Lower GI bleeding: a review of current management, controversies and advances

Clinical outcomes of lower gastrointestinal bleeding in patients managed with lower endoscopy: A tertiary center results

BACKGROUND

Lower gastrointestinal bleeding (LGIB) is an urgent presentation with increasing prevalence and remains a common cause of hospitalization. The clinical outcome can vary based on several factors, including the cause of bleeding, its severity, and the effectiveness of management strategies. The aim of this study is to provide a comprehensive report on the clinical outcomes observed in patients with LGIB who underwent lower endoscopy.

METHODS

All patients who underwent emergency lower endoscopy for fresh bleeding per rectum, from May 2015 to December 2021, were included. The primary outcome was to identify the rate of rebleeding after initial control of bleeding. The second was to measure the clinical outcomes and the potential predictors leading to intervention and readmission.

RESULTS

A total of 84 patients were included. Active bleeding was found in 20% at the time of endoscopy. Rebleeding within 90 days occurred in 6% of the total patients; two of which (2.38%) were within the same admission. Ninety-day readmission was reported in 19% of the cases. Upper endoscopy was performed in 32.5% of the total cases and was found to be a significant predictor for intervention (OR 4.1, P = 0.013). Personal history of inflammatory bowel disease (IBD) and initial use of sigmoidoscopy were found to be significant predictors of readmission [(OR 5.09, P = 0.008) and (OR 5.08, P = 0.019)].

CONCLUSIONS

LGIB is an emergency that must be identified and managed using an agreed protocol between all associated services to determine who needs upper GI endoscopy, ICU admission, or emergency endoscopy within 12 hours.

A rare case of bleeding jejunal ulcer diagnosed by intraoperative use of enteroscopy

INTRODUCTION

Small bowel bleeding can be overt or occult. Despite advances in imaging and endoscopy, the diagnosis and treatment of small bowel bleeding remain challenging due to its length and location. Diagnostic procedures such as push enteroscopy, capsule endoscopy and intraoperative enteroscopy are recommended to identify the source of bleeding.

CASE PRESENTATION

A 33-year-old female with no prior history of bleeding diathesis presented with massive lower GI bleeding. Although she was in hypovolemic shock from bleeding, physical exam, splanchnic angiography and colonoscopy were unable to localize the source of bleeding. The patient continued to bleed and deteriorate despite transfusions. Exploratory laparotomy was done but localizing the source with manual palpation of small bowel was difficult. Intraoperative enteroscopy was done and showed a 2 by 1 cm ulcerative lesion at mid jejunum. Part of jejunum containing the ulcer was resected and anastomosis done. The patient did well postoperatively and on follow up.

CLINICAL DISCUSSION

A bleeding primary jejunal ulcer is rare clinical scenario difficult to diagnose. Intraoperative enteroscopy is useful in cases where initial diagnostic workups are inconclusive. It can be performed using various types of endoscopes, such as a standard or pediatric colonoscope, push enteroscope, or a sonde enteroscope, during laparotomy.

CONCLUSION

Primary jejunal ulcer is a rare cause of massive lower GI bleeding. Although minimally invasive deep endoscopic techniques to diagnose small bowel ulcers are evolving, intraoperative enteroscopy remains to be technically easy and helpful tool to make a diagnosis and guide intervention especially in a patient undergoing laparotomy for bleeding small bowel ulcer.

Importance of communication of CT indication for imaging yield in patients with gastrointestinal bleed

PURPOSE

The indications for requesting a diagnostic test are important for the selection and timing of imaging protocols. We sought to evaluate the diagnostic yield and impact on patient disposition when evaluating computed tomography (CT) of the abdomen and pelvis in adult patients presenting with gastrointestinal bleeding (GIB) to the Emergency Department (ED).

METHODS

This study was an observational cohort study of consecutive adult ED patients with ICD10 codes related to GIB between 5/5/2018 and 6/1/2020. CT reports were reviewed for indications, exam type and findings. Reports were classified as positive (active bleeding, recent bleeding or suspected etiology for GIB), negative or other significant findings. Methodological guidelines for reporting observational studies were followed (STROBE).

