MAJOR LOWER GASTRO-INTESTINAL BLEEDING John Hartley The Academic Surgical Unit, University of Hull, Castle Hill Hospital, Hull, U.K.

Lower gastrointestinal bleeding Modes of Presentation Occult or obscure bleeding Iron deficiency anaemia FOB’s positive Overt bleeding – visible blood PR Intermittent – self limiting Significant haemorrhage Large amounts frank blood Haemodynamic compromise

Lower GI Bleeding - Etiology Angiodysplasia The Others Neoplasms Colitis Ileal & Colonic varices Meckels’ diverticulum Haemorrhoids 40% 20% Others 40% Diverticulosis

Lower GI bleeding - Angiodysplasia Acquired vascular ectasia Degenerative Elderly population Multiple

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

Lower GI bleeding – diverticular disease Non-inflamed tics Ruptured vasa recta

Lower GI bleeding – diverticular disease

Lower GI bleeding – diverticular disease 50% of > 60 yrs Up to 20% bleed 5% massive (mainly right side) Non-inflamed Recurs in 25% McGuire HH et al. Ann Surg 1972; 175: 847-855

Lower GI bleeding – diverticular disease Potential for therapeutic colonoscopy

Lower GI bleeding – cancer Major bleeding uncommon 10 -21 % of significant bleeds

Lower GI bleeding – polyps Uncommon cause Of massive bleeding (<10%)

Lower GI bleeding – ischaemic colitis Abdo pain ++ Bleeding common Usually limited 21 of 311 pts with Major bleed Rossini et al. World J Surg 1989;13:190-192

Lower GI bleeding – the catch!! Adequate anorectal Examination MANDATORY

Lower GI bleeding - clinical Bleeding per rectum 3-6 units transfusion within 24hrs Hb drop to < 10g Blood – cathartic Bright red or plum coloured Usually painless +/- signs of shock

Lower GI bleeding - clinical Management Characterise Resuscitate Differentiate Localise (Treat)

Lower GI bleeding - clinical Resuscitation Large bore cannulae Volume and blood replacement Blood products Monitoring 85% WILL STOP THEREAFTER

Major Lower GI Bleeding Endoscopic & Radiological Procedures Diagnostic Sigmoidoscopy ☺ Scintiscans Colonoscopy Angiography ☺ Barium Enema Enteroclysis Operative Endoscopy Therapeutic Colonoscopy Electrocautery Laser Polypectomy Angiography ☺ Vasopressin Embolisation ☺

Lower GI bleeding - Management Resuscitation +ve (NG Aspirate) OGD -ve Proctoscopy & Sigmoidoscopy Colonoscopy Angiography Radionucleotide scan

Lower GI Bleeding - Bleeding Scans

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.

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

Lower GI bleeding - clinical

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

Lower GI Bleeding Transcatheter coil embolotherapy Extension of diagnostic angiography (Bookstein et al 1977) Immediate haemostasis Risk of colonic ischaemia and infarction (Bookstein et al 1982)

Colonic angiography and embolisation Superselective embolisation Avoid ischaemic complications

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

Angiography for major colonic bleeding Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

Lower GI Bleeding - Embolotherapy Results 13 patients (8 female) Mean age 81yrs (71-87 yrs) Mean systolic BP 76 mmHg (unrecordable in 2 patients) Mean Hb 7.1 g/dl (4-10 g/dl) Mean transfusion vol. 6.0 units (2-8 units) Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

Lower GI Bleeding - Embolotherapy Summary Bleeding point embolised in 13/38 patients (r = 1 for systolic BP < 100mmHg) Embolisation achieved haemostasis in 11/13 patients Ischaemic complications in 3 patients managed conservatively Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

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 necrosis one for bleeding Luchtefeld MA et al. Dis Colon Rectum 2000;43:532-4.

Lower GI Bleeding - Coil embolotherapy In the emergency control of major colonic haemorrhage: Safe both early and late problems appear minimal coils should be placed beyond marginal artery Efficacious Reduces the requirement for emergency surgery complete cessation of bleeding in some may permit planned surgery in others Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

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

Lower GI bleeding - surgery Ensure cause not anorectal Only one bite at cherry! Avoid segmental colectomy unless definite cause Probably avoid primary anastomosis

Major low GI bleeding Unusual Alarming !!! Challenging: - diagnosis - management Multidisciplinary approach - characterise - localise - treat