MAJOR LOWER GASTRO-INTESTINAL BLEEDING

John HartleyThe Academic Surgical Unit, University of Hull,

Castle Hill Hospital, Hull, U.K.

Lower gastrointestinal bleeding

Modes of Presentation• Occult or obscure bleeding

Iron deficiency anaemia FOB’s positive

• Overt bleeding – visible blood PRIntermittent – self limiting

• Significant haemorrhageLarge amounts frank bloodHaemodynamic compromise

Lower GI Bleeding - Etiology

• The Others– Neoplasms– Colitis– Ileal & Colonic varices– Meckels’ diverticulum– Haemorrhoids

Angiodysplasia

40%

40%

20% Others

Diverticulosis

Lower GI bleeding - Angiodysplasia

• Acquired vascular ectasia

• Degenerative

• Elderly population

• Multiple

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

Lower GI bleeding – diverticular disease

Non-inflamed tics

Ruptured vasa recta

Lower GI bleeding – diverticular disease

Lower GI bleeding – diverticular disease

50% of > 60 yrs

Up to 20% bleed5% massive(mainly right side)

Non-inflamed

Recurs in 25%

McGuire HH et al. Ann Surg 1972; 175: 847-855

Lower GI bleeding – diverticular disease

Potential for therapeutic colonoscopy

Lower GI bleeding – cancer

Major bleeding uncommon

10 -21 % of significant bleeds

Lower GI bleeding – polyps

Uncommon causeOf massive bleeding(<10%)

Lower GI bleeding – ischaemic colitis

Abdo pain ++Bleeding commonUsually limited

21 of 311 pts withMajor bleed

Rossini et al. World JSurg 1989;13:190-192

Lower GI bleeding – the catch!!

Adequate anorectalExamination MANDATORY

Lower GI bleeding - clinical

• Bleeding per rectum3-6 units transfusion within 24hrs

Hb drop to < 10g

• Blood – cathartic

• Bright red or plum coloured

• Usually painless

• +/- signs of shock

Lower GI bleeding - clinical

Management

• Characterise

• Resuscitate

• Differentiate

• Localise

• (Treat)

Lower GI bleeding - clinical

Resuscitation

• Large bore cannulae

• Volume and blood replacement

• Blood products

• Monitoring

• 85% WILL STOP THEREAFTER

Major Lower GI Bleeding Endoscopic & Radiological Procedures

• Diagnostic– Sigmoidoscopy ☺– Scintiscans– Colonoscopy– Angiography ☺– Barium Enema– Enteroclysis– Operative Endoscopy

• Therapeutic– Colonoscopy

ElectrocauteryLaserPolypectomy

– Angiography ☺VasopressinEmbolisation ☺

Lower GI bleeding - Management

Resuscitation

(NG Aspirate) OGD

Proctoscopy & Sigmoidoscopy

Colonoscopy Angiography Radionucleotide scan

+ve

-ve

Lower GI Bleeding - Bleeding ScansSulphur Colloid Labelled red cell

Type ofBleeding

active active/intermittant

Sensitivity 0.1 ml/min 0.3-1 ml/min

Duration 30 mins up to 24 hours

Advantages repeatablevery sensitive

detects intermittentbleeding

Disadvantages needs activebleeding

length of study,timing of images

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 1989;76:358-361.

Massive bleeding – acute colonoscopy

An alternative view

• Urgent prep via NG (1-2hrs)

• Site identified in approx. 76%

• Access for therapy

85% will stop anyway

? best performed electively

Lower GI bleeding - clinical

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

Lower GI Bleeding

• Extension of diagnostic angiography Extension of diagnostic angiography (Bookstein et al 1977)(Bookstein et al 1977)

• Immediate haemostasisImmediate haemostasis

• Risk of colonic ischaemia and infarction Risk of colonic ischaemia and infarction (Bookstein et al 1982)(Bookstein et al 1982)

Transcatheter coil embolotherapyTranscatheter coil embolotherapy

Colonic angiography and embolisation

Superselective embolisation

Avoid ischaemic complications

Mrs AB

• 75 yrs

• CVA 6yrs => dysphasic + hemiplegic

• Admitted 10/7 pr bleed– normal UGI + LGI endoscopy => discharged

• Readmitted pr bleed– bp 100/60 pulse 100– resuscitated => bp 140-160 in lab

Angiography for major colonic bleeding

H aem orrhoidsn=2

Sm all bow el sourcen=2

N ot em bolisedn=4

Laparotom y for continued b leedingn=2

(1 post op death)

Im m ediate haem ostasisn=11

Em bolisedn=13

C ontrast extravasationn=17

Em bolised w ith ham eostasisn=1

R ecta l ang iodysp lasian=1

N orm al an iogramn=20

N o C ontrast Extravasationn=21

SM A/IM A angiogramsn=38

Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

Lower GI Bleeding - Embolotherapy

• 13 patients (8 female)13 patients (8 female)

• Mean age 81yrs (71-87 yrs)Mean age 81yrs (71-87 yrs)

• Mean systolic BP 76 mmHg (unrecordable in 2 Mean systolic BP 76 mmHg (unrecordable in 2 patients)patients)

• Mean Hb 7.1 g/dlMean Hb 7.1 g/dl (4-10 g/dl)(4-10 g/dl)

• Mean transfusion vol. 6.0 units (2-8 units)Mean transfusion vol. 6.0 units (2-8 units)

ResultsResults

Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

Lower GI Bleeding - Embolotherapy

• Bleeding point embolised in 13/38 patients (r = 1 Bleeding point embolised in 13/38 patients (r = 1 for systolic BP < 100mmHg)for systolic BP < 100mmHg)

• Embolisation achieved haemostasis in 11/13 Embolisation achieved haemostasis in 11/13 patientspatients

• Ischaemic complications in 3 patients managed Ischaemic complications in 3 patients managed conservatively conservatively

SummarySummary

Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

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 necrosisone for bleeding

Luchtefeld MA et al. Dis Colon Rectum 2000;43:532-4.

Lower GI Bleeding - Coil embolotherapy

• SafeSafe– both early and late problems appear minimalboth early and late problems appear minimal– coils should be placed beyond marginal arterycoils should be placed beyond marginal artery

• EfficaciousEfficacious– Reduces the requirement for emergency surgeryReduces the requirement for emergency surgery– complete cessation of bleeding in somecomplete cessation of bleeding in some– may permit planned surgery in othersmay permit planned surgery in others

In the emergency control of major colonic In the emergency control of major colonic haemorrhage:haemorrhage:

Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

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

Lower GI bleeding - surgery

• Ensure cause not anorectal

• Only one bite at cherry!• Avoid segmental

colectomy unless definite cause

• Probably avoid primary anastomosis

Major low GI bleeding

• Unusual• Alarming !!!• Challenging:

- diagnosis- management

• Multidisciplinary approach- characterise- localise- treat