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Value of Laparotomy in the Diagnosis of Obscure Gastrointestinal Haemorrhage Gut: First Published As 10.1136/Gut.37.2.187 on 1 August 1995

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Value of Laparotomy in the Diagnosis of Obscure Gastrointestinal Haemorrhage Gut: First Published As 10.1136/Gut.37.2.187 on 1 August 1995 Gut 1995; 37: 187-190 187 Value of laparotomy in the diagnosis of obscure gastrointestinal haemorrhage Gut: first published as 10.1136/gut.37.2.187 on 1 August 1995. Downloaded from M P N Lewis, D E Khoo, J Spencer Abstract Methods Over a nine year period a total of 137 During a nine year period between 1982 and patients were investigated for obscure 1991, 137 patients were referred to one con- gastrointestinal bleeding on one surgical sultant at this institution for the assessment unit. In 20 patients visceral angiography and further treatment of obscure gastrointesti- strongly suggested the presence of caecal nal bleeding. Fifty three patients had a laparo- or right colonic angiodysplasia. These tomy to establish a diagnosis after extensive patients were treated by an appropriate investigations failed to find a cause. Their colectomy and they are not considered median age was 62, with a range of 17 to 84 further in this study. Similarly lesions of and comparable sex distribution (male to the small bowel detected by preoperative female ratio 27:26). Most of the patients were investigations are not considered here. extraregional tertiary referrals (42) with a Fifty five patients were offered diagnostic further four from overseas, four from hospitals laparotomy after the failure of other within our district, and three from our region. investigations to establish a diagnosis. All patients had been investigated previously to Two patients refused. A diagnostic lapar- varying degrees and may therefore be unrepre- otomy was performed in the remaining sentative of patients with obscure rectal bleed- 53. At operation if no visible lesion was ing in district hospitals. Some of the patients seen an on table enteroscopy was per- have been reported previously.3-5 formed using a colonoscope passed per A full history was taken and a complete oram and, ifnecessary, per anum. In nine physical examination was performed in all (17%) patients no cause for bleeding was patients. Clotting disorders and other blood found. In 18 (34%) patients there was a dyscrasias were excluded by appropriate small bowel vascular anomaly, in 14 laboratory tests. Initial investigations included (26%) a small bowel tumour, in four at least one colonoscopy and two or more (7.5%) a bleeding Meckel's diverticulum, upper gastrointestinal endoscopies. All http://gut.bmj.com/ and in eight (15%) other miscellaneous patients underwent a selective coeliac, superior lesions. Laparotomy, with on table and inferior mesenteric angiography. In young enteroscopy where indicated, elucidated patients, a technetium-99m pertechnetate scan the cause ofbleeding in 44 patients (83%). was performed to exclude a Meckel's diver- It was associated, however, with a post- ticulum. In patients who were not bleeding at operative death rate of 7.5% (four the time of angiography in whom no vascular patients). After seemingly appropriate abnormality could be shown, either a 99mTc on September 25, 2021 by guest. Protected copyright. surgery, rebleeding occurred in 14 labelled red blood cell or 99mTc labelled colloid patients (26%). Of 18 patients with small scan was performed to aid localisation. Barium bowel vascular anomalies seven rebled contrast studies were always performed in (39%), at an average follow up interval of older patients (median age 50). In most this 32 months. was a small bowel enema, and in patients (Gut 1995; 37: 187-190) in whom colonoscopy was incomplete or technically unsuccessful, a barium enema was Keywords: laparotomy, gastrointestinal haemorrhage. performed. When a diagnosis could not be reached with these investigations, patients were subjected to laparotomy. When no gross Gastrointestinal bleeding is a common reason macroscopic abnormality could be found, for admission to hospital. In most cases the intraoperative endoscopy was performed using diagnosis is achieved using upper gastrointesti- a 160 cm colonoscope passed per oram and nal endoscopy, colonoscopy, selective mesen- manipulated by the operating surgeon to Department of teric angiography, scintigraphy, and barium inspect the upper gastrointestinal tract to the Surgery, Royal studies.' In a few patients, however, the diag- distal ileum. Postgraduate Medical nosis remains concealed despite conventional The resected specimens from these opera- School, Hammersmith Hospital, London investigations. These patients have gastro- tions were subject to pathological examination M P N Lewis intestinal bleeding of obscure origin.2 The and the information gained was used to reach a D E Khoo decision to proceed to laparotomy after exten- final