[Diagnosis and management of lower gastrointestinal hemorrhage. Retrospective analysis of 233 cases]

Characteristics, outcomes, and risk factors of surgery for acute lower gastrointestinal bleeding: nationwide cohort study of 10,342 hematochezia cases

BACKGROUND

Current evidence on the surgical rate, indication, procedure, risk factors, mortality, and postoperative rebleeding for acute lower gastrointestinal bleeding (ALGIB) is limited.

METHODS

We constructed a retrospective cohort of 10,342 patients admitted for acute hematochezia at 49 hospitals (CODE BLUE J-Study) and evaluated clinical data on the surgeries performed.

RESULTS

Surgery was performed in 1.3% (136/10342) of the cohort with high rates of colonoscopy (87.7%) and endoscopic hemostasis (26.7%). Indications for surgery included colonic diverticular bleeding (24%), colorectal cancer (22%), and small bowel bleeding (16%). Sixty-four percent of surgeries were for hemostasis for severe refractory bleeding. Postoperative rebleeding rates were 22% in patients with presumptive or obscure preoperative identification of the bleeding source and 12% in those with definitive identification. Thirty-day mortality rates were 1.5% and 0.8% in patients with and without surgery, respectively. Multivariate analysis showed that surgery-related risk factors were transfusion need ≥ 6 units (P < 0.001), in-hospital rebleeding (P < 0.001), small bowel bleeding (P < 0.001), colorectal cancer (P < 0.001), and hemorrhoids (P < 0.001). Endoscopic hemostasis was negatively associated with surgery (P = 0.003). For small bowel bleeding, the surgery rate was significantly lower in patients with endoscopic hemostasis as 2% compared to 12% without endoscopic hemostasis.

CONCLUSIONS

Our cohort study elucidated the outcomes and risks of the surgery. Extensive exploration including the small bowel to identify the source of bleeding and endoscopic hemostasis may reduce unnecessary surgery and improve the management of ALGIB.

Severe esophageal bleeding in colorectal cancer due to antitumor therapy: A case report

Colorectal cancer is the third most common type of cancer worldwide, with >1 million cases diagnosed each year. Gastrointestinal bleeding is a common complication of colorectal cancer and is usually associated with the erosion and hemorrhage of the primary tumor. However, in patients who undergo a radical hemicolectomy and do not develop local recurrence, gastrointestinal bleeding may be a result of medical treatments or comorbidities. Esophageal bleeding in such patients is rare. Here, a case of severe esophageal bleeding due to anti-angiogenesis therapy with bevacizumab, and chemotherapy with the FOLFIRI regimen (irinotecan, folinic acid and 5-fluorouracil) in a patient with colorectal cancer is reported, and the possible pathogenesis of this event is analyzed based on the existing literature, in order to provide a reference for such cases.

Monochromatic energy computed tomography image for active intestinal hemorrhage: A model investigation

AIM: To investigate the value of computed tomography (CT) spectral imaging in the evaluation of intestinal hemorrhage.

METHODS: Seven blood flow rates were simulated in vitro. Energy spectral CT and mixed-energy CT scans were performed for each rate (0.5, 0.4, 0.3, 0.2, 0.1, 0.05 and 0.025 mL/min). The detection rates and the contrast-to-noise ratios (CNRs) of the contrast agent extravasation regions were compared between the two scanning methods in the arterial phase (AP) and the portal venous phase (PVP). Comparisons of the CNR values between the PVP and the AP were made for each energy level and carried out using a completely random t test. A χ² test was used to compare the detection rates obtained from the two scanning methods.

RESULTS: The total detection rates for energy spectral CT and mixed-energy CT in the AP were 88.57% (31/35) and 65.71% (23/35), respectively, and the difference was significant (χ² = 5.185, P = 0.023); the total detection rates in the PVP were 100.00% (35/35) and 91.4% (32/35), respectively, and the difference was not significant (χ² = 1.393, P = 0.238). In the AP, the CNR of the contrast agent extravasation regions was 3.58 ± 2.09 on the mixed-energy CT images, but the CNRs were 8.78 ± 7.21 and 8.83 ± 6.75 at 50 and 60 keV, respectively, on the single-energy CT images, which were significantly different (3.58 ± 2.09 vs 8.78 ± 7.21, P = 0.031; 3.58 ± 2.09 vs 8.83 ± 6.75, P = 0.029). In the PVP, the differences between the CNRs at 40, 50 and 60 keV different monochromatic energy levels and the polychromatic energy images were significant (19.35 ± 10.89 vs 11.68 ± 6.38, P = 0.010; 20.82 ± 11.26 vs 11.68 ± 6.38, P = 0.001; 20.63 ± 10.07 vs 11.68 ± 6.38, P = 0.001). The CNRs at the different energy levels in the AP and the PVP were significantly different (t = -2.415, -2.380, -2.575, -2.762, -2.945, -3.157, -3.996 and -3.189).

CONCLUSION: Monochromatic energy imaging spectral CT is superior to polychromatic energy images for the detection of intestinal hemorrhage, and the detection was easier in the PVP compared with the AP.

Evaluation of dual-phase multi-detector-row CT for detection of intestinal bleeding using an experimental bowel model

To evaluate dual-phase multi-detector-row computed tomography (MDCT) in the detection of intestinal bleeding using an experimental bowel model and varying bleeding velocities. The model consisted of a high pressure injector tube with a single perforation (1 mm) placed in 10-m-long small bowel of a pig. The bowel was filled with water/contrast solution of 30-40 HU and was incorporated in a phantom model containing vegetable oil to simulate mesenteric fat. Intestinal bleeding in different locations and bleeding velocities varying from zero to 1 ml/min (0.05 ml/min increments, constant bleeding duration of 20 s) was simulated. Nineteen complete datasets in arterial and portal-venous phase using increasing bleeding velocities, and seven negative controls were measured using a 64 MDCT (3-mm slice thickness, 1.5-mm reconstruction increment). Three radiologists blinded to the experimental settings evaluated the datasets in a random order. The likelihood for intestinal bleeding was assessed using a 5-point scale with subsequent ROC analysis. The sensitivity to detect bleeding was 0.44 for a bleeding velocity of 0.10-0.50 ml/min and 0.97 for 0.55-1.00 ml/min. The specificity was 1.00. The area under the curve was calculated to be 0.73, 0.88 and 0.89 for reader 1, 2 and 3, respectively. Dual-phase MDCT provides high sensitivity and specificity in the detection of intestinal bleeding with bleeding velocities of 0.5-1.0 ml/min. Therefore, MDCT should be considered as a primary diagnostic technique in the management of patients with suspected intestinal bleeding.