Lower intestinal bleeding in the elderly

Impact of emergency angiography in massive lower gastrointestinal bleeding

Fifty patients with massive lower gastrointestinal bleeding were initially managed with emergency angiography. The average age was 67.2; mean hematocrit, 23.7; and average transfusion, 7.6 units. Thirty-six patients (72%) had bleeding site located; bleeding sites were distributed throughout the colon. Etiologies of bleeding included diverticular disease (19 patients) and arteriovenous malformations (15 patients). Twenty of 22 (91%) patients receiving selective intra-arterial vasopressin stopped bleeding; however, 50% rebled on cessation of vasopressin. Thirty-five of 50 (70%) patients underwent surgery, with 57% operated on electively after vasopressin therapy. Seventeen patients had segmental colectomy, with no rebleeding. Nine of the 17 patients had diverticular disease in the remaining colon. Operative morbidity in these 35 patients was significantly improved when compared to previously reported patients undergoing emergency subtotal colectomy without angiography (8.6% vs. 37%) (p less than 0.02). Emergency angiography successfully locates the bleeding site, allowing for segmental colectomy. Vasopressin infusion transiently halts bleeding, permitting elective surgery in many instances.

Influence of selective mesenteric arteriography on the outcome of emergency surgery for massive, lower gastrointestinal hemorrhage. A 15-year experience

From 1970 to 1984, 64 patients with massive hemorrhage of lower gastrointestinal origin were treated at the intensive care unit, Surgical Department, Malmö General Hospital. The records of these patients have been studied retrospectively. Emergency exploration for hemostasis was performed on 31 patients, while in 33 patients hemorrhage stopped with conservative therapy. Acute selective mesenteric arteriography revealed the bleeding site in 16 of 28 patients (57 percent). The commonest bleeding sources detected by selective mesenteric arteriography were diverticular disease and angiodysplastic lesions of the colon. Fourteen patients with positive arteriography finding were operated on as emergencies, resulting in two postoperative deaths. Ten patients were operated on as emergencies without preoperative arteriography. Despite intraoperative efforts, no bleeding source was found in three of those patients. In the remaining seven patients, the diagnoses were similar to the 14 patients with positive arteriography. Five of 10 patients in this group died postoperatively. Emergency laparotomy eventually was necessary in seven of 12 patients with negative arteriography. This group had a variety of diagnoses and no postoperative mortality. Positive preoperative mesenteric arteriography findings allowed the surgeon to perform a limited resection of the bleeding bowel segment with a reduced postoperative mortality.

Utility of specimen angiography in angiodysplasia of the colon

This study reviews the utility of specimen angiography in identifying colonic lesions clinically thought to represent angiodysplasia. Four elderly patients presented with acute rectal bleeding. The diagnosis of angiodysplasia was made preoperatively in 3 patients by colonoscopy or angiography, or both. These specimens were injected with silicon rubber compound, xerographed, cleared with methyl salicylate, and examined with transillumination before histologic sampling. Although this technique was not used in the fourth case, fortuitous random sampling of the ascending colon revealed vascular changes indicative of angiodysplasia that correlated with a preoperative bleeding scan. Associated lesions in 1 patient were carcinoma of the colon and primary amyloidosis, the concurrence of which has not been described previously. With the injection technique the lesions of angiodysplasia appear grossly as spiderlike, dilated blood vessels. Microscopically, dilated veins, venules, and capillaries are found in the submucosa only or in the mucosa and submucosa. The importance of the postoperative injection is that it prevents the collapse of the blood vessels and enables the pathologist to identify the lesions grossly. As these lesions are usually small, this is important for proper sampling and histologic documentation.

Cecal angiodysplasia localized by 99mtechnetium blood-pool scintigraphy and specimen venography

Angiodysplasia of the right colon may be difficult to diagnose. The usual methods of choice, selective abdominal angiography and colonoscopy, may be impracticable or fail. When bleeding occurs, 99mtechnetium blood-pool scintigraphy is a simple and reliable method of localizing vessel leakage. We present a case of an 84-year-old woman with severely bleeding angiodysplasia, where the source of bleeding was localized by means of scintigraphy using 99mTc in vivo labeled red blood cells. After right hemicolectomy, the angiodysplastic lesion was confirmed by specimen venography utilizing a barium gelatin mixture.

