Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee

Lower gastrointestinal bleeding--management

Although acute LGIB is only about one fifth as common and is usually less hemodynamically significant than upper gastrointestinal bleeding, it presents numerous unique clinical challenges. The best diagnostic approach for patients with active bleeding is unknown, but urgent prepared colonoscopy is safe and likely to be beneficial (Fig. 3, Table 2). In patients who have aggressive bleeding or recurrent bleeding, it is critical for the practitioner to judge when angiography and surgery are necessary.

Cirugía urgente en las hemorragias digestivas bajas graves

INTRODUCTION

There are no conclusive studies that would allow us to distinguish between patients with severe lower gastrointestinal hemorrhage (LGIH) who require emergency surgery and those who do not. The aim of the present study was to determine the clinical and epidemiological factors that would allow us to distinguish between severe LGIH requiring emergency surgery and self-limiting LGIH and to analyze the surgical management of these patients.

MATERIAL AND METHODS

We reviewed 175 patients with LGIH (severe rectal bleeding with a decrease in hematocrit > or = 10 points or transfusion of at least three units of packed red blood cells) treated between 1980 and 2002 and selected 28 patients (16%) who required emergency surgery. The control group consisted of patients with LGIH who did not require surgery. Student's t-test and the Chi-squared test were used in the statistical analysis.

RESULTS

Comparison of severe LGIH requiring emergency surgery with self-limiting LGIH revealed three variables that could serve as a guide to differentiating between these entities, namely: age less than 80 years (p = 0.013), the presence of hypotension on arrival at the emergency department (p < 0.0001), and cause of bleeding (p < 0.0001). Among patients requiring emergency surgery, the origin was ano-rectal in nine (32%) and consequently the approach used was perianal. In the remaining patients (n = 19) the abdominal approach was used. In 10 patients, etiologic diagnosis was not available before surgery and the source of bleeding was identified during the intervention in 6 of these patients. In the four remaining patients without etiological diagnosis before surgery, subtotal colectomy was performed. In the remaining patients, local resection of the affected area was performed (3 right hemicolectomies, 9 small bowel resections, and 3 resections of Meckel's diverticulum). Morbidity was 18% and mortality was 7%.

CONCLUSION

Distinguishing between self-limiting LGIH and LGIH requiring emergency surgery is difficult. In our series, the only factors predictive of emergency surgery were hemodynamic instability on arrival at the emergency department and age less than 80 years. Cause of bleeding is not a predictive factor as it generally unknown at symptom onset.

Superselective Catheterization and Embolization as First-Line Therapy for Lower Gastrointestinal Bleeding

Emergent operative intervention for lower gastrointestinal bleeding (LGIB) is associated with significant morbidity and mortality. Advances in endovascular techniques have made superselective catheterization and embolization (SSCE) of small visceral arterial branches possible. We hypothesized that SSCE for LGIB would be an effective first-line therapy and associated with low mortality. We identified all patients that underwent visceral angiography at our institution from 1997 to 2003. Records from all patients with documented LGIB and in whom SSCE was used as first-line therapy were reviewed. Twenty-three patients (69 ± 11 years) were treated with SSCE as an initial intervention for LGIB. A definitive bleeding site was identified in 95 per cent of cases (22/23). Eleven patients (48%) developed an early complication [recurrent bleeding (n = 5; two required surgery), asymptomatic ischemic colonic mucosa (n = 3), acute renal insufficiency (n = 1; resolved), and femoral pseudo-aneurysm (n = 2; one treated operatively)]. Long-term (mean 19 months) follow-up was available for 17 patients. Five patients (22%) experienced recurrent LGIB, and three patients had evidence of colonic ischemic. One patient required endoscopic dilation of a stricture, and three underwent surgical resection. There was no mortality in our series. In this series, SSCE was an effective first-line therapy for LGIB. Rebleeding and ischemia rates were low.

