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Review Article

DIAGNOSIS AND TREATMENT OF ACUTE LOWER GASTROINTESTINAL

Rasim Gençosmanoglu, M.D.* / Resit ínceoglu, M.D.**

* Surgical Unit, Institute o f , Marmara University, Istanbul, Turkey.

** Departm ent o f General , School o f , Marmara University, Istanbul, T u r k e y .

ABSTRACT INTRODUCTION

Lower gastrointestinal (LGI) bleeding is a Gastrointestinal bleeding is divided into upper common clinical problem for which multiple and lower sources. Lower gastrointestinal diagnostic tests and therapeutic interventions bleeding (LGI) is defined as hemorrhage arising have been developed but no optimal approach distal to the ligament of Treitz. The source of has been established. Acute LGI bleeding bleeding is the colon in more than 95% of cases, presents a difficult clinical challenge. Initial with the remaining 5% arising from small bowel attention must always be directed at sites (1). A variety of disorders are associated resuscitation. and angiography may with LGI bleeding, however and offer accurate diagnosis and therapeutic angiodysplasias are the most common. The interventions in most cases. is severity of LGI bleeding ranges from occult blood useful for the detection of the bleeding site as loss to massive hemorrhage and shock. This well as for the identification of patients for further article focuses on the presentation, diagnosis, angiographic intervention in cases where the and management of acute LGI bleeding. hemorrhage is ongoing. Although the least invasive effective solution to the bleeding Definitions and Incidence problem is generally the best, emergency If there is a need of 3 to 5 units of blood over 24 undirected surgery may be necessary in some hours to maintain the patient’s stability, the patients. In that case, subtotal colectomy can be bleeding is considered as massive (2). The origin done with acceptable morbidity and mortality of acute LGI bleeding is closely associated with rates. If the bleeding site is identified, the patient’s age, with a mean age of 65 (63-77) segmentary resection is preferred in the surgical years (3,4). An upper gastrointestinal source may treatment of LGI bleeding. be responsible in approximately 1 0 % of patients presenting with massive (5).

Key Words: Lower gastrointestinal bleeding, Eighty percent of acute bleeding episodes stop Dlverticulosis, Angiodysplasia, , spontaneously; however, bleeding is recurrent in

Scintigraphy, Angiography, Colectomy. 25% of patients (6 ). Despite the refinem ents in diagnostic techniques, no source of bleeding is

identified in 8 % to 12% of cases (7,8). Acute LGI

(Accepted 5 March, 2001) Marmara Medical Journal 2001 ;14(2):119-130

Correspondance to: Rasim Gençosmanoglu, M.D. - e.mail address: [email protected] 119 Rasim Gençosmanoğlu, et ai

bleeding has an annual hospitalization rate of should raise the possibility of a stercoral ulcer, 20.5-27 per 100.000 (9-11). The incidence and a recent colonoscopic polypectomy suggests

increases with age, with a greater than 2 0 0 -fold postpolypectomy-bleeding (9). Aspirin or increase from the 20s to the 80s (11). This rise in nonsteroidal anti-inflammatory drug (NSAID) use incidence most likely represents the increasing is strongly associated with LGI bleeding, prevalence of colonic diverticulosis and particularly diverticular bleeding (9). angiodysplasia with age (12). The reported mortality rate is 2% to 4% in patients with acute LG I bleeding (9). ETIOLOGY

Initial Evaluation Diverticulosis and angiodysplasias are the most The most important step in the initial evaluation common causes of acute LGI bleeding. The other of the bleeding patient is assessment of the less frequent causes are shown in Table 1. severity of blood loss so that adequate resuscitation can be performed. The extent of bleeding is often clear on physical examination. Table I.: Etiology of acute LGI bleeding. Postural hypotension alone suggests a 20% blood volume loss, whereas pallor, hypotension, A. Frequent causes and tachycardia reflect a 30% to 40% blood 1. Diverticulosis volume loss (3). While the patient is being 2. Angiodysplasias resuscitated, a diagnostic evaluation should be B. Less frequent causes started. This includes a thorough history and 1. Solitary rectal ulcer syndrome physical examination that may be helpful 2. Colonic varices determining the source of the bleeding. One should remember that it is critical to adequately 3. Portal colopaty resuscitate any patient with acute LGI bleeding 4. Small bowel diverticula before any definitive diagnostic or therapeutic 5. Meckel’s diverticulum intervention is performed (3). A nasogastric 6. Dieulafoy lesion of the colon and aspirate should be performed to rule out an 7. upper Gl source of bleeding. 8. Colorectal tumors

