Lower GI bleeding

Aliu Sanni, MDLong Island College Hospital

17th June, 2010

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Case Presentation

CC: Hematochezia HPI: 28yr old male presents with 1 day episode

of bloody stools. Denies any abdominal pain. PMH: Similar history 1year ago. Inconclusive

colonoscopy Meds: None NKDA Social: +tobacco, denies EtOH/drugs

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Case Presentation

Physical Exam T 97 HR 89 BP 124/78 R18 Abd- soft, NT/ND DRE- BRBPR, no mass, no hemorrhoids, normal

tone Chest- CTA bilat CVS-S1S2 no murmur

Labs Wbc 10.4, H/H 12.2/35.5, Platelets 250 Chem 12- WNL PT/PTT- WNL

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Hospital course- Admission day

Syncope in ER. No change in vital signs or Hematocrit Persistent dizziness / light headedness ICU admission for observation

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Hospital course – Admission day

EGD- acute gastritis, no ulcers Colonoscopy- poor bowel preparation Meckel’s scan- normal study CT Enterography- rounded fecal material around

the ileocecal valve.

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Hospital course- HD 1

Colonoscopy- Fresh and old clots noted from the colon tracking back to the small bowel. Possible small bowel source of bleeding

Capsule endoscopy inserted following colonoscopy Post colonoscopy hematocrit 28 ( from 33) Repeat Hct post transfusion of 1 PRBC was 28. Patient taken to the OR

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Hospital course

Intra-opExploratory laparotomy, ileoscopy, right hemicolectomy with ileocolic anastomosis

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Pathology

PathologyDiverticulosis with impacted fecalith, mucosal ulceration, acute inflammation and granulation tissue

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Management of GI bleedingdownstatesurgery

Management of lower GI bleedingdownstatesurgery

Management of Lower GI bleeding- Etiology

Colonic bleeding (95%) % SB bleeding (5%)Diverticular disease 30-40 AngiodysplasiaIschemia 5-10 UlcersAnorectal disease 5-15 Crohn’s DxNeoplasia 5-10 RadiationInfectious colitis 3-8 Meckel’s diverticulumPostpolypectomy 3-7 NeoplasiaIBD 3-4 Aortoenteric fistulaAngiodysplasia 3Radiation colitis 1-3Other 1-5Unknown 10-25

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Etiologies- Diverticular disease

Most common etiology Bleeding from penetration of vasa recti via the

mucosa 75% stop spontaneously Colonoscopy diagnosis of choice Epinephrine injection, electrocautery & endoclipping Embolization Surgery

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Etiologies - Angiodysplasia

Acquired degenerative lesions secondary to progressive dilation of normal blood vessels

Associated with aortic stenosis and renal failure Appears as red stellate lesions with a surrounding

rim of pale mucosa Sclerotherapy, electrocautery, selective gel foam

embolization. Segmental resection

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Etiologies - Neoplasia

Uncommon cause of lower GI bleeding Associated with Fe deficiency anemia GISTs associated with massive hemorrhage Diagnosis by colonoscopy Segmental resection

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Etiologies -Anorectal disease

Major causes are internal hemorrhoids, anal fissures and colorectal neoplasia

Exclude all other causes of lower GI bleed Medical or surgical management of anorectal

diseases

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Etiologies - Colitis

Inflammatory bowel disease, infectious colitis, radiation proctitis and ischemia

Ulcerative colitis associated more with GI bleeding

Medical or surgical management of primary cause of bleeding

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Etiologies -Mesenteric ischemia

Acute / chronic arterial or venous insufficiency Hx of AF, CHF, AMI, hypercoagulability, pressors

and vasculitis Acute - watershed areas of splenic flexure and

rectosigmoid Supportive care- bowel rest, IV abx,

cardiovascular support and correction of low flow state

Surgery in progressive ischemia and gangrene

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Management of GI bleed- Diagnostics

Radionuclide scanning- Technetium labeled RBCs- Detects bleeding as slow as 0.1ml/min- Localization accuracy of 40-60%- Guide to using angiography

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Management of GI bleed- Diagnostics

Mesenteric Angiography- Ongoing hemorrhage in range of 0.5-1 ml/min- Catheter directed vasopressin and embolization- Complications include hematomas, arterial

thrombosis, contrast reactions and acute renal failure

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Management of GI bleed- Diagnostics

Colonoscopy- Minimal to moderate bleeding- Active bleeding, adherent clot- Identifies bleeding source in up to 95% of cases- Diagnostic and therapeutic

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Causes of Obscure GI bleedingUPPER GI SMALL BOWEL COLONAngiodysplasia Crohn’s disease ColitisPeptic ulcer Meckel’s diverticulum Ulcerative colitisAortoenteric fistula Lymphoma Crohn’s colitisNeoplasia Radiation enteritis Ischemic colitisHIV related Ischemia Radiation colitisLymphoma Bacterial infection Solitary rectal ulcerSarcoidosis Metastasis AmyloidosisHemobilia Angiodysplasia LymphomaHemorrhagic pancreatitis EndometriosisMetastasis Angiodysplasia

NeoplasiaHIV relatedHemorrhoids

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Diagnosis of Obscure GI bleeding

Repeat Endoscopy

Conventional imaging (RBC scan, angiography, SB Enteroclysis)

Small bowel endoscopy

Capsule endoscopy

Intra-operative endoscopy

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Urgent Colonoscopy for Evaluation and Management of Acute Lower GI Hemorrhage: A Randomized

Controlled Trial

Methods- Consecutive patients with LGIB randomized to Urgent Colonoscopy (UC) vs. Standard Care Algorithm (SC)

50 patients in each group Active bleeding treated with epinephrine injection or

electrocautery Primary end point- rebleeding Mean f/up: UC/SC= 62months /58 months.

BT Green, DC Rockey, P Jowell etal Am J Gastroenterol 2005;100:2395-2402

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Standard care algorithm. Technetium RBC scanning was performed on patients with suspected active bleeding while those without active bleeding had an elective colonoscopy. Patients with a positive technetium scan went to visceral angiography while those with a negative scan had an elective colonoscopy. Active bleeding on angiography was treated. All patients receiving angiography (whether positive or negative) had an elective colonoscopy.

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Conclusions

No difference in mortality, hospital & ICU stay, transfusion requirements, early or late re-bleeding and need for surgery.

Urgent colonoscopy did not significantly improve outcomes in patients with LGIB.

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