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Acute Lower Gastrointestinal Bleeding
Jonathan P. Terdiman, M.D. University of California, San
Francisco
Lower GI Bleeding
• Epidemiology, Etiology and Outcomes • Presentation and Diagnosis • Therapy • Management strategy by clinical scenario • Putting it all together
Epidemiology and outcome
• Annual incidence is 20-30/100, 000 – 1/4 to 1/3 of all acute bleeds requiring hospital stay
• Disease of the elderly – 200 fold increase from the 3rd to 9th decades of life
• Comorbid medical conditions are common • NSAID use is common
– > 50%
Strate L; B&W 1996-99
Strate L; B&W 2001-2003
Schmulewitz N; Duke, 1993-2000
Retrospective Prospective Retrospective
Number 275 252 415
Mean age 70 66 67
Cause
Diverticulosis 41% 30% 41%
Rectal ulcers: stercoral, solitary ulcer
8% 9% 6%
Postpolypectomy 6% 7% 2%
AVM 1% 3% 3%
Hemorrhoids 11% 11% 13%
Ischemic colitis 11% 10% 8%
Other colitis (IBD, infectious, radiation)
12% 15% 7%
Neoplasm 3 % 6% 7%
No source found 7% 9% 11%
Epidemiology and outcome
• Outcome depends on etiology and comorbidities – > 80% of bleeding will stop spontaneously and
not recur – 5-10% will have persistent or severe bleed – Mortality is < 5%
Outcomes Author/ year
N Continued or rebleeding
Died Surg Tx
pRBCs (SD)
LOS (Days)
Strate 2005
275 4.0% 2.6% 2.5 (4.5)
Strate 2003
252 7% 2.4% 3.6% 2.0 (3.0)
4.3
Schmule- witz 2003
565 11% 3% 5% 3.1 (3.9)
6.7
Das 2003
332 19% 5% 2.2 4.4
Diverticular Bleeding
Intractable bleed in hospital = 7%
In hospital mortality = 2% Longstreth Am J Gastro 1997;92:419
Presentation • Vital signs
– 20-30% with shock or orthostasis • Form of bleeding
– Hematochezia versus melena • Abdominal pain
– Present versus absent, location • Directed history and Exam
– Comorbid conditions • Labs
Risks for Ongoing Bleeding
• Strate et al. Arch Int Med, 2003 – HR > 100 OR, 3.67 – Sys BP < 115 OR, 3.45 – Syncope OR, 2.82 – Painless OR, 2.43 – Overt bleed (4 hr) OR, 2.32 – ASA use OR, 2.07 – 2 active comorbid OR, 1.93
Risks for Severe Bleed
• Severe bleeding (ongoing bleed and/or > 2 units transfusion) occurs in: – 79-84% with > 3 risk factors 17% of total – 43% with 1-3 risk factors 78% of total – 6-9% with 0 risk factors 5% of total
Strate et al. Am J Gastro, 2005
Outcomes Based on Risk • Low Risk = 0 factors
– Surgery = 0% – Death = 0% – LOS = 2.8 days
• Moderate Risk = 1-3 risk factors – Surgery = 1.5% – Death = 2.9% – LOS = 3.1 days
• High Risk = > 3 risk factors – Surgery = 7.7% – Death = 9.6% – LOS = 4.6 days
Risk of Death���Strate, Clin Gastro Hepatol, 2008
• Nationwide audit in US • Mortality = 3.9% • Risk factors
– Age > 70 OR = 4.9 – Int ischemia OR = 3.5 – >/= 2 comorbid OR = 3.0 – Nosocomial bleed OR = 2.4 – Coagulopathy OR = 2.3 – Hypovolemia OR = 2.2 – Transfusion OR = 1.6 – Men OR = 1.5
Hospitalization • Abnormal vital signs • Ongoing rectal bleeding • Active/multiple comorbid conditions • Suspicion of upper tract bleed • Previous aortic surgery • Severe anemia (HgB < 8) • Fever, leukocytosis • Abdominal pain/tenderness
Triage/LOS • Clinical criteria
– High, Moderate, Low – HIGH Risk: shock or > 3-4 units blood/day
• Endoscopic or Angiographic Criteria? – High Risk
• Active arterial bleed , ulcer with vessel, from TIC • Cancer
– Lower Risk • Polyp/polypectomy, ectasia, colitis, anorectal
Triage and Optimal Length of Stay
• Data are scarce compared with upper GI bleed
• Expert opinion – High risk
• ICU for 24 hours, hospital for 72 hours – Moderate Risk
• Hospital for 24-48 hours, early refeeding – Low Risk
• Feed and early discharge
Critical Initial Diagnostic Steps • Upper versus lower tract bleed
– Color of bleed – NG aspirate – History – Labs – EGD
• Anorectal versus other lower source of bleed – History – Bedside anoscopy
Nasogastric Aspirate
• > 90% of those with red, pink or black aspirates have upper GI source
• > 60% of those with negative (bilious) aspirate have lower source, < 1% with upper source
• Equivocal aspirate? – 10% or more of upper tract bleeds (DU)
Rapid purge colonoscopy
Observe: no bleed, colonoscopy w/in 1-2 days
Angiography
Nuclear bleeding scan; If neg, colonoscopy
If positive, angio
Sigmoidoscopy
?
