Controlled, semielective, segmental resection for massive colonic hemorrhage

Management of Acute Lower Gastrointestinal Haemorrhage in a Surgical Unit Over a 4-Year Period

Over a 4-year period 107 patients, 5% of all emergency admissions, were admitted to one surgical unit with significant lower gastrointestinal haemorrhage (requiring more than a 2-unit transfusion of blood). Twenty-three individuals required more than 3 units of blood, and 7 life-saving surgery. All subjects undergoing surgery required more than 3 units of blood in the first 24 hours of admission. Arteriography was diagnostic in 5 of the 9 subjects in whom it was performed. Arteriography was positive if performed in the first 24 hours of admission. A flow chart of the management of patients with lower gastrointestinal haemorrhage is presented.

How should I treat a patient with life-threatening gastrointestinal bleeding early after coronary drug-eluting stent implantation?

BACKGROUND

A 68-year-old man was referred for stable angina pectoris and a large apical perfusion defect on stress myocardial scintigraphy. Medical history included chronic oral anticoagulation with warfarin due to longstanding atrial fibrillation, type 2 diabetes mellitus, hypertension, and dyslipidaemia.

INVESTIGATION

Coronary angiography.

DIAGNOSIS

Severe stenosis of the mid left anterior descending coronary artery.

TREATMENT

Percutaneous coronary intervention with implantation of drug-eluting stent.

Lower gastrointestinal bleeding: a review

Lower gastrointestinal bleeding (LGIB) continues to be a problem for physicians. Acute LGIB is defined as bleeding that emanates from a source distal to the ligament of Treitz. Although 80% of all LGIB will stop spontaneously, the identification of the bleeding source remains challenging and rebleeding can occur in 25% of cases. Some patients with severe hematochezia require urgent attention to minimize further bleeding and complications. This article reviews the causes, diagnostic methods, and endoscopic treatment of LGIB.

Mesenteric angiography for lower gastrointestinal hemorrhage: are there predictors for a positive study?

PURPOSE

Selective mesenteric angiography is an expensive, invasive, diagnostic, and therapeutic tool for lower gastrointestinal hemorrhage. Some institutions have required a positive nuclear medicine bleeding scan before angiography. We have attempted to determine if this is a valid screening test for mesenteric angiography. Are there any other factors to predict which patients are actively bleeding and who will benefit from angiography?

METHODS

All cases of mesenteric angiography for hemorrhage performed during a 12-year period were reviewed.

RESULTS

A total of 131 angiograms were performed during a 12-year period with 45 patients demonstrating active bleeding; 54 patients had a bleeding scan before angiography. A positive bleeding scan did not increase the percentage of positive angiograms. A history of prior gastrointestinal bleeding, transfusions, orthostatic hypotension, or tachycardia were not predictors for a positive angiogram.

DISCUSSION

This study could not identify any single useful predictor that will increase the likelihood of obtaining a positive angiogram. Nuclear medicine scans should not be used routinely as a screening test for angiography.

Lower gastrointestinal bleeding

BACKGROUND

Lower gastrointestinal bleeding can be a confusing clinical conundrum, the satisfactory evaluation and management of which requires a disciplined and orderly approach. Diagnosis and management has evolved with the development of new technology such as selective mesenteric angiography and colonoscopy.

PURPOSE

This study was undertaken to review the available data in the literature and to determine the current optimum method of evaluation and management of lower gastrointestinal hemorrhage most likely to result in a successful outcome.

METHODS

Data available on the topic of lower gastrointestinal bleeding in the English literature were obtained via MEDLINE search and were reviewed and analyzed.

RESULTS

The colonic origin of lower gastrointestinal hemorrhage in order of decreasing incidence is diverticulosis, inflammatory bowel disease, including ischemic and infectious colitis, colonic neoplasia, benign anorectal disease, and arteriovenous malformations. Approximately 10 to 15 percent of all cases of rectal bleeding are attributable to a cause that is proximal to the ligament of Treitz. Small intestinal sources such as arteriovenous malformations, diverticula, and neoplasia account for between 3 and 5 percent of all cases. Colonoscopy successfully identified an origin in severe hematochezia in 74 to 82 percent of cases. Mesenteric angiography has a sensitivity of 42 to 86 percent. The best method of management depends on whether hemorrhage persists, the severity of continued hemorrhage, the cumulative transfusion requirement, and the specific origin of bleeding.

