colonoscope. Despite continuous attempts to clean the lens intraluminally, the scope was removed twice to clean the lens manually. Prior to the third insertion, an endoscopic cap was placed. The cap improved visibility by preventing blood from adhering to the lens allowing for safe insertion of the colonoscope. Careful inspection of the cecum revealed an actively bleeding Dieulafoy lesion. A single endoscopic clip was placed, achieving hemostasis and the patient was discharged home without further issue. Use of endoscopic caps during lower GI bleeding has not been well studied. Their use has been shown to improve adenoma detection rates (ADR) when cap fitted colonoscopy (CFC) was compared to non-CFC. This benefit was attributed to improved visualization within the colon. Cap fitted EGD has also been shown to improve visualization and ease of access to target lesions. The case described above shows that CFC may be a very useful tool in localizing and treating lower GI bleeding sources through improved visualization and ultimately achieving hemostasis.