[Is there progress in the operative treatment of sigmoid diverticulitis]

A high percentage of people in the civilized Western world develops colonic diverticula. Signs of illness are coming from inflammation around the diverticula. Resection therapy is indicated after several inflammation episodes. The operation has often to be performed in case of emergency: Ileus, bleeding, perforation. We recommend the primary resection of the sigmoid colon with an transverse colostomy or the Hartmann operation even in case of perforation or peritonitis. We operated 140 patients. The mortality rate in our hospital was 12% of the elective and 27% of the emergency operations.

Selective visceral angiography for unexplained acute gastrointestinal bleeding in a district general hospital

Eleven patients are reported with unexplained gastrointestinal haemorrhage (GIH) presenting over a 2 year period in whom selective visceral angiography (SV A) was carried out after a negative endoscopy. SV A revealed the anatomical source of bleeding in all eleven patients and the aetiology in six of them. The latter comprised two tumours of the small bowel, an A-V malformation of the jejunum, enlarged pancreaticoduodenal vessels, angiodysplasia of the caecum and carcinoma of the rectum. Of the remaining five patients, four were seen to have active bleeding into the large bowel and one into the duodenum. Local surgical resection was carried out in nine patients, only one of whom rebled. There was one preoperative and one postoperative death. Experience with this technique has altered our management such that SV A is carried out sooner, saving the patient repeated admissions, investigations and transfusions. SV A is recommended as a pre-operative investigation for the surgeon managing acute unexplained GIH.

Intestinal vascular ectasia. Improving diagnostic capability poses therapeutic dilemma

A case of gastrointestinal bleeding in a 73-year-old man secondary to vascular ectasia is presented. The use of the 99m technetium-tagged erythrocyte scanning to localize the bleeding site and arteriography to document a vascular malformation strongly suggested this diagnosis. Elective hemicolectomy failed to eliminate bleeding, however. Endoscopic and surgical therapies are available for this condition, but the relative frequency of postoperative rebleeding requires conservatism in recommending surgical excision.

Angiodysplasia. Clinical presentation and colonoscopic diagnosis

Angiodysplasia is a recently recognized important cause of lower intestinal bleeding in older patients. Although angiography is an established procedure for the diagnosis of angiodysplasia, colonoscopy is being used increasingly for evaluation of lower intestinal bleeding. In order to define the nature of bleeding due to angiodysplasia and the appropriate role of colonoscopy, 80 patients diagnosed by angiography, pathology, or colonoscopy were reviewed. Bleeding attributable to angiodysplasia varied from acute life-threatening hemorrhage to occult blood in stools. Thirteen patients with angiodysplasia had no bleeding and were identified incidentally by colonoscopy performed for other indications. Eighty-nine percent of the lesions were located in the right colon and there was a mean of 1.5 angiodysplastic lesions per patient. The sensitivity of colonoscopy compared to angiography and pathology was 68% overall and 81% when the colon was completely examined and lesions were located in the colon. The predictive value of a positive colonoscopic diagnosis was 90% in this population. Colonoscopy should be employed as an initial study in patients with chronic or mild acute rectal bleeding.

Gastrointestinal hemorrhage

Two types of upper gastrointestinal bleeding can be differentiated in the critical care setting: bleeding caused by a gastroenterologic disorder or bleeding that develops as a complication of a nongastroenterologic critical illness. A clinical approach to upper gastrointestinal bleeding is presented. Lower gastrointestinal hemorrhage and the diagnosis of gastrointestinal bleeding in infants and children are also briefly discussed.