CONCLUSION

Lower gastrointestinal hemorrhage is a complex clinical problem that requires disciplined and sophisticated evaluation for successful management. Diverticulosis is the most common cause. Colonoscopy is the diagnostic procedure of choice both for its accuracy in localization and its therapeutic capability. Selective mesenteric angiography should be reserved for those patients in whom colonoscopy is not practical. Precise identification of the bleeding source is crucial for a successful outcome. Specific directed therapy, such as segmental colonic resection for bleeding diverticulosis, is associated with the highest success rate and the lowest morbidity. A complete review of lower gastrointestinal bleeding is contained herein.

The conundrum of lower gastrointestinal bleeding

Acute massive hematochezia provides one of the greatest diagnostic and therapeutic challenges to the physician. Although most patients stop bleeding spontaneously and further evaluation can be carried on with less urgency, 10% to 15% require urgent diagnostic and therapeutic procedures. Clearly, the least invasive effective solution to the bleeding problem is generally the best, although in some cases, emergency undirected surgery may be necessary. Subtotal colectomy can be done with acceptable morbidity and mortality in this situation, provided that the surgeon is confident of a colonic source of the bleeding. An understanding of the strategies outlined above encourages the management of such patients with an eye to maximizing therapeutic benefit while minimizing morbidity.

Lower gastrointestinal tract bleeding

Lower GI bleeding can be slow and chronic or massive and fatal. ED evaluation of these patients begins with history directed at determining the severity and amount of bleeding, and eliciting symptoms of volume depletion. Physical examination determines orthostasis, exclusion of an upper GI source for bleeding, and rectal examination. Laboratory evaluation is directed at determining baseline status of hemoglobin/hematocrit and platelet adequacy, as well as assessing concomitant medical problems. Although many of these patients are elderly, resuscitation is vigorous and should not be deterred by other medical problems. Differential diagnosis can be broad in the ED, but the vast majority of bleeding is caused by diverticulosis or angiodysplasia. Diagnostic capabilities are limited in the ED, but our skill at stabilization and resuscitation has helped decrease morbidity and mortality in acute lower GI bleeding.

Accurate localization and surgical management of active lower gastrointestinal hemorrhage with technetium-labeled erythrocyte scintigraphy

OBJECTIVE

There is disagreement over the reliability of technetium Tc 99m (99mTc)-labeled erythrocyte scintigraphy in the localization of active lower gastrointestinal hemorrhage. A previous study at The New York Hospital-Cornell Medical Center that showed a superior sensitivity for localization of scintigraphy versus angiography in surgical patients led the authors to emphasize scintigraphy as the diagnostic test of first choice in the clinical diagnostic algorithm. The authors hypothesized that tagged erythrocyte scintigraphy can be used accurately as the primary diagnostic modality in localizing acute bleeding and guiding surgical intervention.

METHODS

The authors conducted a 5-year, retrospective analysis of 224 inpatients who underwent scintigraphic imaging for diagnosis and localization of active lower gastrointestinal bleeding. Using scintigraphy as the primary diagnostic test, with colonoscopy, upper endoscopy, and angiography as adjunctive studies, 99mTc-labeled erythrocyte scans were performed at the clinician's discretion and were reviewed again for study purposes by two nuclear radiologists who were blinded to clinical outcome. Adjunctive diagnostic tests also were ordered for clinical indications.