Review article: the management of lower gastrointestinal bleeding

Several recent advances have been made in the evaluation and management of acute lower gastrointestinal bleeding. This review focuses on the management of lower gastrointestinal bleeding, especially acute severe bleeding. The aim of the study was to critically review the published literature on important management issues in lower gastrointestinal bleeding, including haemodynamic resuscitation, diagnostic evaluation, and endoscopic, radiologic, and surgical therapy, and to develop an algorithm for the management of lower gastrointestinal bleeding, based on this literature review. Publications pertaining to lower gastrointestinal bleeding were identified by searches of the MEDLINE database for the years 1966 to December 2004. Clinical trials and review articles were specifically identified, and their reference citation lists were searched for additional publications not identified in the database searches. Clinical trials and current clinical recommendations were assessed by using commonly applied criteria. Specific recommendations are made based on the evidence reviewed. Approximately, 200 original and review articles were reviewed and graded. There is a paucity of high-quality evidence to guide the management of lower gastrointestinal bleeding, and current endoscopic, radiologic, and surgical practices appear to reflect local expertise and availability of services. Endoscopic literature supports the role of urgent colonoscopy and therapy where possible. Radiology literature supports the role of angiography, especially after a positive bleeding scan has been obtained. Limited surgical data support the role of segmental resection in the management of persistent lower gastrointestinal bleeding after localization by either colonoscopy or angiography. There is limited high-quality research in the area of lower gastrointestinal bleeding. Recent advances have improved the endoscopic, radiologic and surgical management of this problem. However, treatment decisions are still often based on local expertise and preference. With increased access to urgent therapeutic endoscopy for the management of acute upper gastrointestinal bleeding, diagnostic and therapeutic colonoscopy can be expected to play an increasing role in the management of acute lower gastrointestinal bleeding.

Atypical Etiology of Massive Gastrointestinal Bleeding: Arterio-Enteric Fistula following Enteric Drained Pancreas Transplant

Pancreas transplantation is an established treatment for selected type I insulin-dependent diabetes mellitus (DM). Increasingly, enteric drainage of exocrine secretions has been performed in preference to bladder drainage. We present two cases of massive gastrointestinal hemorrhage (GIH) related to arterial-graft duodenal fistulas, a rare cause of massive bleeding. Case 1 DM is a 49-year-old male who underwent simultaneous kidney pancreas transplantation (SPK) for DM and end-stage renal disease (ESRD). He developed a transplant duodenal stump leak that resolved with drainage. He presented with massive hemorrhage at 2 months. Angiography revealed a fistula between the graft-recipient arterial anastomosis and the stump leak. This was managed by transplant pancreatectomy. Case 2 SB is a 37-year-old male who underwent pancreas-after-kidney transplantation (PAK) for type I DM. At 6 months, the pancreas graft failed due to chronic rejection. He presented 9 months later with massive hemorrhage. Upper and lower endoscopy were inconclusive. Angiography revealed a fistula between the transplant arterial graft and the transplant duodenum. This was initially managed by coil embolization and definitively by transplant pancreatectomy. Patients with functional or nonfunctional pancreas transplants presenting with massive GIH not readily localized by endoscopy should undergo angiography to exclude this unusual etiology.

Early predictors of severe lower gastrointestinal bleeding and adverse outcomes: a prospective study

BACKGROUND & AIMS

Unlike in upper tract bleeding, prognostic factors for ongoing or recurrent bleeding from the lower gastrointestinal tract have not been well-defined. The aim of this study was to identify risk factors for severe lower gastrointestinal bleeding and for significant adverse outcomes.

METHODS

All patients seeking attention at a university emergency department for gastrointestinal bleeding were prospectively identified during a 3-year period. Ninety-four of 448 (21%) admitted patients had lower gastrointestinal bleeding. Clinical predictors available in the first hour of evaluation were recorded. The primary outcome, severe lower gastrointestinal bleeding, was defined as gross blood per rectum after leaving the emergency department associated with either abnormal vital signs (systolic blood pressure < 100 mm Hg or heart rate > 100/min) or more than a 2-unit blood transfusion during the hospitalization. Significant adverse outcomes, including death, were tabulated.

RESULTS

Thirty-seven patients (39%) had severe lower gastrointestinal bleeding. Independent risk factors for severe lower gastrointestinal bleeding were initial hematocrit </=35% (odds ratio [OR], 6.3; 95% confidence interval [CI], 2.2-16.7); presence of abnormal vital signs (systolic blood pressure < 100 mm Hg or heart rate > 100/min) 1 hour after initial medical evaluation (OR, 4.3; 95% CI, 1.4-12.5); and gross blood on initial rectal examination (OR, 3.9; 95% CI, 1.2-13.2). Nineteen patients (20%) experienced a significant adverse outcome, including 3 deaths. The main independent predictor of adverse outcomes was severe lower gastrointestinal bleeding (OR, 5.3; 95% CI, 1.7-16.5).

CONCLUSIONS

Risk factors are available in the first hour of evaluation in the emergency department to identify patients at risk for severe lower gastrointestinal bleeding. Severe lower gastrointestinal bleeding is a significant risk factor for global adverse outcomes.

Diverticular disease of the colon

Colonic diverticulosis refers to small outpouchings from the colonic lumen due to mucosal herniation through the colonic wall at sites of vascular perforation. Abnormal colonic motility and inadequate intake of dietary fibre have been implicated in its pathogenesis. This acquired abnormality is typically found in developed countries, and its prevalence rises with age. Most patients affected will remain entirely asymptomatic; however, 10-20% of those affected can manifest clinical syndromes, mainly diverticulitis and diverticular haemorrhage. As our elderly population grows, we can anticipate a concomitant rise in the number of patients with diverticular disease. Here, we review the incidence, pathophysiology, clinical presentation, and management of diverticular disease of the colon and its complications.

