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
CASE # 1
Chief Complaint 67 year old male Called to the intensive care unit to see a patient with bright red blood per rectum
History of Present Illness POD # 2Aorto-bi-iliac graft aorto-renal artery graft for aortoiliac disease
History of Present Illness In ICU, stable for last 24 hrs HR 90, BP 115/80, Temp 37.5 BRBPR x 2, now watery diarrhea LLQ abdominal pain Hgb = 8, WBC 18, urine output 5cc/hr
Past Medical History Cecal angiodysplasia Sigmoid diverticular disease History of colon polyps – s/p polypectomy complicated by postpolypectomy bleed
Family History 2 brothers with colon cancer 1 sister with uterine cancer 1 sister with gastric cancer
Differential Diagnosis? Colon cancer C. difficile colitis Ischemic colitis Aorto-enteric fistula Colonic/Sb Angiodysplasia Gastric or duodenal ulcer
Work Up and Plan ? Resuscitated, transfused, Abx started Stool sent for C. diff colitis Flexible sigmoidoscopy
Plan Flex Sig15 – 60 cm loss of vascular pattern intense erythema, purple discoloration
Hospital Course Fluids, optimized hemodynamics More BRBPR, watery diarrhea Worsening LLQ pain, confused HR 130, BP 90/60, T 38.9 Repeat Flex Sig : “ much worse than yesterday !”
Operative Management Left colon/sigmoid, patchy necrosis – Left Hemicolectomy – End Colostomy – Hartmann Pouch How would you manage the rectal stump??
Postop Course Discharged from the hospital on POD 14 2 Months later… Emergency Fem – pop Graft thrombosis, emboli 1 Month later…In ER with BRBPR…..
Hospital Course On coumadin, INR = 3, Hgb = 7 Admitted to ICU, transfused Passes 400cc amount of bright red blood per RECTUM!
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
Meckel’s Scan In children, sensitivity 85%, specificity 95% In adults, sensitivity 65%, specificity 9%. Sensitivity decreases during acute bleeding Intestinal duplication & nodular lymphoid hyperplasia can give false-positives
CASE # 3
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 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 U – 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:
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