RESULTS

Using delayed periodic scintigraphic imaging, results of 115 scans (51.3%) demonstrated bleeding, with 96 scans (42.9%) localizing to a specific anatomic site. Patients with positive scans were five times more likely to require surgery (p < 0.005) than patients with negative scans, and surgical patients were twice as likely to localize by scintigraphy (p < 0.0001). Fifty patients (22.3%) required surgical intervention to control hemorrhage and had a bleeding site confirmed by both clinical and pathologic examinations. Forty-eight of those patients (96%) had a bleeding site determined preoperatively. For 37 patients with bleeding sites localized preoperatively by scintigraphy, 36 (97.3%) had correct localization based on surgical pathology. Only one patient required a subtotal colectomy solely because of nonlocalized bleeding. No patient bled postoperatively, and there was no mortality in either operated or nonoperated patients. The mean volume of transfused erythrocytes was similar in both scan-localized and nonlocalized surgical patients.

CONCLUSION

When performed correctly and interpreted conservatively, scintigraphy is a useful and safe means of guiding segmental resection, and should be the primary tool used in the diagnosis of patients with active lower gastrointestinal bleeding.

Diagnosis and treatment control of bleeding colorectal angiodysplasias by endoscopic Doppler sonography: a preliminary study

The diagnostic accuracy and practical impact of trans-endoscopic Doppler ultrasonography were prospectively investigated in an open preliminary study of patients with hemorrhage from colonic vascular malformations. From January 1, 1991, to December 31, 1992, 437 consecutive patients were seen with lower gastrointestinal bleeding. In 15 cases the source of hemorrhage proved to be colorectal angiodysplasias (3.4%). In all cases bleeding had stopped spontaneously before the endoscopic examination. Upper gastrointestinal causes of bleeding were excluded endoscopically in each patient. To detect the superficial arterial vessels responsible for the hemorrhage a total of 32 lesions were scanned by trans-endoscopic Doppler ultrasonography. Twenty-nine vascular malformations in 12 patients were Doppler-positive (91%) and 3 lesions in 3 patients were Doppler-negative without an arterial signal. All Doppler-positive lesions had injection therapy with epinephrine and polidocanol. Twenty-six of the 29 sclerosed angiodysplasias (90%) in 9 patients could not be found endoscopically 2 weeks later, confirming the success of therapy. Doppler noise was still recorded in 3 visible malformations in the remaining 3 patients, indicating insufficient treatment. Further injections were made into these lesions, and the vascular anomalies were finally eliminated. During 6 months of follow-up, one of the 12 treated patients relapsed with an actively bleeding cecal angiodysplasia. After repeated endoscopic hemostasis, no further hemorrhage was observed in this patient. No bleeding recurred in the 3 patients with Doppler-negative lesions. Endoscopic Doppler sonography may help in the identification of intestinal angiodysplasias. The technically simple method allows objective evaluation of the endoscopic findings and enables monitoring of local endoscopic therapy.

Acute lower gastrointestinal bleeding

Lower gastrointestinal bleeding ranges from occult blood loss to massive hemorrhage and shock. There are many causes but diverticulitis and angiodysplasia remain the most common sources of major hemorrhage. This article emphasizes the cause and evaluation of moderate to severe acute lower gastrointestinal bleeding.

The causes and management of lower GI bleeding: a study based on clinical observations at Hanyang University Hospital

During the period of the study, lower GI bleeding patients comprised a constant 1.6% of the total admitted patients at Hanyang University Hospital annually. There were no statistically significant changes according to year. The 970 cases were classified as follows: hemorrhoid and anal fissure 65.5%, malignant neoplasm 21.1% (rectal cancer 16.9%, sigmoid colon cancer 3.3%, anal cancer 0.9%), benign neoplasm 4.2%, ulcerative colitis 3.3%, infectious colitis 2.3%, ischemic colitis 1.8%, radiation colitis 1.3%, diverticulosis 0.3%, and others 0.2%. Ulcerative colitis and rectosigmoid cancer showed increasing trends, while other disease groups showed no change in the occurrence rate. Hemorrhoid and anal fissure developed mostly in the 30s age group, benign polyp and ulcerative colitis in the 40s age group, malignant neoplasm in the 50s age group, and ischemic colitis and radiation colitis in the 60s age group. There was no sexual predominance of lower GI bleeding. About 10% of the patients admitted to the hospital needed transfusions, particularly patients with ulcerative colitis (21.9%) and radiation colitis (23.1%). 20.2% of the patients improved with supportive measures and medical treatment and 79.8% underwent surgical operation. In particular, 51.2% of the patients with benign neoplasm underwent polypectomies.