Lower gastrointestinal bleeding

Lower gastrointestinal bleeding is defined as blood loss that originates from a source distal to the ligament of Treitz and results in hemodynamic instability or symptomatic anemia. Although approximately 10% to 15% of patients presenting with acute severe hematochezia have an upper gastrointestinal source of bleeding identified on upper endoscopy, the most common causes of lower gastrointestinal bleeding are diverticulosis, hemorrhoids, ischemic colitis, and angiodysplasia. As with upper gastrointestinal bleeding, lower gastrointestinal bleeding ceases spontaneously in most cases.

Gastrointestinal bleeding in the elderly

Gastrointestinal bleeding in elderly individuals is a frequent cause of consultation with a physician and of hospital admissions. Co-morbidity and greater medication use in this steadily growing patient group influence the clinical course and adversely affect outcome. Clinical presentation is often predictable and guides subsequent patient management. Due to a surprising lack of prospective controlled data in the area of gastrointestinal bleeding, the selection of diagnostic and therapeutic manoeuvres often depends more on local expertise and availability than on an algorithmic approach. Advances in endoscopic, medical, radiological and surgical treatment modalities offer promising new diagnostic and therapeutic tools, particularly in concerted applications. Outcome studies on the appropriate sequence and linking of these modalities are urgently needed. This chapter will address clinical presentation, aetiology, diagnosis and treatment of both upper and lower gastrointestinal bleeding in the elderly.

Colonoscopic management of lower gastrointestinal hemorrhage

Lower gastrointestinal bleeding is a common reason for hospitalization, especially among the elderly. Unlike that of upper gastrointestinal bleeding, the diagnostic and therapeutic approach to individuals with lower gastrointestinal bleeding is not well standardized. Recent reports indicate that early colonoscopy may be the best strategy to improve outcomes and reduce costs. However, good prospective, controlled data on the role of colonoscopy in the management of lower gastrointestinal bleeding are still required. Colonoscopy can establish a definite or probable diagnosis in greater than 80% of individuals with lower gastrointestinal bleeding. Based on the best available evidence, it appears that clinical and colonoscopic data may be combined in an effort to predict outcome and suggest optimal length of stay. It also appears that therapeutic colonoscopy can arrest or prevent bleeding in certain high-risk patients, offering the opportunity to change the natural history of the bleed.

[Role of early colonoscopy in severe acute lower gastrointestinal bleeding]

BACKGROUND

Severe acute lower gastrointestinal bleeding (SALGIB) accounts for 15% of cases of acute lower gastrointestinal bleeding (ALGIB). The incidence increases with age and comorbidity. Identification of the origin of bleeding may be difficult. Colonoscopy has been proposed as the primary investigative tool.

AIM

To assess the role of early colonoscopy as the primary method of evaluation in patients with SALGIB.

PATIENTS AND METHOD

Retrospective study based on a guideline for clinical practice approved in our institution. The study included 50 patients with SALGIB admitted to our gastrointestinal bleeding unit between January 1998 and April 2000. SALGIB was suspected when patients fulfilled two or more of the following criteria: 1) significant hemodynamic compromise, 2) decrease in hemoglobin 2 g/dl, and 3) transfusion requirement >= 2 blood units. Early colonoscopy was performed within 24 hours of onset of bleeding. An accurate endoscopic diagnosis was established if a lesion with active bleeding, visible non-hemorrhagic vessel or adherent red clot was identified. A presumptive diagnosis was made when hematochezia or fresh blood localized in a colonic segment, associated with a single, potentially hemorrhagic lesion, was observed and when the results of esophagogastroduodenoscopy were negative. Colonoscopy, esophagogastroduodenoscopy, barium studies, nuclear scan and angiography were performed.

RESULTS

Two hundred twenty-two patients were admitted for ALGIB. Fifty patients(22%) fulfilled the SALGIB criteria. The male/female ratio was 1:1. Definitive diagnosis was accurate in 20 patients. The most frequent cause was angiodysplasia (6 patients) and rectal ulcer (6 patients). Eighteen patients had a presumptive diagnosis; of these 14 had diverticulosis. In 12 patients, no cause was identified. Colonoscopy was performed in 45 patients, of which 32 were performed early and 13 electively. Accurate endoscopic diagnosis was more frequently established with early colonoscopy than with elective colonoscopy (15 [47%] vs 2 [15%], p < 0.05). The results of urgent nuclear scans contributed to accurate diagnosis in 5 out of the 10 patients in whom this technique was performed. Angiography was performed in 2 patients. Endoscopic therapy was attempted in 4 patients, all during early colonoscopy. Ten patients (20%) underwent surgery and 3 patients (6%) died.

