Presentation on theme: "Case Presentations (Lower Gastrointestinal Bleeding) What Would You Do? What We Did!! Eric J. Dozois, MD Division of Colon and Rectal Surgery Mayo Clinic."— Presentation transcript:
Case Presentations (Lower Gastrointestinal Bleeding) What Would You Do? What We Did!! Eric J. Dozois, MD Division of Colon and Rectal Surgery Mayo Clinic Rochester, Minnesota
Goals of the Presentation Interesting cases of LGIB Stimulate discussion - audience Review key points of topic
Frequency of Signs and Symptoms in Patients with Aorto-Enteric Fistula Proportion Effected (%) GI bleeding (“herald”) 94 Hematemasis 78 Back or Abd pain 48 Melena 46 Shock 33 Pulsatile mass 17 Syncope 10
Meckel’s Diverticulum (MD) Incidence of MD in general population is 1% Bleeding MD is the most common cause of acute lower GI bleeding in pediatric patients The most common presentation in a child is obstruction, and it is adults bleeding *Park et al. Ann Surg 2005;241:529
Meckel’s Diverticulum 16% - are symptomatic Presentation varies – perforation, obstruction, bleeding 29% - ectopic or abnormal tissue Park et al. Ann Surg 2005;241:529
Chief Complaint 88 yr old male Asked to see in the medical ICU for lower gi bleeding
History of Present Illness Outside hospital, passed 800cc blood Hgb 8.0 Colonoscopy - clots & diverticula Transfused 4 units, Hgb remained 8.2 Transferred to Mayo, given 2 units Stable in intensive care unit
Past Medical History 10 episodes of LGIB in 20 years, ….4 in last 6 months 1990 - Gastric ulcer Coronary Artery Disease – MI x 2
Differential Diagnosis Diverticular bleed Angiodysplasia Carcinoma UGI Source – recurrence of gastric ulcer?
Work Up? EGDNGT related erosions only ColonoscopyBlood throughout colon TI intubated – dark blood No active bleeding site Scattered diverticula throughout colon, dense in sigmoid
Work Up? Enteroclysis – jejunal & ileal diverticula Tagged RBC scan - Negative Provocative Angiogram : – Access through common femoral artery – IMA, the SMA – Heparin - 5000U – tPA - 10 to 50mg in 5mg increments Now What? Negative
Hospital Course Stabilized in ICU, observed Transferred to floor, resumed diet Ready for discharge on HD 7
Surgical Management Abdominal exploration Intraoperative small bowel enteroscopy Total abdominal colectomy, ileostomy
GI Bleed of Unknown Source In 95% of cases LGI bleeding can be diagnosed by a combination of endoscopy, scintigraphy, and barium studies (enteroclysis, barium enema) 1 Blind surgical resection is associated with significant re-bleed rates & high mortality 2 1 Welch et al. Adv Surg 1973;7:95 2 Hoedema et al. Dis Colon Rectum 2005;48:2010
Mesenteric Angiography *Vernava et al. Dis Colon Rectum 1997;40:846-858.
Selective Mesenteric Angiogram Therapeutic Intervention Vasopressin – 90% success, re-bleeding up to 50% – Arrhythmia, pulmonary edema, MI Super Selective Embolization – 100% success, re-bleed 7% – 40% (expertise) – Bowel infarct rare Methylene blue or India ink - localize
Provocative Angiography* Indicated when all other studies fail Uses anticoagulant (heparin), vasodilator (tolazoline), & thrombolytic agent (tPA) Major side effects are possible Success in small series = 20% - 65% *Ryan et al. J Vasc Interv Radiol 2001;12:1273
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