Evaluation and management of massive lower gastrointestinal hemorrhage

Sixty-eight patients with massive lower gastrointestinal (G.I.) hemorrhage underwent emergency arteriography. Patients were transfused an average of six units of packed red blood cells within 24 hours of admission. The bleeding source was localized arteriographically in 27 (40%), with a sensitivity of 65% among patients requiring emergency resection. However, twelve of the 41 patients with a negative arteriogram still required emergency intestinal resection for continued hemorrhage. Radionuclide bleeding scans had a sensitivity of 86%. The right colon was the most common site of bleeding (35%). Diverticulosis and arteriovenous malformation were the most common etiologies. Selective intra-arterial infusion of vasopressin and embolization were successful in 36% of cases in which they were employed and contributed to fatality in two patients. Twenty-three patients underwent segmental resection, whereas seven patients required subtotal colectomy for multiple bleeding sites or negative studies in the face continued hemorrhage. Intraoperative infusion of methylene blue via angiographic catheters allowed successful localization and resection of bleeding small bowel segments in three patients. Overall mortality was 21%. The mortality for patients without a malignancy, with a positive preoperative arteriogram, and emergency segmental resection was 13%.

Management of major colonic haemorrhage

Major colonic haemorrhage remains a difficult diagnostic and therapeutic problem. We propose that those patients who continue to bleed after resuscitation are best served by immediate laparotomy. High flow antegrade irrigation and intra-operative colonoscopy can then be used to localize the site of bleeding and allow appropriate excisional surgery rather than blind colonic resection.

Improvement of oral colonic lavage with supplemental simethicone

We have noted that colons of patients prepared for colonoscopy with Golytely, a nonabsorbable electrolyte lavage solution, frequently contain foam which may obscure small mucosal lesions. Therefore, a randomized, blinded controlled trial was performed to determine the prevalence of Golytely-induced foam and the effect of supplemental simethicone in decreasing the prevalence of foam. Foam was present in 32% of colons prepared with Golytely alone but in none of the colons prepared with Golytely supplemented with simethicone. In addition, only 5% of colons prepared with supplemental simethicone had residual stool noted at the time of colonoscopy, a significant improvement over the 39% prevalence of residual stool in colons prepared with Golytely alone. Addition of simethicone to Golytely lavage decreases the prevalence of colonic foam and residual stool.

A retrospective study on the management of rectal bleeding

This paper reports on a retrospective study of 70 patients who were admitted to the Royal Adelaide Hospital with rectal bleeding. The study demonstrates several points; first, that there are two distinct groups of patients. The majority of patients had minor bleeds that ceased spontaneously. The remaining group of patients (12%) had what could be described as massive rectal bleeds. There was also noted to be a significant number of patients (21%) who were discharged with no final diagnosis. The utilization of investigations such as angiography and nuclear medicine scans was minimal. The paper concludes that there is a need to establish a protocol for the management of rectal bleeding and, if diagnostic yield is to be satisfactory, energetic attempts must be made to commence investigations at presentation, as soon as resuscitative measures are in progress.

Current management of patients with lower gastrointestinal bleeding

Other than gastrointestinal bleeding, there are few clinical emergencies the successful management of which is so dependent on the setting of priorities. Sequential attention to resuscitation, localization, specific diagnosis, and definitive therapy at a pace proportional to the rate of blood loss results in a satisfactory outcome in most patients who present with lower gastrointestinal bleeding.

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.

Typhoid colitis with massive lower gastrointestinal bleeding. An unexpected behavior of Salmonella typhi

Three cases of salmonella colitis with massive lower gastrointestinal hemorrhage are presented. The patients had fever, diarrhea, and abundant hematochezia; blood and bone marrow cultures were positive for Salmonella typhi. Because of bleeding, all patients underwent hemicolectomy; previous mesenteric arteriograms showed the colonic hemorrhagic sites. The pathologic and radiologic findings are described.

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.