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Lower GI Bleeding

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... or anal sources Upper gastrointestinal hemorrhage may present with ... must be considered in the diagnostic and therapeutic phases of the care ... – PowerPoint PPT presentation

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Title: Lower GI Bleeding


1
Lower GI Bleeding
  • 4/6/11

2
LGIB
  • Distal to ligament of Treitz
  • Annual incidence rate of 20.5/100,000
  • Male predominance
  • Incidence of significant bleeding increases with
    age
  • May suggest changes associated with the small
    intestine and colon
  • Reflects the prevalence of diverticulosis and
    angiodysplasia in the elderly

3
LGIB
  • May present as melena or hematochezia
  • Melena typically suggests bleeding from a more
    proximal source (colon or small intestine)
  • Hematochezia suggests left colonic, rectal, or
    anal sources
  • Upper gastrointestinal hemorrhage may present
    with rectal bleeding given bloods cathartic
    effect and rapid intestinal transit (10-15 of
    cases)

4
LGIB
  • Most often the intestinal bleeding resolves
    spontaneously
  • Once it resolves, investigations should begin to
    identify the potential sources
  • On occasion, the intestinal hemorrhage does not
    resolve
  • Creates hemodynamic compromise
  • Ongoing hemorrhage demands aggressive medical and
    surgical management
  • Oftentimes patients are plagued with significant
    comorbidities that complicate their individual
    resuscitation
  • Comorbidities must be considered in the
    diagnostic and therapeutic phases of the care
    plan
  • Current increased patient exposure to
    antiplatelet therapy associated with treatment of
    cardiovascular conditions may increase the
    comorbid challenges in patients with lower
    gastrointestinal massive hemorrhage

5
Etiology
  • Diverticula
  • Angiodysplasia
  • Ischemic colitis
  • Inflammatory bowel disease
  • Intestinal tumors or malignancies
  • NSAID-related nonspecific colitis
  • Meckels diverticulum
  • Anorectal diseases

6
Diverticular disease
  • Outpouchings of the mucosa and submucosa through
    defects in the muscular layer of the bowel at
    sites of penetration of the vasa recta
  • Thinning of the media in the vasa recta
    predisposes to intraluminal rupture focal injury
    may occur from trauma related to a fecalith
  • incidence spans a range of 15 to 48
  • relatively rare event affecting only 417 of
    patients with diverticulosis

7
Diverticular disease
  • Operative management is indicated when bleeding
    continues unabated and is not amenable to
    angiographic or endoscopic therapy
  • Should be considered in patients with recurrent
    bleeding localized to the same colonic segment
  • In a stable healthy patient, the operation
    consists of a segmental bowel resection (usually
    a right colectomy or sigmoid colectomy) followed
    by a primary anastomosis

8
Angiodysplasia
  • Thin-walled arteriovenous communications located
    within the submucosa and mucosa of the intestine
  • May be congenital or acquired, isolated or
    multiple
  • In the acquired form, distortions of the
    postcapillary venules may arise as a degenerative
    lesion associated with increases in intraluminal
    pressure
  • Results in thickening and ectasia
  • The vessels eventually entangle as tufts within
    the submucosa and erode into the mucosa proper

9
Angiodysplasia
  • Colonoscopic criteria
  • Mucosal surface contains a cherry red lesion that
    is typically flat
  • Greater than 2 mm in size
  • Have a fern-like appearance
  • A central feeding vessel is not always visible

10
Occult Hemorrhage
  • Occurs infrequently
  • no more than 5 of all patients admitted with LGI
    massive hemorrhage
  • Frequent recurrences create chronic anemic states
    in patients and require occasional admissions for
    transfusions
  • May harbor angiodysplasias in the small intestine
    or right colon
  • May benefit from small bowel contrast radiography
    or capsule endoscopy
  • Elective angiography with cecal magnification may
    reveal small angiodysplasias

11
Occult Hemorrhage
  • If the hemorrhage recurs and investigations fail
    to reveal the source, a variety of provocative
    diagnostic angiographic studies have been
    described
  • Most studies prefer to incite bleeding using
    either heparin or thrombolytics
  • Once the site of bleeding is identified, it may
    be difficult to control without surgery
  • Prepare and hold an operating room
  • Once the location is identified, a superselective
    catheter is left in the distal artery
  • During surgery, the surgeon can palpate the
    catheter within the vessel and direct the
    surgical resection

12
Initial Assessment
  • Establish IV access (large bore) and start IV
    fluids
  • restore volume and replete red blood cell
    deficiencies
  • Labs
  • CBC, electrolytes, coags, type and cross
  • All coagulopathies require reversal!
  • NG tube placed will screen for the presence of
    upper gastric sources for bleeding
  • Kovacs and Jensen noted 17.9 of LGI hemorrhage
    presentations involved an upper gastrointestinal
    source
  • NG tube is effective in detecting prepyloric
    hemorrhage