RESULTS

Among 943 patients with GIB during the study period, 33% (n = 312) had an abdominopelvic CT ordered. Most CTs included contrast, 64.1% (n = 200) used a single portal venous phase and 28.9% (n = 90) were multi-phase. CT identified active bleeding in 4.2% (n = 13/312) and intraluminal blood in 2.9% (n = 9/312) patients. Patients that had GIB indications on the CT order (n = 142) were more likely to receive a multiphase study compared to those without GIB indication (n = 94) (43.0% vs. 8.5%, difference 34.5%, 95% CI 23.7% to 43.7%, p < 0.0001). Patients that received multiphase studies were more likely to have a source of GIB identified compared to single-phase (18.9% vs 1.5%, OR 15.3, 95% CI 4.4 to 53.7, p < 0.0001). In 40.3% (n = 117/290) of patients without bleeding, an intra-abdominal cause for their symptoms was identified. Those with GIB or with an identified cause were more likely to be admitted.

CONCLUSIONS

One-third of patients evaluated in the ED with GIB had a CT ordered. Active GIB was detected more often when multiphase exams were performed. Multiphase exams are done more often if GIB is listed in the CT indication. When a CT is positive, patients are more likely to be admitted or observed. Accurate indications are critical to optimize exam performance.

Management of Acute Lower Gastrointestinal Bleeding: A Survey to Assess Adherence to Guidelines Across the United Kingdom and Ireland

Introduction: Acute gastrointestinal bleeding (GIB) is a common surgical problem requiring hospitalization in the United Kingdom (UK) and Ireland. The first UK lower gastrointestinal bleeding (LGIB) management guidelines were published in 2019 by the British Society of Gastroenterology (BSG). We aimed to evaluate self-reported adherence to BSG clinical guidance (CG) within the UK and Ireland.

Methods and materials: A Questionnaire was designed based on LGIB BSG CG 2019 using Google Forms (Google LLC, Mountain View, CA). This was distributed to surgical consultants and senior surgical practitioners (specialists, Trust grade registrars, and specialist registrars) across different centers in the UK and Ireland over four weeks (13th March to 5th April 2021). Data were analyzed using Statistical Package for Social Sciences (SPSS) version 27 (IBM Corp., Armonk, NY, USA).

Results: A total of 64 responses were recorded from 18 different centers in the UK and Ireland. The ratio of consultants and registrars was almost the same (34:30, 53.1%:46.9%). The majority of respondents were from colorectal surgery (65.6%, n=42) followed by general surgeons (23.4%, n=15). A total of 41 respondents (64.1%) admitted that BSG CG 2019 were practically applicable at their center. Approximately 75% of respondents did not use or were unaware of the Shock index or Oakland score to stratify patients. That translated into 59% opting to admit patients with a minor bleed. Around 36% wanted to perform a CT angiogram for a stable major bleed, while 37% were unaware of the interventional radiology (IR) referral pathway.

Conclusion: There is patchy adherence to the guidelines leading to significant variations in LGIB management practice and avoidable admissions.

Factors influencing hospital stay duration for patients with mild ischemic colitis: a retrospective study

Background

Ischemic colitis is the most prevalent ischemic injury of the gastrointestinal tract. The majority of patients with mild ischemic colitis usually achieve complete clinical recovery shortly. However, the predictors of longer hospital stay duration are unclear. This study aimed to evaluate the predictors of hospital stay duration for patients with mild ischemic colitis.

Methods

We retrospectively evaluated 100 patients with mild ischemic colitis between January 2010 and December 2020 at Xiangya Hospital (a tertiary care center). The clinical characteristics and therapeutic drugs of patients who were hospitalized for ≤ 8 days and ≥ 12 days were compared.

