major lower gastro- intestinal bleeding john hartley the academic surgical unit, university of hull,...
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MAJOR LOWER GASTRO-INTESTINAL BLEEDING
John HartleyThe 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 FOB’s positive
• Overt bleeding – visible blood PRIntermittent – self limiting
• Significant haemorrhageLarge amounts frank bloodHaemodynamic compromise
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Lower GI Bleeding - Etiology
• The Others– Neoplasms– Colitis– Ileal & Colonic varices– Meckels’ diverticulum– Haemorrhoids
Angiodysplasia
40%
40%
20% Others
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 > 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
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Lower GI bleeding – diverticular disease
Potential for therapeutic colonoscopy
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Lower GI bleeding – cancer
Major bleeding uncommon
10 -21 % of significant bleeds
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Lower GI bleeding – polyps
Uncommon causeOf massive bleeding(<10%)
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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
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Lower GI bleeding – the catch!!
Adequate anorectalExamination MANDATORY
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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
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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
ElectrocauteryLaserPolypectomy
– Angiography ☺VasopressinEmbolisation ☺
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Lower GI bleeding - Management
Resuscitation
(NG Aspirate) OGD
Proctoscopy & Sigmoidoscopy
Colonoscopy Angiography Radionucleotide scan
+ve
-ve
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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
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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 1989;76:358-361.
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Massive bleeding – acute colonoscopy
An alternative view
• Urgent prep via NG (1-2hrs)
• Site identified in approx. 76%
• Access for therapy
85% 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
• 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
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Colonic angiography and embolisation
Superselective embolisation
Avoid ischaemic complications
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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
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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.
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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.
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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.
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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 necrosisone for bleeding
Luchtefeld MA et al. Dis Colon Rectum 2000;43:532-4.
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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.
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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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