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LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding.

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Presentation on theme: "LOWER GI BLEEDING 4/6/11. LGIB  Distal to ligament of Treitz  Annual incidence rate of 20.5/100,000  Male predominance  Incidence of significant bleeding."— Presentation transcript:


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 blood’s 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  Meckel’s 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 4%–17% 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  0.1–0.5 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 6–7 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


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