Results

Of the 100 patients included, 63 (63%) were hospitalized for ≤ 8 days and 37 (37%) were hospitalized for ≥ 12 days. Patients with cerebrovascular disease (29.7% vs. 11.1%, p = 0.019) and abdominal surgical history (29.7% vs. 7.9%, p = 0.004) were more likely to be hospitalized for ≥ 12 days than for ≤ 8 days. The d-dimer levels [0.78 (0.41–1.82) vs. 0.28 (0.16–0.73), p = 0.001] and positive fecal occult blood test results (86.5% vs. 60.3%, p = 0.006) were higher in patients who were hospitalized for ≥ 12 days than in those who were hospitalized for ≤ 8 days. Probiotic use was greater in patients hospitalized for ≤ 8 days (76.2% vs. 54.1%, p = 0.022). Multivariate analysis indicated that cerebrovascular disease (odds ratio [OR] = 4.585; 95% confidence interval [CI] 1.129–18.624; p = 0.033), abdominal surgical history (OR = 4.551; 95% CI 1.060–19.546; p = 0.042), higher d-dimer levels (OR = 1.928; 95% CI 1.024–3.632; p = 0.042), and higher positive fecal occult blood test results (OR = 7.211; 95% CI 1.929–26.953; p = 0.003) were associated with longer hospital stays.

Conclusion

Cerebrovascular disease, abdominal surgical history, higher d-dimer levels, and higher positive fecal occult blood test results are independent and significant factors that influence longer hospital stays for patients with mild ischemic colitis. Probiotics helped reduce hospital stay in these patients.

Use of over-the-scope clips in the colon in clinical practice: results from a German administrative database

BACKGROUND : The efficacy and safety of over-the-scope (OTS) clips in the colon is limited. This study aimed to evaluate OTS clip use in the colon in routine colonoscopy.

METHODS

Using administrative data from a large health insurance company, patients with OTS clip placement during colonoscopy were identified and analyzed by specific administrative codes. Indication for OTS clipping was analyzed, and follow-up was evaluated for surgical and repeat endoscopic interventions.

RESULTS

In 505 patients, indications for OTS clips were iatrogenic perforations (n = 80; Group A), polypectomy (n = 315; Group B), colonic bleeding (n = 51; Group C), and various underlying diseases (n = 59; Group D). In 11 Group A patients (13.8 %), surgical interventions occurred, mostly within 24 hours after clipping (n = 9), predominantly overstitching (n = 8). OTS clipping during polypectomy (Group B) was for complications (e. g. bleeding in 27 %) or was applied prophylactically. Only five patients required early surgery, three of whom had colorectal cancer. In four Group C patients (7.8 %), surgical resections were performed (persistent bleeding n = 1, colorectal cancer n = 2), while six patients underwent early repeat colonoscopy for recurrent bleeding. During further follow-up (days 11-30), 17 patients underwent resection for colonic neoplasms (n = 12) or persistent bleeding (n = 4), but only one case could be directly traced back to local OTS clip complication.

CONCLUSION

Colonic OTS clipping appears safe and effective in selected indications and complications in clinical routine but must be anatomically and technically feasible, avoiding overuse.

Analysis of time delay between computed tomography and digital subtraction angiography on the technical success of interventional embolisation for treatment of lower gastrointestinal bleeding

INTRODUCTION

A retrospective study was undertaken to determine a potential relationship, based on the time delay, between a positive lower gastrointestinal bleed demonstrated on computed tomography (CT) and a positive digital subtraction angiographic (DSA) study and the impact on technical success.

METHODS

This study investigated the correlation of time delays between imaging modalities and technical success with endovascular embolisation procedures over a 10-year period.

RESULTS

A total of 110 patient events were analysed, and it was observed that the greater the time delay between modalities (up to 7 h), the weaker the correlation between a bleed observed on CT and DSA. This was also reflected by the technical success of the embolisation treatment. Patients experienced shorter delays when the event occurred out of normal business hours, however with decreased rates of technical success.

CONCLUSIONS

There is a suggestion patients should be escalated to the angiography suite for DSA imaging as soon as possible to maximise the ability to angiographically observe acute bleeding and treat appropriately with interventional embolisation. More research in this area is required to statistically confirm this.

Characteristics of patients treated for active lower gastrointestinal bleeding detected by CT angiography: Interventional radiology versus surgery

PURPOSE

To determine radiological or clinical criteria guiding treatment decisions in active lower gastrointestinal bleeding (LGIB).

