MAJOR LOWER GASTRO-INTESTINAL BLEEDING

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MAJOR LOWER GASTRO-INTESTINAL BLEEDING
John Hartley The Academic Surgical Unit,
University of Hull, Castle Hill Hospital, Hull,
U.K.
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Lower gastrointestinal bleeding

• Modes of Presentation
• Occult or obscure bleeding
• Iron deficiency anaemia
• FOBs positive
• Overt bleeding visible blood PR
• Intermittent self limiting
• Significant haemorrhage
• Large amounts frank blood
• Haemodynamic compromise

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Lower GI Bleeding - Etiology
Angiodysplasia

• The Others
• Neoplasms
• Colitis
• Ileal Colonic varices
• Meckels diverticulum
• Haemorrhoids

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20 Others
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Diverticulosis
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Lower GI bleeding - Angiodysplasia

• Acquired vascular ectasia
• Degenerative
• Elderly population
• Multiple

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Lower GI bleeding - Angiodysplasia

• Uncommon in healthy individuals
• Benign course with low risk of re-bleeding
• Endoscopic therapy non- bleeding lesions not
  necessary

Foutch PG et al. Am J Gastroenterol 1995
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Lower GI bleeding diverticular disease
Non-inflamed tics Ruptured vasa recta
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Lower GI bleeding diverticular disease
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Lower GI bleeding diverticular disease
50 of gt 60 yrs Up to 20 bleed 5
massive (mainly right side) Non-inflamed Recurs
in 25
McGuire HH et al. Ann Surg 1972 175 847-855
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Lower GI bleeding diverticular disease
Potential for therapeutic colonoscopy
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Lower GI bleeding cancer
Major bleeding uncommon10 -21 of significant
bleeds
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Lower GI bleeding polyps
Uncommon cause Of massive bleeding (lt10)
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Lower GI bleeding ischaemic colitis
Abdo pain Bleeding common Usually limited 21
of 311 pts with Major bleed Rossini et al. World
J Surg 198913190-192
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Lower GI bleeding the catch!!
Adequate anorectal Examination MANDATORY
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Lower GI bleeding - clinical

• Bleeding per rectum 3-6 units transfusion within
  24hrs
• Hb drop to lt 10g
• Blood cathartic
• Bright red or plum coloured
• Usually painless
• /- signs of shock

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Lower GI bleeding - clinical

• Management
• Characterise
• Resuscitate
• Differentiate
• Localise
• (Treat)

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Lower GI bleeding - clinical

• Resuscitation
• Large bore cannulae
• Volume and blood replacement
• Blood products
• Monitoring
• 85 WILL STOP THEREAFTER

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Major Lower GI Bleeding Endoscopic
Radiological Procedures

• Diagnostic
• Sigmoidoscopy ?
• Scintiscans
• Colonoscopy
• Angiography ?
• Barium Enema
• Enteroclysis
• Operative Endoscopy

• Therapeutic
• Colonoscopy
• Electrocautery
• Laser
• Polypectomy
• Angiography ?
• Vasopressin
• Embolisation ?

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Lower GI bleeding - Management
Resuscitation
ve
(NG Aspirate)
OGD
-ve
Proctoscopy Sigmoidoscopy
Colonoscopy
Angiography
Radionucleotide scan
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Lower GI Bleeding - Bleeding Scans
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Lower GI Bleeding - Bleeding Scans

• Tech. labelled red cell scan
• Sensitivity 97
• Specificity 85
• 48 of 50 patients had bleeding site identified
  preop
• One patient TAC for failure to localise
• No postop bleeding
• Nicholson et al Br J Surg 198976358-361.

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Massive bleeding acute colonoscopy

• An alternative view
• Urgent prep via NG (1-2hrs)
• Site identified in approx. 76
• Access for therapy85 will stop anyway
• ? best performed electively

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Lower GI bleeding - clinical
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Lower GI Bleeding - Angiography

• Both diagnostic and therapeutic potential
• Needs active bleeding
• haemodynamically unstable patient
• Highly operator dependant
• Can be repeated
• leave sheath in place
• Embolise if source identified

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Lower GI Bleeding
Transcatheter coil embolotherapy

• Extension of diagnostic angiography (Bookstein
  et al 1977)
• Immediate haemostasis
• Risk of colonic ischaemia and infarction
  (Bookstein et al 1982)

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Colonic angiography and embolisation
Superselective embolisation Avoid ischaemic
complications
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Mrs AB

• 75 yrs
• CVA 6yrs gt dysphasic hemiplegic
• Admitted 10/7 pr bleed
• normal UGI LGI endoscopy gt discharged
• Readmitted pr bleed
• bp 100/60 pulse 100
• resuscitated gt bp 140-160 in lab

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Angiography for major colonic bleeding
Nicholson AA, Ettles DF, Hartley JE et al. Gut
1998434-5.
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Lower GI Bleeding - Embolotherapy
Results

• 13 patients (8 female)
• Mean age 81yrs (71-87 yrs)
• Mean systolic BP 76 mmHg (unrecordable in 2
  patients)
• Mean Hb 7.1 g/dl (4-10 g/dl)
• Mean transfusion vol. 6.0 units (2-8 units)

Nicholson AA, Ettles DF, Hartley JE et al. Gut
1998434-5.
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Lower GI Bleeding - Embolotherapy
Summary

• Bleeding point embolised in 13/38 patients (r 1
  for systolic BP lt 100mmHg)
• Embolisation achieved haemostasis in 11/13
  patients
• Ischaemic complications in 3 patients managed
  conservatively

Nicholson AA, Ettles DF, Hartley JE et al. Gut
1998434-5.
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Lower GI Bleeding - Embolotherapy

• 26 pts, positive angiograms
• Mean transfusion 7 units (/- 1.43)
• 16 pts attempted embolisation
• Immediate haemostasis 14 pts (82)
• Rebleeding in 3 (one rpt embolisation)
• 2 pts required surgery
• one colonic necrosis
• one for bleeding
• Luchtefeld MA et al. Dis Colon Rectum
  200043532-4.

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Lower GI Bleeding - Coil embolotherapy
In the emergency control of major colonic
haemorrhage

• Safe
• both early and late problems appear minimal
• coils should be placed beyond marginal artery
• Efficacious
• Reduces the requirement for emergency surgery
• complete cessation of bleeding in some
• may permit planned surgery in others

Nicholson AA, Ettles DF, Hartley JE et al. Gut
1998434-5.
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Lower GI Bleeding -Surgery

• Make sure the cause is not anorectal
• haemorrhoids
• rectal cancer or proctitis
• Only one bite of the cherry!
• total colectomy is the procedure of choice
• avoid segmental colectomy unless definite cause
• probably avoid primary anastomosis

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Lower GI bleeding - surgery

• Ensure cause not anorectal
• Only one bite at cherry!
• Avoid segmental colectomy unless definite cause
• Probably avoid primary anastomosis

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Major low GI bleeding

• Unusual
• Alarming !!!
• Challenging
• - diagnosis - management
• Multidisciplinary approach - characterise -
  localise
• - treat

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