diagnosis. When angiodysplasia was sus- J Spencer sive investigation has failed to produce a cause pected the histological specimen was usually Correspondence to: should be based on the knowledge of the diag- injected with intra-arterial barium-gelatin and Mr J Spencer, Department of thera- for confirmation. Surgery, Royal Postgraduate nostic sensitivity, complication rate, and autoradiography performed Medical School, peutic potential of laparotomy with or without A questionnaire was sent to the patients' Hammersmith Hospital, to London W12 ONN. on table enteroscopy. This study aims referring consultants and general practitioners the value of in obscure to determine the outcome of Accepted for publication evaluate laparotomy longterm surgery 7 December 1994 gastrointestinal bleeding. in survivors with respect to rebleeding rates, 188 Lewis, Khoo, Spencer TABLE I Presentingfeatures duodenojejunal flexure. These included a Presentingfeature Number partial gastrectomy in one case in whom blood was confirmed to originate from the stomach Gastrointestinal bleeding 32 Melaena 25 on laparotomy (histology failed to show any Changed rectal bleeding 5 abnormality) and a right hemicolectomy in one Gut: first published as 10.1136/gut.37.2.187 on 1 August 1995. Downloaded from Bright rectal bleeding 1 Haematemesis only 1 in whom there was a high degree of suspicion Anaemia (faecal occult blood) 21 of angiodysplasia of the caecum. This was not confirmed by histological assessment and there was further occult bleeding in the postopera- death, and tumour recurrence rates. A tive period. In one patient the proximal response rate of 90% was obtained. The jejunum was found to contain blood in the remainder were followed up for a median dura- lumen though no bleeding site could be identi- tion of six weeks. The average length of follow fied; a resection biopsy specimen of 9 cm of up in all patients was 31 months (median 24). jejunum failed to show any abnormality. In one patient an old Roux-en-Y anastomosis was excised and refashioned as the suspected Results bleeding point. Presentingfeatures (Table I) Overt gastrointestinal bleeding was the main Pathology presenting feature in 35 patients. Eighteen In 44 patients the final diagnosis was con- patients presented with melaena only, six with firmed or established by histological examina- changed rectal bleeding, and four with bright tion of resected lesions or by postmortem rectal bleeding. Seven had haematemesis in examination in three of four patients who died addition to melaena. Three patients presented (Table II). with shock. Eighteen presented with iron defi- ciency anaemia only with positive faecal occult blood. The average duration of symptoms was Outcome 76 weeks with a range of one week to seven There were four deaths in the immediate post- years. The average duration of symptoms operative period (Table III). varied between final diagnostic groups, being In all these cases laparotomy was under- longest paradoxically for small bowel tumours taken either during or immediately after an (160 weeks), similarly long for small bowel acute bleed. In patients two and three the vascular anomalies (131 weeks), and shortest entire bowel was full of blood and no cause of for Meckel's diverticula (60 weeks). These bleeding could be found. The final diagnosis differences did not reach statistical signifi- was established at postmortem examination. In http://gut.bmj.com/ cance, but nevertheless the duration of symp- case four blood was found in the right toms reflects the difficulty in reaching a hemicolon and a right hemicolectomy was diagnosis. Sixty per cent of patients presenting performed, the provisional diagnosis of angio- with blood in the stool had a small bowel dysplasia being based on the preoperative find- tumour. This was the more probable finding ing of fresh blood in the proximal colon with compared with other possible diagnoses a negative selective arteriogram. Histological (p<0'00 1). assessment of the resection specimen did not on September 25, 2021 by guest. Protected copyright. confirm an angiodysplastic lesion, however, and the patient subsequently bled again. No Investigations cause for bleeding was found at postmortem Selective visceral angiography was carried out examination. In patients two to four the cause in all patients before operation and gastroin- of death resulted from hypovolaemic shock testinal contrast studies in 74%. Labelled red from further uncontrollable blood loss. cell scans were performed in 14 patients and There were 14 patients where further gas- showed the area of bleeding correctly in six, trointestinal bleeding occurred (26%, Table incorrectly in three. A total of five had a 99mTc Meckel's scan all of which were negative, TABLE II Final diagnoses including one patient in whom this diagnosis was everqtually made. Diagnosis Number Small bowel vascular 18 Tumour 14 Operative Leiomyoma 5 findings Adenocarcinoma
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