MATERIALS AND METHODS

We consecutively and retrospectively included all patients admitted to our emergency department for acute LGIB proven by CT angiography (CTA) from 2004 to 2017. Patients were divided into two groups depending on whether they first underwent interventional radiological (IR) or surgical treatment. Two radiologists reviewed CTA and angiographic images. Patients' hemodynamic and clinical parameters, delay between imaging and treatment, procedure characteristics, and outcomes were investigated to detect differences between the two groups.

RESULTS

Initial management consisted of IR in 62 cases (70.5%) and surgery in 26 (29.5%). IR cases were older than surgical cases (74.3 vs 64.3y, p = 0.014). Baseline hemodynamic parameters were similar between the two groups. For colonic bleeding sources, the delay between CTA and IR was shorter than between CTA and surgery (p = 0.027), while there was a trend towards a shorter delay for all LGIB taken together (p = 0.061). In cases with hematochezia or melena, IR was more frequently performed than surgery (p = 0.001). Surgical cases showed higher base excesses (p = 0.039) and lactate levels (p = 0.042) after treatment compared with IR cases. Length of hospital stay was similar between the two groups (p = 0.728). During angiography, 41 (66%) cases were embolized. Complications occurred in three cases after IR (7%) and in five after surgery (19%).

CONCLUSION

Initial management of active LGIB revealed by CTA (i.e. IR versus surgery), may depend on age and clinical signs, rather than hemodynamic parameters.

Early Endoscopy Is Associated with Better Clinical Outcomes in Patients Hospitalized with Ischemic Bowel Disease

BACKGROUND AND AIMS

Providing diagnostic and therapeutic interventions, lower gastrointestinal endoscopy is a salient investigative modality for ischemic bowel disease (IB). As studies on the role of endoscopic timing on the outcomes of IB are lacking, we sought to clarify this association.

METHODS

After identifying 18-to-90-year-old patients with a primary diagnosis of IB from the 2012-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, we grouped them based on timing of endoscopy into three: early (n = 9268), late (n = 3515), and no endoscopy (n = 18,452). We explored the determinants of receiving early endoscopy, the impact of endoscopic timing on outcomes (mortality and 13 others), and the impact of the type of endoscopy (colonoscopy vs. sigmoidoscopy) on these outcomes among the early group (SAS 9.4).

RESULTS

Less likely to receive early endoscopy were Blacks compared to Whites (adjusted odds ratio [aOR] 0.81 95% CI [0.70-0.94]), and individuals on Medicaid, Medicare, and uninsured compared to the privately insured group (aOR 0.80 [0.71-0.91], 0.70 [0.58-0.84], and 0.68 [0.56-0.83]). Compared to the late and no endoscopy groups, patients with early endoscopy had less mortality (aOR 0.53 [0.35-0.80] and 0.09 [0.07-0.12]), shorter length of stay (LOS, 4.64 [4.43-4.87] days vs. 8.87 [8.40-9.37] and 6.62 [6.52-7.13] days), lower total hospital cost (THC, $41,055 [$37,995-$44,361] vs. $72,598 [$66,768-$78,937] and $68,737 [$64,028-$73,793]), and better outcomes. Similarly, among those who received early endoscopy, colonoscopy had better outcomes than sigmoidoscopy for mortality, THC, LOS, and adverse events.

CONCLUSION

Early endoscopy, especially colonoscopy, is associated with better clinical outcomes and decreased healthcare utilization in IB. Unfortunately, there are disparities against Blacks, and non-privately insured individuals in receiving early endoscopy.

Successful hemostasis of active lower GI bleeding using a hemostatic powder as monotherapy, combination therapy, or rescue therapy

BACKGROUND AND AIMS

Acute lower GI bleeding is a frequent cause of hospital admission. The objective of this study was to evaluate the safety and performance of a hemostatic powder (TC-325/Hemospray) in the treatment of nonvariceal lower GI bleeding.

METHODS

Patients were enrolled into this prospective, multicenter, single-arm study at 4 tertiary care centers in Canada. Fifty patients with active lower GI bleeding of multiple different causes (52 bleeding sites) underwent topical endoscopic application of hemostatic powder. The primary endpoint was powder-related adverse events within 30 days of the index procedure. Secondary endpoints were initial hemostasis as well as recurrent bleeding and mortality within 30 days of the index procedure.

