Lower GI bleeding Aliu Sanni, MD Long Island College Hospital 17 th June, 2010
Case Presentation CC: Hematochezia HPI: 28yr old male presents with 1 day episode of bloody stools. Denies any abdominal pain. PMH: Similar history 1year ago. Inconclusive colonoscopy Meds: None NKDA Social: +tobacco, denies EtOH/drugs
Case Presentation Physical Exam T 97 HR 89 BP 124/78 R18 Abd- soft, NT/ND DRE- BRBPR, no mass, no hemorrhoids, normal tone Chest- CTA bilat CVS-S1S2 no murmur Labs Wbc 10.4, H/H 12.2/35.5, Platelets 250 Chem 12- WNL PT/PTT- WNL
Hospital course- Admission day Syncope in ER. No change in vital signs or Hematocrit Persistent dizziness / light headedness ICU admission for observation
Hospital course Admission day EGD- acute gastritis, no ulcers Colonoscopy- poor bowel preparation Meckel s scan- normal study CT Enterography- rounded fecal material around the ileocecal valve.
Hospital course- HD 1 Colonoscopy- Fresh and old clots noted from the colon tracking back to the small bowel. Possible small bowel source of bleeding Capsule endoscopy inserted following colonoscopy Post colonoscopy hematocrit 28 ( from 33) Repeat Hct post transfusion of 1 PRBC was 28. Patient taken to the OR
Hospital course Intra-op Exploratory laparotomy, ileoscopy, right hemicolectomy with ileocolic anastomosis
Pathology
Pathology downstatesurgery
Pathology
Pathology Pathology Diverticulosis with impacted fecalith, mucosal ulceration, acute inflammation and granulation tissue
Management of GI bleeding
Management of lower GI bleeding
Management of Lower GI bleeding- Etiology Colonic bleeding (95%) % SB bleeding (5%) Diverticular disease 30-40 Angiodysplasia Ischemia 5-10 Ulcers Anorectal disease 5-15 Crohn s Dx Neoplasia 5-10 Radiation Infectious colitis 3-8 Meckel s diverticulum Postpolypectomy 3-7 Neoplasia IBD 3-4 Aortoenteric fistula Angiodysplasia 3 Radiation colitis 1-3 Other 1-5 Unknown 10-25
Etiologies- Diverticular disease Most common etiology Bleeding from penetration of vasa recti via the mucosa 75% stop spontaneously Colonoscopy diagnosis of choice Epinephrine injection, electrocautery & endoclipping Embolization Surgery
Etiologies - Angiodysplasia Acquired degenerative lesions secondary to progressive dilation of normal blood vessels Associated with aortic stenosis and renal failure Appears as red stellate lesions with a surrounding rim of pale mucosa Sclerotherapy, electrocautery, selective gel foam embolization. Segmental resection
Etiologies - Neoplasia Uncommon cause of lower GI bleeding Associated with Fe deficiency anemia GISTs associated with massive hemorrhage Diagnosis by colonoscopy Segmental resection
Etiologies -Anorectal disease Major causes are internal hemorrhoids, anal fissures and colorectal neoplasia Exclude all other causes of lower GI bleed Medical or surgical management of anorectal diseases
Etiologies - Colitis Inflammatory bowel disease, infectious colitis, radiation proctitis and ischemia Ulcerative colitis associated more with GI bleeding Medical or surgical management of primary cause of bleeding
Etiologies -Mesenteric ischemia Acute / chronic arterial or venous insufficiency Hx of AF, CHF, AMI, hypercoagulability, pressors and vasculitis Acute - watershed areas of splenic flexure and rectosigmoid Supportive care- bowel rest, IV abx, cardiovascular support and correction of low flow state Surgery in progressive ischemia and gangrene
Management of GI bleed- Diagnostics Radionuclide scanning - Technetium labeled RBCs - Detects bleeding as slow as 0.1ml/min - Localization accuracy of 40-60% - Guide to using angiography
Management of GI bleed- Diagnostics Mesenteric Angiography - Ongoing hemorrhage in range of 0.5-1 ml/min - Catheter directed vasopressin and embolization - Complications include hematomas, arterial thrombosis, contrast reactions and acute renal failure
Management of GI bleed- Diagnostics Colonoscopy - Minimal to moderate bleeding - Active bleeding, adherent clot - Identifies bleeding source in up to 95% of cases - Diagnostic and therapeutic
Causes of Obscure GI bleeding UPPER GI SMALL BOWEL COLON Angiodysplasia Crohn s disease Colitis Peptic ulcer Meckel s diverticulum Ulcerative colitis Aortoenteric fistula Lymphoma Crohn s colitis Neoplasia Radiation enteritis Ischemic colitis HIV related Ischemia Radiation colitis Lymphoma Bacterial infection Solitary rectal ulcer Sarcoidosis Metastasis Amyloidosis Hemobilia Angiodysplasia Lymphoma Hemorrhagic pancreatitis Endometriosis Metastasis Angiodysplasia Neoplasia HIV related Hemorrhoids
Diagnosis of Obscure GI bleeding Repeat Endoscopy Conventional imaging (RBC scan, angiography, SB Enteroclysis) Small bowel endoscopy Capsule endoscopy Intra-operative endoscopy
Urgent Colonoscopy for Evaluation and Management of Acute Lower GI Hemorrhage: A Randomized Controlled Trial Methods- Consecutive patients with LGIB randomized to Urgent Colonoscopy (UC) vs. Standard Care Algorithm (SC) 50 patients in each group Active bleeding treated with epinephrine injection or electrocautery Primary end point- rebleeding Mean f/up: UC/SC= 62months /58 months. BT Green, DC Rockey, P Jowell etal Am J Gastroenterol 2005;100:2395-2402
Standard care algorithm. Technetium RBC scanning was performed on patients with suspected active bleeding while those without active bleeding had an elective colonoscopy. Patients with a positive technetium scan went to visceral angiography while those with a negative scan had an elective colonoscopy. Active bleeding on angiography was treated. All patients receiving angiography (whether positive or negative) had an elective colonoscopy.
Conclusions No difference in mortality, hospital & ICU stay, transfusion requirements, early or late rebleeding and need for surgery. Urgent colonoscopy did not significantly improve outcomes in patients with LGIB.