CONCLUSIONS

In 22% of patients with ALGIB admitted to our hospital bleeding was severe. Colonoscopy is the diagnostic tool of choice. When performed within 24 hours of hospital admission, this technique provides more accurate diagnosis than when performed electively.

Lower intestinal bleeding

Lower gastrointestinal tract bleeding is a frequent cause of physician consultations and hospital admissions. Clinical presentation is predictable and significantly influences subsequent patient management. Controversy surrounding diagnosis and treatment of lower gastrointestinal bleeding results from a surprising lack of prospective controlled data. Thus, selection of diagnostic and therapeutic manoeuvres often depends more on local expertise and availability than on an algorithm approach. Advances in endoscopic, radiological and surgical equipment and techniques offer promising new diagnostic and therapeutic modalities, particularly in concerted applications. Outcome studies on the appropriate sequence and linking of these modalities are urgently needed. The present chapter will address clinical presentation, aetiology, diagnosis and treatment of lower gastrointestinal tract bleeding.

Acute gastrointestinal bleeding

Acute gastrointestinal bleeding is a significant worldwide medical problem. Despite modern measures for diagnosis and treatment, morbidity and mortality rates associated with gastrointestinal bleeding remain largely unchanged. Aggressive medical resuscitation while initiating an evaluation to localize the site of blood loss remains the key to successful management of acute gastrointestinal bleeding. A multidisciplinary approach with early involvement of a gastroenterologist, surgeon, and radiologist can be extremely helpful in the management of these patients. With the logical and direct approach to the evaluation of patients with gastrointestinal bleeding described in this article, most episodes can be managed successfully.

Surgical management of gastrointestinal bleeding

Severe gastrointestinal bleeding has historically been a clinical problem primarily under the purview of the general surgeon. Diagnostic advances made as the result of newer technologies, such as fiberoptic and video endoscopy, selective visceral arteriography, and nuclear scintigraphy, have permitted more accurate and targeted operations. More importantly, they have led to safe, effective nonoperative therapeutic interventions that have obviated the need for surgery in many patients. Today, most gastrointestinal bleeding episodes are initially managed by endoscopic or angiographic control measures. Such interventions are often definitive in obtaining hemostasis. Even temporary cessation or attenuation of massive bleeding in an unstable patient permits a safer, more controlled operative procedure by allowing an adequate period of preoperative resuscitation. Despite the less frequent need for surgical intervention, traditional operative approaches, such as suture ligation, lesion or organ excision, vagotomy, portasystemic anastomosis, and devascularization procedures, continue to be life-saving in many instances. The proliferation of laparoscopic surgery has fostered the application of minimally invasive techniques to highly selected patients with gastrointestinal bleeding. Intraoperative endoscopy has greatly facilitated the accuracy of laparoscopic surgery by endoscopic localization of bleeding lesions requiring excision. It is anticipated that the evolving technologies pertinent to the diagnosis and management of gastrointestinal bleeding will continue to promote collaboration and cooperation between gastroenterologists, radiologists, and surgeons.

Diagnosis and management of lower gastrointestinal bleeding

There are few randomized, prospective trials evaluating the optimal diagnostic and therapeutic strategies in the management of lower gastrointestinal bleeding. However, recent data suggest that urgent colonoscopy represents a safe and effective initial diagnostic approach. The role of tagged erythrocyte scintigraphy is yet to be defined, but it may be of utility as a screening test for visceral angiography. Colonoscopy and angiography both offer substantial therapeutic options but remain of unproved benefit from a treatment standpoint; surgery continues to play an important role in the management of lower gastrointestinal bleeding. Obscure gastrointestinal bleeding, which often presents as lower gastrointestinal bleeding, continues to be one of the most challenging diagnostic and therapeutic problems in gastroenterology. Occult gastrointestinal bleeding, often arising from the lower gastrointestinal tract, usually mandates gastrointestinal evaluation.

Diverticular disease of the colon

Diverticular disease of the colon is quite common in developed countries, and its prevalence increases with age. Although present in perhaps two thirds of the elderly population, the large majority of patients will remain entirely asymptomatic. Nonetheless, an estimated 20% of those affected may manifest clinical illness, mainly diverticulitis, with its potential complications of abscesses, fistulas, and obstruction, as well as lower intestinal hemorrhage. The purpose of this report is to review our understanding of the epidemiology, pathophysiology, clinical presentation, and treatment options for this disorder.