RESULTS

Most patients (96%) had a single bleeding site, and most bleeding (73%) was due to polypectomy. Overall, the powder was applied as monotherapy in 13 bleeding sites (25%), as combination therapy in 22 bleeding sites (42.3%), and as rescue therapy in 17 bleeding sites (32.7%). Hemostasis was achieved in 98% of patients. No patient experienced a powder-related adverse event. Five patients (10%) developed recurrent bleeding within 30 days. One patient (2%) died within 30 days of powder application, but the death was not directly related to hemostatic powder use.

CONCLUSIONS

The hemostatic powder is a safe and effective option for patients with lower GI bleeding of varying causes, and in particular, postpolypectomy hemorrhage. The hemostatic powder is effective as monotherapy, part of a combination approach, or as a rescue therapeutic option for the treatment of nonvariceal lower GI bleeding. (Clinical trial registration number: NCT02099435.).

Two-year retrospective analysis of patients undergoing direct to procedure flexible sigmoidoscopy investigation with rectal bleeding as a primary complaint

BACKGROUND AND AIMS

 Rectal bleeding affects ~15 % of the general population and is a common reason for referral to gastroenterologists by primary care physicians. Direct to procedure flexible sigmoidoscopy is an appealing modality to investigate rectal bleeding due its diagnostic yield, safety profile, and accessibility. Patients referred on a routine basis for direct to procedure clinic by primary care physicians with the sole complaint of rectal bleeding have not previously been studied. Our study aims to explore the spectrum of diagnoses and evaluate for potential clinical predictors of underlying pathology in this specific patient population.

METHODS

 In total, 528 charts of patients referred to the Kingston General Hospital and Hotel Dieu Hospital endoscopy units (Kingston, Canada) with the sole complaint of rectal bleeding were reviewed. All of these patients were referred on a routine basis to direct to procedure clinic from primary care physicians. The performance of various clinical variables in predicting significant pathology was assessed by univariate analysis.

RESULTS

 The diagnostic spectrum of the cohort studied included hemorrhoids (75.5 %), anal fissures (4 %), ulcerative colitis (3.2 %), Crohn's disease (1.1 %), indeterminate proctitis/colitis (1.7 %), and colorectal malignancy (2.7 %). Of the various clinical variables assessed, only male sex predicted significant pathology (25.2 % of males vs 17.6 % of females, P  < 0.05).

CONCLUSION

 Our study highlights the need for a thorough investigation of rectal bleeding given the lack of clinical predictors. Future prospective studies with more patients are needed to fully assess the utility of various clinical variables in predicting pathology in this patient population. This would allow for more effective triaging of a routine rectal bleeding, a very common reason for patient referral to gastroenterologists by primary care physicians. Flexible sigmoidoscopy was not associated with complications or missed diagnosis in our study. As such, the technique appears to be a suitable initial investigative modality for patients with rectal bleeding.

Acute lower gastrointestinal bleeding in Sudanese patients: a study on 301 patients in a specialized centre

BACKGROUND AND STUDY AIMS

Lower gastrointestinal bleeding originates from a site distal to the ligament of Treitz. It can present as an acute life-threatening or chronicbleeding. It is common among older patients and those with comorbidity. The common causes are diverticular disease, angiodysplasias, neoplasms, colitis, ischaemia and anorectal disorders. The aim of this study is to determine the prevalence and causes of acute lower gastrointestinal bleeding among Sudanese patients.

PATIENTS AND METHODS

In a period of 2 years we studied 301 patients with fresh rectal bleeding out of 5625 patients with gastrointestinal bleeding in Ibn Sina Specialized Hospital, Khartoum, Sudan, This is a cross sectional observational hospital based study. All patients with fresh rectal bleeding within 24 h were included and consented.

