1. Division of Colon & Rectal Surgery
Mayo Clinic
Division of Colon & Rectal Surgery
Integrated Care
For
Digestive Disease

2. Non-Tumoral Bleeding Diverticular Disease & Angiodysplasia
Eric J. Dozois, MD
Division of Colon and Rectal Surgery
Mayo Clinic
Rochester, Minnesota

3. Lower GI Bleed Background
1% of acute hospital admissions
Mortality ranges from 5% – 40%
85% - will stop spontaneously
15% - require aggressive resuscitation, multiple diagnostic modalities & intense medical and surgical management
Hoedema et al. Dis Colon Rectum 2005;48:2010

4. Common Causes of Major LGIB Mayo Clinic 1988 – 1996, 1018 pts*
Diverticulosis 30%
Post-polypectomy %
Ischemia %
Ulcerations %
Malignancy %
Angiodysplasia %
Radiation proctopathy 2%
Inflammatory bowel disease 2%
*Permission from CJ Gostout, MD

5. Common Causes of Major LGIB Mayo Clinic 1988 – 1996, 1018 pts*
Diverticulosis 30%
Angiodysplasia 4%

7. Diverticular Bleeding Non-inflammatory Pathogenesis Vasa Recta

8. Diverticular Bleeding
Most patients have minor bleeding
30% - 50% have massive bleeding
Spontaneously resolves in 70% - 80%
Browder etal. Ann Surg 1986 Nov;204(5): Gostout et al. J Clin Gastroenterol 1992;14(3):260-7.

9. Diverticular Bleeding
Re-bleeding in 20% - 30%**
1/3 of major LGIB in elderly*
*Leitman, etal. Ann Surg 1989;209: **Breen et al. Semin Colon Rectal Surg 1997;8:128

10. Diagnosis - Diverticular Bleeding
Diagnostic Options:
Colonoscopy**
Tagged RBC scan
Mesenteric Angiogram

11. Diagnosis by Colonoscopy
Study N Specific Dx Endo Tx
Chaudhry (’98)
Kok (’98)
Jensen (’00)
Antuaco (’01)
Green (’05)
Total
(88%) (12%)

12. Non-Surgical Intervention
Therapeutic Endoscopy:
Epinephrine injection – 4 quadrants
Multipolar cautery
Endoscopic hemoclip
Combination therapy – Epi & clips
Super-Selective Angiography:
Constriction - vasopressin
Embolization – gelfoam, microcoil

13. Epinephrine + Gold Probe Cautery
Diverticular Bleeding

14. QuickClip 2
(Olympus)
Triclip
(Wilson-Cook)
Resolution
(Boston Scientific)

15. Endoscopic Clipping

16. Endoscopic Clipping

17. With permission by LM Wong Kee Song
Endoscopic Hemo Clips for Acute Colonic Diverticular Bleeding Mayo Clinic Experience
Methods:
Study cohort identified from the prospectively collected GIBT database ( )
Clinical, endoscopic & outcome data were assessed
DDW 2006
With permission by LM Wong Kee Song

18. Results – Diverticular Bleeding
Patients (n = 28)
Mean Age (47-92)
Transfusions (0-17)
R colon/L colon / 18
No. clips used (1-6)
Follow-up (mos) (1-59)
DDW 2006
With permission by LM Wong Kee Song

19. Results - Diverticular Bleeding
Immediate hemostasis 28/28 (100%)
Recurrent bleeding /28 (14%)
Long-term hemostasis 25/28 (89%)
Endoscopy complications 0/ (0%)
Surgical intervention 3/ (11%)
Bleed-related mortality 0/ (0%)
DDW 2006
With permission by LM Wong Kee Song

20. Surgical Intervention
Surgical intervention will ultimately be required in 24% - 78% who bleed chronically*
In 18% - 25% urgent intervention is necessary due to persistent instability despite aggressive resuscitation**
*McGuire HH. Ann Surg 1994;220:653 **Bokhari et al. Dis Colon Rectum 1997;39:191

21. Surgical Intervention
Elective (Acute or Chronic):
2 or more episodes of transfusion dependant bleeding
Emergent (Unstable):
Stabilized first - endoscopic or angiographic technique (bridge!)

22. Surgical Management Identified: Directed segmental resection
Unidentified:
Intraoperative colonoscopy
Blind hemicolectomy
Blind subtotal colectomy

23. Colectomy, Re-bleed Rate & Mortality
Operation Re-bleed Morbidity Mortality
Dir. Seg %
Subtotal %
Blind Seg % % 57%
Parkes et al. Am Surg 1993;59:676

24. Angiodysplasia AVMs, vascular ectasias, angiomas
Common source of LGIB in elderly
15% have massive bleeding
85% intermittent, subacute bleeding
Recurrence rate 25%
Often multi-focal, (R) colon common

25. Angiodysplasia in GI Tract
Colon is most common site in GI tract
Cecum 37%
Ascending colon 17%
Transverse colon 7%
Descending colon 7%
Sigmoid colon 18%
Rectum 14%
Hocter W. et al. Endoscopy 1985 Sep;17(5):182-5.

26. Angiodysplasia
In some series, it accounts for 20% - 30% of LGI bleeding, and may be the most frequent cause in patients over the age of 65.
Can present with occult blood loss or acute bleeding, causing orthostasis or hypotension
Boley et al. Gastroenterology 1977;72: Browder et al. Ann Surg 1986;204(5):530-6.

27. Diagnosis - Angiodysplasia
Diagnostic Options:
Colonoscopy**
Tagged RBC scan
Mesenteric Angiogram*
Selective Angiogram

30. Pooling of Contrast in Cecum

31. Non-Surgical Intervention
Therapeutic Endoscopy:
Cautery, epinephrine, argon beam coag.
Perforation risk (*R colon)
Argon beam is preferred modality
Super-Selective Angiogram:
Treatment of choice for Sb angiectasias
Vasopressin, embolization

33. Angiodysplasia Jejunum

34. Surgical Management
Persistent transfusions or life threatening hemorrhage may be arrested with angiogram directed therapy to stabilize for surgery
Endoscopic or angiographic localization (tattoo) (bridging) can improves outcome
Multi-focal dz may require subtotal colectomy
Avoid blind segmental colectomy

35. Conclusions Diverticular & Angiodysplastic Bleeding
Chronic vs. Acute presentation
Therapeutic endoscopy and angiography may cure or temporize disease
Surgery reserved for chronic transfusion requirements or life-threatening bleeding

36. Conclusions Diverticular & Angiodysplastic Bleeding
Both are multi-focal disease processes & require localization for directed surgical therapy
Collaborative effort by the radiologist, endoscopist & surgeon optimizes patient care