One Division: ���Parallel Practices
None Recurrent/ Intermittent
Continuous Severe/ Rapid
Rapid purge; non-emergent colonoscopy
Rapid-purge; Urgent colonoscopy
Angiography
Observe; prep non-emergent colonoscopy
Scintigraphy: Angiography vs.
Elective colonoscopy
Angiography
Nuclear scintigraphy • O.1 ml/min = 1 unit rbc/2-4 hours • Two purposes:
– Screening prior to angiography • Increase likelihood of positive angio
– Localization for surgery • Assessing “accuracy” in clinical studies
– Variable techniques – Variable thresholds for performing study – Variable times to angiography or surgery – Variable criteria for determining “accurate”
localization
Author Year
Total Scans
Positive scans Correct localization
Positive angiograms
Olds 2005
127 39% 48% 42%
Levy 2003
40* 70% 45% 0%
Ng 1997
160 54% - 43%
Suzman 1996
224 51% 78% 44%
Rantis 1995
80 48% 73% -
Voeller 1991
59 32% 69% -
Hunter 1990
203 26% 41% 44%
99mTc RBC for LGIB: Recent Studies
*
RBC Scintigraphy
• Summary of 16 studies with 1418 patients: 78% accurate versus 22% inaccurate
• Details matter – Active bleed at time of scan – Technetium Tc 99m-labeled in vitro – Early positive versus late positive – Upper tract source excluded
Nuclear Medicine as a Prelude to Angiography
• Ng et al. Dis Colon Rectum 40: 1997. – 160 patients, 1989-1994 – 86 positive scans 47 underwent angiography – Look for “blush” on nuclear medicine – Grp 1 (33) blush < 2 min 20/33 positive angio – Grp 2 (14) blush > 2 min 13/14 (-) angio – Immediate blush should go to angio; if > 2 min—
colonoscopy or observe
Angiography • Diagnosis
– Femoral access • 5 Fr catheters with steerable wires
– Selective access of SMA, IMA catheterization (sometimes celiac)
• Endoscopic identification/marking of bleeding lesion with clips facilitates
• Endovascular therapy – Vasopressin infusion no longer used – Sub-3 Fr catheter placed to most peripheral arteries
• Microcoils (1-2 mm) for colon • Polyvinyl microspheres (350-500 um) for small
intestine
Angiography: UCSF Experience • 17 patients with angiographically detected
lower tract bleeding • Subselective embolization possible in 14
– Tracker 2.5 Fr coaxial microcatheter – metallic coils for embolization
• Durable hemostasis in 13/14 • Bowel infarction or other major procedure
related morbidity in 0 Am J Surg 1997;174:24-28
Meta-analysis of Angiography for LGIB
Khanna A et al: J Gastrointest Surg 2005;9:343
• Included: – 7 cases series; all with > 10 pts with major
LGIB tx’ed with attempted embolization • Results:
– Median 30 d rebleeding rate: 14% (0-75) • Rebleed w/ Non-diverticular source: 45%
(OR 3.4 vs diverticular bleeding) – 75 % of rebleed w/in 3.5 days
Urgent Colonoscopy • Colonoscopy w/in 6-24 hours of admission • Rapid purge: Get serious!