RESULT

Lower gastrointestinal bleeding constituted 5.37% of total cases of gastrointestinal bleeding. The mean age of patients was 55.43 ± 17.779, male: female ratio was 2:1. The most common cause (if upper gastrointestinal bleeding is excluded) was diverticular disease 39.6% (n = 61) followed by piles 24.1% (n = 35), colonic tumours 12.34% (n = 19), ulcerative colitis 5.19% (n = 8), Crohn's 5.19% (n = 8), colonic polyps 3,89% (n = 6), angiodysplesia 4.5% (n = 7), colonic ulcer 2.59% (n = 4), ischaemic colitis 1.3%, nonspecific colitis 1.3% (n = 2), and small bowel source in 1.3% (n = 2). The majority of those patients with diverticular disease were male and with first presentation. The commonest cause in those patients younger than 20 years was polyps, and in those between 21 and 40 was piles followed by inflammatory bowel disease, and in those between 41 and 60 years old was piles followed by diverticular disease and tumours, and in those above 60 years was diverticular disease followed by piles and tumours. The correlation between positive colonoscopy finding and diabetes and the use of nonsteroidal anti-inflammatory drugs were statistically significant. The one-month mortality rate was 2.3% CONCLUSION: Acute lower gastrointestinal bleeding is common among elderly patients and the commonest cause is diverticular disease. Colonoscopy plays an important role in the diagnosis. Most patients respond to conservative therapy.

Multidetector-Row Computed Tomography and Colonoscopy for Detecting a Rectal Dieulafoy Lesion as a Source of Lower Gastrointestinal Hemorrhage

A Dieulafoy lesion of the rectum is a very rare entity that can cause massive lower gastrointestinal (GI) hemorrhage. Identifying the bleeding point is sometimes difficult because these lesions are very small. We herein describe an 82-year-old man with active hemorrhage due to a rectal Dieulafoy lesion. He was referred to our hospital because of persistent hematochezia from the morning of that day. He had a history of atrial fibrillation, chronic heart failure, diabetes mellitus, and hyperuricemia. Prompt multidetector-row computed tomography (MDCT) enabled us to detect active bleeding from the lower rectum. Subsequently, colonoscopy revealed an exposed vessel in the lower rectum without surrounding ulceration, and hemostasis was successfully achieved using a hemostatic forceps with soft coagulation. After hemostasis had been achieved, the patient recovered and was discharged without complications and rebleeding. He is doing well 6 months after discharge from the hospital. Sequential examination by MDCT and colonoscopy is considered an efficient treatment strategy for patients with active lower GI bleeding.

Evaluation and management of lower gastrointestinal bleeding

Lower gastrointestinal bleeding (LGIB) is a common cause of presentation to the emergency department and hospital admissions. The incidence of LGIB increases with age and the most common etiologies are diverticulosis, angiodysplasia, malignancy and anorectal diseases. Foremost modality for evaluation and treatment of LGIB is colonosopy. Other diagnostic tools such as nuclear scintigraphy, computed tomography, angiography and capsule endoscopy are also frequently used in the workup of LGIB. Choice of treatment modality depends on the hemodynamic status of the patient, rate of bleeding, expertise and available resources. We present a comprehensive review of the evaluation and management of LGIB.

Acute Lower Gastrointestinal Bleeding: Characteristics and Clinical Outcome of Patients Treated With an Intensive Protocol

Background

In recent years major advances have been made in the management of patients with acute lower gastrointestinal bleeding. The aim of this study was to investigate the characteristics and clinical outcome of patients with acute lower gastrointestinal bleeding (ALGIB) treated with an intensive protocol.

Methods

We analyzed the medical records of 528 patients with ALGIB. All patients after hemodynamic stabilization underwent colonoscopy during the first 24 h of hospitalization and capsule enteroscopy when needed. Patients with massive ongoing bleeding underwent computed tomography angiography (CTA), and when active bleeding was detected embolization was immediately performed.