13
Evaluation
  • Digital anorectal examination and anoscopy
  • Rigid proctosigmoidoscopy will allow the examiner
    to evacuate the rectum of blood and clots
  • Excludes internal hemorrhoids, anorectal solitary
    ulcers, neoplasms, and colitis
  • Colonoscopy and angiography offer therapeutic
    intervention
  • Nuclear scanning is purely diagnostic

14
Evaluation
  • subdivide patients into 3 general clinical
    categories
  • minor and self-limited
  • major and self-limited
  • major and ongoing
  • Major ongoing hemorrhage requires prompt
    intervention with angiography or surgery
  • Minor, self-limited may undergo colonic lavage
    and colonoscopy within 24 hours
  • Major, self-limited need diagnostic tests to
    determine if they require prompt therapy or
    observation

15
Radionuclide imaging
  • Detects the slowest bleeding rates
  • 0.10.5 mL/min
  • More sensitive than angiography
  • Unfortunately cannot reliably localize the site
    of hemorrhage
  • The specificity of small bowel versus large
    intestine bleeding does not reliably compare with
    angiography
  • Two general techniques
  • technetium sulfur colloid scans
  • 99mTc pertechnetate-tagged RBCs

16
Radionucleotide imaging
  • Immediate positive blush (within the first 2
    minutes of scanning)
  • highly predictive of a positive angiogram (60)
  • predictive for surgery in 24
  • If study did not demonstrate a blush
  • highly predictive of a negative angiogram (93)
  • the need for surgery decreased to 7

17
Colonoscopy
  • If the patient appears stable with self-limited
    hemorrhage, colonoscopy is the preferred
    diagnostic study
  • Major benefit depends on ability to provide a
    definitive localization of ongoing active
    bleeding and the potential for therapy
  • Many landmarks for colonoscopy may be obscured
    during hemorrhage
  • Once the endoscopist highlights a bleeding
    source, the region requires a tattoo to mark the
    site
  • If the hemorrhage continues and fails medical
    management, the tattoo assists in localizing the
    hemorrhage
  • Therapeutic armamentarium i
  • thermal agents such as heater probes, bipolar
    coagulation, and laser therapy
  • Injection therapy uses topical and intramucosal
    epinephrine
  • Mechanical therapy includes endoscopically
    applied clips

18
Angiography
  • Diagnostic and therapeutic
  • Acute, major hemorrhage with ongoing bleeding
    requires emergency angiography
  • Patients with an early blush during nuclear
    scintigraphy may benefit from therapeutic
    angiography
  • May define a potential source for hemorrhage in
    occult and recurrent gastrointestinal hemorrhage
  • Requires a hemorrhage rate of at least 1 mL/min
  • Yields range from 40 to 78

19
Angiography
  • Highly accurate localization provides for focused
    therapy
  • Intraarterial vasopressin infusion
  • 0.2 U/min up to 0.4 U/min
  • Systemic effects and cardiac impact may limit
    maximizing the dosage
  • Controls bleeding in 91 of patients
  • Bleeding may recur in up to 50 of patients
  • Arterial embolization
  • Superselective mesenteric angiography with
    microcatheters in the vasa recta
  • Vessels as small as 1 mm
  • Risk of intestinal infarctions of larger
    selective vessels may exceed 20
  • Provides immediate arrest of the bleeding
  • Combination of agents to control bleeding
  • Gelfoam pledgets, coils, and polyvinyl alcohol
    particles
  • Arteriography also has complications
  • arterial thrombosis, distant arterial emboli, and
    renal toxicity from dye

20
Operative therapy
  • Few patients currently require surgical treatment
  • Hemodynamically unresponsive to initial
    resuscitation
  • Site of hemorrhage localized, but available
    therapeutic interventions fail to control the
    bleeding
  • Patient mortality increases with their
    transfusion requirements
  • Once reaches 67 units and the hemorrhage remains
    ongoing, surgical intervention becomes eminent
  • First objective in surgery focuses on the
    location of the intraluminal blood with the goal
    of segmentally isolating the possible sources of
    bleeding
  • if no source appears obvious, may consider
    intestinal enteroscopy

21
Operative therapy
  • If the source of bleeding cannot be found, and it
    appears to arise from the colon, the surgeon
    should perform a subtotal or total colectomy
  • Stable patients will tolerate a primary
    ileosigmoid or ileorectal anastomosis
  • Unstable patients require an end ileostomy with
    closure of the rectal stump or a mucous fistula
  • Once stable, the patient may return for ileostomy
    closure.
  • The rectum and sigmoid colon require
    reexamination endoscopically to assure no
    bleeding persists.

22
Algorithm
23
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