– Polyethylene glycol-based preps – 1 Liter q 30-45 minutes – Median 6 L (range: 4-14L) – Time required: 3-4 hrs – NG tube: required in one-third – Consider: metoclopramide 10 mgIV – Goal: clear effluent (if not, give more) – Colonoscopy w/in 1 hr of clearance
• If ongoing bleeding, colonoscopy when effluent is pink with no clots
“Urgent” (W/in 24 h) Colonoscopy in LGIB
Study (year) N Specific Dx Endoscopic Complications
Tx Green, 2005 50 48 17 2% Angtuaco, 2001 39 29 4 - Kok, 1998 190 148 10 0% Chaudhry, 1998 85 82 17 1%
TOTAL 364 307 (84%) 48 (13%)
Urgent Colonoscopy: UCLA Experience
• Urgent colonoscopy after rapid purge • diagnostic yield
– 80%; endoscopic – treatment in 40% – complications in 0%
• Retrospective Results – angio rate from 50 to < 5% – BE rate from 25 to 0% – surgery rate from 20 to < 5% – LOS from 10 to 5 days and ICU stay from 3 to
1 day – Cost reduced $10, 000 per patient
Bleeding diverticula (n=3) Rx’d with Gold Probe (10-15W, 1 sec pulses X 6-18 pulses)
VV at edge of tic
Gold probe applied Flattened VV
Savides et al. GIE 1994;40:70-72
Colonoscopy and Severe Diverticular Bleed: UCLA Experience
• Study 1 - 73 patients (medical/surgical) • Study 2 - 48 patients (medical/colonoscopy) • Definite TIC bleed: 17/73 versus 10/48
– Study 2: severe hematochezia = 150 • Outcomes
– Study 1 - 9/17 with ongoing bleed, 6/17 to OR – Study 2 - 0/10 with ongoing bleed
NEJM 2000;342:78-82
Urgent Colonoscopy?���Green, Rockey et al., Am J Gastro, 2005
• RCT of urgent colonoscopy versus standard care with angio for ongoing bleed
• Urgent colonoscopy in 50 – Endo Rx in 17
• Standard care in 50 – Angio Rx in 10
Urgent Colonoscopy Standard Care Statistics Definite bleed source 42 % 21 % OR 2.6
(CI, 1.1-6.2) Presumptive bleed source
26 % 20 % OR 1.6 (CI, 1.1-6.2)
No diagnosis 4 % 24% P < 0.05 Hospital stay (days) 5.8 6.6 NS PRBCs 4.2 (0.4) 5.0 (0.5) NS Surgery 14% 12% NS Early rebleed 22 % 30 % NS Late rebleed 16% 14% NS
Results
Early Colonoscopy • Strate et al. (Am J Gastroenterol, 2003; GIE, 2005)
– 252 patients admitted with LGIB – No benefit with respect to need for surgery,
death – Colonoscopy within 24 hours associated with
less transfusion and shorter LOS (hazards ratio, 2.02; 1.5-2.6) • < 24 hours = 2.1 days • 24-48 hours = 2.7 days • > 48 hours = 4.4 days
Urgent Surgery • Segmental resection after localization of
bleed – Rebleeding < 15% – Mortality < 10%
• Blind segmental resection – Rebleeding 35-75% during hospital stay – Mortality 20-50%
• Emergency total colectomy – Rebleeding > 0-60% – Mortality > 10-40%
Surgery for LGI Hemorrhage���Directed Segmental Resection
Case #1
• 85 year old woman – multiple medical problems – hematochezia and tachycardia – vital signs normalize with IV fluid and NG
lavage is bilious – initial Hct is 28% – no further hematochezia is passed in the ED.
Question #1: What test to order?
1. EGD and Flex Sig 2. Colonoscopy 3. RBC scan 4. Angiography
Case #1
• While being prepared for colonoscopy the patient passes more BRBPR and her BP drops. Her vital signs normalize with an increase in her transfusion rate.
Question #2
• RBC scan is (+) for activity at the splenic flexure of the colon. Now what intervention?
1. Colonoscopy 2. Angiogram and embolization of site if active
bleeding seen 3. Angiogram as prelude to surgery if bleed
localized 4. Surgery now
Case #2
• 27 year old man – hematochezia, normal BP and tachycardia – HR remains elevated despite IV fluids – no further hematochezia in the ED – NG lavage is clear and initial Hct is 31%.
Question #3
• What test (s) should be undertaken first? 1. EGD + Flex Sig 2. Colonoscopy 3. RBC scan 4. Angiography
Case #2 • You perform and urgent EGD and flex
sigmoidoscopy. – results are negative – no further bleeding over the next 12 hours – Colonoscopy is negative – after the colonoscopy more BRBPR with
tachycardia and drop in hematocrit – NG lavage is bilious again
Question #4
• What should you do now? 1. Repeat colonoscopy 2. RBC scan 3. Angiography 4. Enteroscopy 5. Capsule endoscopy
Case #2
• RBC scan is positive in ileum • Angiogram is performed and active
bleeding seen and vessel embolized • After angiogram, CT enterography
demonstrates mass in ileum • Elective operative resection reveals GIST
Case #3
• 64 year old man – hematochezia, tachycardia, bilious NG
lavage and Hct of 28% – two further episodes of hematochezia in
the ED
Case #3
• While being prepared for colonoscopy an rbc scan is obtained and is negative
• Colonoscopy – diverticula throughout the colon, L >> R – No stigmata of ongoing or recent
bleeding are seen, no therapy given
Case #3
• While being observed in the hospital – several more discrete episodes of
hematochezia with change in VS – Rbc scans obtained again, positive in
LLQ – Angiogram, negative for active bleed – Patient has received a total of 8 units of
blood
Question #5
• What intervention now? 1. Left hemicolectomy? 2. Total abdominal colectomy? 3. Repeat Angiography? 4. Repeat colonoscopy?
Hematochezia
Any of following? Pulse > 100/min BP < 100 mmHg BRBPR w/in 4hrs
Admit to Floor Observe If no further bleeding Elective colonoscopy; If recurrent BRBPR, Initiate rapid purge
Admit to TCU/ICU Initiate rapid purge Colonoscopy w/in 1 hr of prep
NG lavage Consider EGD in high risk groups
If massive bleeding/unable to clear, Angiography (no RBC scan) Surgery consult
No Yes
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