Results

The mean age of the patients was 70.2 ± 14.6 years and 271 (51.3%) of them were men. At least one comorbidity was present in 464 patients (87.9%), cardiovascular disease in 266 (50.4%), while 158 (30%) patients were on antiplatelet drugs and 96 (18.2%) on anticoagulants. The most common causes of bleeding were diverticulosis (19.7%) and ischemic colitis (19.3%). Thirty-six patients (6.9%) had small intestinal bleeding. In 117 patients (22.2%) active bleeding or recent bleeding stigmata were found and in 82 of them (92.1%) endoscopic hemostasis was applied. Embolization was performed in 10 (1.9%) and was successful in seven (70%) cases, while surgical hemostasis was required in only six (1.1%) cases. Forty-four (8.3%) patients had a rebleeding episode, and 13 patients died with an overall mortality of 2.5%.

Conclusions

Management of ALGIB based on an intensive protocol is safe and effective. The bleeding source can be identified in most cases with a favorable outcome.

Segmental colectomy for bleeding diverticular disease guided by the PEEP test

Many patients with massive lower gastrointestinal (GI) haemorrhage from diverticulosis are subjected to total colectomy when preoperative localisation is unavailable. We dissected colectomy specimens and noted that there was limited retrograde reflux in most of these cases. Therefore, we sought to assess the value of a positive endoluminal erythrocyte presence (PEEP) test (presence of fresh blood in the caecum) to direct segmental colectomies in 14 patients who required emergency operations for massive lower GI haemorrhage. Overall, 13 (93%) patients who had segmental colectomy guided by the PEEP test had successful control of bleeding. There was no mortality and a 14% postoperative morbidity after segmental resections guided by the PEEP test. One patient had persistent bleeding and required a completion colectomy on the third postoperative day. We propose that the PEEP test be added to the surgical armamentarium to guide segmental resection in the absence of localisation by conventional means. However, we advocate blind total colectomy if the PEEP test is equivocal and early completion colectomy if there is significant re-bleeding.

The Clinical Outcomes of Lower Gastrointestinal Bleeding Are Not Better than Those of Upper Gastrointestinal Bleeding

The incidence of lower gastrointestinal bleeding (LGIB) is increasing; however, predictors of outcomes for patients with LGIB are not as well defined as those for patients with upper gastrointestinal bleeding (UGIB). The aim of this study was to identify the clinical outcomes and the predictors of poor outcomes for patients with LGIB, compared to outcomes for patients with UGIB. We identified patients with LGIB or UGIB who underwent endoscopic procedures between July 2006 and February 2013. Propensity score matching was used to improve comparability between LGIB and UGIB groups. The clinical outcomes and predictors of 30-day rebleeding and mortality rate were analyzed between the two groups. In total, 601 patients with UGIB (n = 500) or LGIB (n = 101) were included in the study, and 202 patients with UGIB and 101 patients with LGIB were analyzed after 2:1 propensity score matching. The 30-day rebleeding and mortality rates were 9.9% and 4.5% for the UGIB group, and 16.8% and 5.0% for LGIB group, respectively. After logistic regression analysis, the Rockall score (P = 0.013) and C-reactive protein (CRP; P = 0.047) levels were significant predictors of 30-day mortality in patients with LGIB; however, we could not identify any predictors of rebleeding in patients with LGIB. The clinical outcomes for patients with LGIB are not better than clinical outcomes for patients with UGIB. The clinical Rockall score and serum CRP levels may be used to predict 30-day mortality in patients with LGIB.

New advances in lower gastrointestinal bleeding management with embolotherapy

Lower gastrointestinal bleeding (LGIB) is associated with high morbidity and mortality. Embolization is currently proposed as the first step in the treatment of acute, life-threatening LGIB, when endoscopic approach is not possible or is unsuccessful. Like most procedures performed in emergency setting, time represents a significant factor influencing outcome. Modern tools permit identifying and reaching the bleeding site faster than two-dimensional angiography. Non-selective cone-beam CT arteriography can identify a damaged vessel. Moreover, sophisticated software able to detect the vessel may facilitate direct placement of a microcatheter into the culprit vessel without the need for sequential angiography. A further important aspect is the use of an appropriate technique of embolization and a safe and effective embolic agent. Current evidence shows the use of detachable coils (with or without a triaxial system) and liquid embolics has proven advantages compared with other embolic agents. The present article analyses these modern tools, making embolization of acute LGIB safer and more effective.