Severe Gastrointestinal Bleeding

Acute lower gastrointestinal hemorrhages in geriatric patients

Age is a risk factor in acute lower gastrointestinal hemorrhages (LGIH). The objectives here were to analyze: (1) diagnostic and therapeutic handling, (2) related morbidity and mortality, (3) the indications for surgery, and (4) the evolution of acute LGIH in patients > or =80 years. Forty-three patients >80 years with acute LGIH were reviewed retrospectively. In 86% (n = 37) related comorbidities were found, in 9% (n = 4) there had been prior colorectal surgery, 19% (n = 8) were antiaggregated, and 7% (n = 3) were anticoagulated. One hundred thirty-two cases of acute LGIH in patients <80 years were used as a control group. Student's t test and the chi-square test were applied. On arrival at the emergency ward 11 cases (26%) had hemodynamic instability and 8 of these were stabilized using conservative measures. In 39 cases an endoscopy was performed, allowing for an etiological diagnosis in 59% (n = 23) of cases, above all in those carried out in an urgent or semiurgent way. The arteriography permitted an etiological diagnosis in two of the four cases in which it was carried out. In seven patients (16%) urgent surgery was indicated: three were hemorrhoidectomies, three were subtotal colectomies, and one was a resection of the small intestine. The morbidity rate was 10% (n = 4) in the patients who were not treated and 14% (n = 1) in those treated, with a mortality rate of 8% (n = 3) and 14% (n = 1), respectively. The rate of relapse of bleeding after discharge from hospital was 42% (n = 18), with nine of these needing to be readmitted into hospital. In comparison with the control group, they present a different bleeding etiology (diverticulosis as opposed to the benign anal-rectal and small intestinal pathology in the younger population; P = 0.017), surgery is indicated with less frequency (9 versus 33%; P = 0.007), and there is a higher relapse rate (42 versus 26%; P = 0.045). Acute LGIH in geriatric patients relents in most cases with the use of conservative measures, although there is a high percentage of related morbidity and mortality, and of relapse of bleeding.

Gastrointestinal bleeding in older people

Aging is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in older people a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in older people are reviewed. Important management issues considered include hemodynamic resuscitation, anticoagulation, and endoscopic and surgical therapy.

Embolization of the vasa recta in acute lower gastrointestinal hemorrhage: A report of five cases

PURPOSE

To present our preliminary experience in embolization of the vasa recta in acute gastrointestinal hemorrhage.

METHODS

In four of five patients with acute gastrointestinal hemorrhage superselective embolization of the vasa recta was performed. In one patient in whom superselective catheterization of the bleeding vas rectum was technically impossible, the origin of this vessel was embolized at the level of the terminal arcade. The following embolization materials were used: microcoils and polyvinyl alcohol particles (355-500 microm), n = 2; microcoils only, n = 2; Gelfoam particles, n = 1.

RESULTS

Bleeding was found in two patients in the small bowel (jejunum and ileum) and in three patients in the colon. Immediate hemostasis was achieved in all patients. No signs of ischemia or infarction were observed after intervention.

CONCLUSIONS

Superselective embolization of the vasa recta proved efficient and safe in our small patient group. Advantages of this technique are reduction of the embolized area to a minimum and direct control of hemostasis.