Recurrent gastrointestinal bleeding of obscure origin: report of 17 cases and a guide to logical management

Seventeen patients with chronic obscure gastrointestinal bleeding presenting over a 5-year period are described. While representing only 6 per cent of the total number of admissions due to gastrointestinal haemorrhage they required a disproportionate amount of medical attention, including 67 admissions, 73 radiological and 56 endoscopic procedures and transfusion of a total of 198 units of blood. The diagnoses included 5 cases of recurrent acute upper gastrointestinal erosions, 7 small bowel abnormalities and 4 colonic lesions, with 1 patient undiagnosed. Eight arteriovenous malformations (AVM) were demonstrated angiographically and one Meckel's diverticulum identified by a 99Tcm pertechnetate scan. There were 5 cases in which laparotomy yielded the final diagnosis and in one of these peroperative endoscopy of the small bowel was required. On the basis of our experience and a review of other series, a logical plan of investigation is described for such difficult cases.

Major hemorrhage and perforation due to a solitary cecal ulcer in a patient with end-stage renal failure

A case of solitary cecal ulcer with major hemorrhage followed by perforation after treatment with intra-arterial vasopressin in a patient with end-stage renal failure is presented. Though vasopressin has been used with success in the treatment of colonic hemorrhage, caution should be applied in patients with a bleeding cecal ulcer as the vasoconstriction produced by vasopressin may cause perforation in an area whose blood supply is already compromised.

Evaluation and medical therapy of acute gastrointestinal bleeding

Gastrointestinal bleeding is a major reason for hospitalization and an important cause of morbidity and mortality. Diagnosis and treatment of this common clinical problem has changed markedly over the past 40 years. The initial approach to patients with gastrointestinal bleeding should be both therapeutic and diagnostic, with close attention to cardiovascular status and clotting parameters. Once the patient is stabilized, clinical history, physical examination, gastric aspirate, and laboratory data should be assessed to determine if the bleeding site is in the upper or lower gastrointestinal tract. Once that is determined, a more specific diagnosis should be made if possible, as therapy often will depend upon a precise diagnosis. Therapy includes angiographic and pharmacologic techniques, as well as tamponade in the case of esophageal varices. The use of antacids in acute upper gastrointestinal bleeding is well established, while the role of cimetidine is less clear. Newer modalities of treatment, such as the use of laser coagulation, are currently being evaluated.

Lower gastrointestinal bleeding. Diagnostic approach and management conclusions

The management of patients with lower gastrointestinal bleeding requires a systematic approach based on defined diagnostic and therapeutic methods. Although in 80 percent of patients bleeding will stop spontaneously, 25 percent will have rebleeding and 50 percent of those with rebleeding will bleed again. Angiography documents specific bleeding sites but raises questions related to the incidence, site and frequency of bleeding, as well as the necessity of demonstrating extravasation. We reviewed 49 arteriograms performed for lower gastrointestinal bleeding. We conclude from our findings that angiography identifies a presumptive cause of bleeding in 49 percent of patients; angiography identified the site of bleeding in 86 percent of the patients with active bleeding, thus allowing segmental colectomy. We believe that documentation of angiodysplasia in a patient with lower gastrointestinal bleeding is presumptive evidence for the site of bleeding. Angiography is useful and worthwhile in the work-up of patients with lower gastrointestinal bleeding in an attempt to plan localized, definitive resection, and this may lead to a lower mortality rate.

Lower GI bleeding in the elderly. Diverticulosis and angiodysplasia as dominant causes

Angiography has greatly improved the precision of diagnosis of massive lower gastrointestinal bleeding in elderly patients. This, in turn, has permitted a more conservative approach, even when operative management becomes necessary. It bears emphasis, however, that hematochezia in elderly patients is usually relatively benign and tends to cease spontaneously. An overly enthusiastic diagnostic or therapeutic course is not warranted, and conservative control of the acute episode, followed by sufficient evaluation to rule out malignancy, is probably all that is necessary. When massive bleeding becomes persistent or recurrent, however, it is clearly life threatening, and a vigorous diagnostic and therapeutic program should be initiated promptly.

Emergency surgery for acute colonic haemorrhage--a retrospective study

This paper reports a retrospective study of 28 patients undergoing emergency laparotomy and colonic resection for acute colonic haemorrhage out of a total of 292 patients admitted with the condition. The paper concludes that in those cases where the bleeding site cannot be accurately localized angiographically prior to laparotomy, the preferred surgical procedure should be total abdominal colectomy with ileoproctostomy as more limited colonic resection leads to an unacceptably high morbidity and mortality.