The history often suggests an etiology. Hematochezia, passage of bloody stool, blood, Diverticular Disease or blood clots from the , is the major Colonic diverticula are common defects of the symptom of patients with acute LGI bleeding. large bowel wall acquired with aging. The is sticky, black, foul-smelling stool that existence of colonic diverticula has been results from bacterial degradation of hemoglobin recognized since the early 19th century, when (13). It indicates a bleeding source proximal to they were regarded as pathologic findings of little the ligament of Treitz, but can result from clinical significance (14). The probable reasons bleeding in the small intestine or proximal colon. for the increase of its prevalence during the last Melena is often confused with clotted blood; two centuries are the changes in the western diet however, melena is black and does not turn toilet and the longer mean lifetime, long enough to water red, whereas clotted blood does. acquire a disorder principally associated with advancing age. Until the 1950s, physicians Abdominal pain may result from ischemic bowel, recognized diverticula to be an important source inflammatory bowel disease (IBD), or ruptured of LGI bleeding (14). aortic aneurysm (3). Painless massive bleeding is most characteristic of vascular bleeding from Before the introduction of colonoscopy, diverticula, angiodysplasia, or . diverticulosis was thought to be the most Bloody may suggest IBD or an frequent cause of severe LGI bleeding in older infectious origin, whereas bleeding with rectal people (15-17). In several studies, urgent pain is seen with anal fissures, hemorrhoids, and colonoscopy after thorough removal of blood and rectal ulcers. A history of severe stool from the colon indicated that diverticular

120 Acute lower Gl bleeding

hemorrhage was the second most common have wider necks and domes than left-sided diagnosis, after colonic angioma, among elderly diverticula (3). patients who were hospitalized because of very severe ongoing hematochezia (16,17). Diverticular disease is most commonly seen in Improvements in endoscopic technology have the older western people regardless of ethnic made it possible for endoscopists not only to background (26). The prevalence of the disease diagnose sources of bleeding accurately but also linearly increases with advancing age, such that to achieve hemostasis of diverticula with active approximately 5% of persons in the 5th decade bleeding, visible vessels, and adherent clots and of life and more than 50% of individuals in the 9th other bleeding sites (16,18). decade of life are affected (14). The disorder is uncommon in Asia and Africa, occurring in less As mentioned above, the prevalence of than 1% of the population (14). diverticulosis is related to the patient’s age. It is present in more than 50% of persons over 60 Bleeding from diverticula is usually sudden in years old but in only 1% to 2% of persons onset, painless, and massive. Bleeding most younger than 30 (19,20). It remains the most often occurs from a single diverticula and stops common cause of acute LGI bleeding, although spontaneously in 80% to 90% of patients, some studies have found angiodysplasia to be a although in 10% to 25% it will recur (7,20). more common cause in the elderly (7,20). A deficiency of dietary fiber is suggested as one Colonic diverticula are pseudodiverticula, of the factors that affects the difference in the because their walls do not contain all the layers occurrence of diverticulosis (27). Burkitt (27) of the normal colonic wall (14). They do not arise hypothesized that this may explain why the randomly around the circumference of the colon disease is seen more commonly in western but originate in four distinct rows that correspond populations who consume a diet high in refined to the four sites of penetration of the major carbohydrates and low in vegetable fiber. On the branches of the vasa recta. These sites are one other hand, it was shown that the prevalence of each side of the mesenteric tenia and one close diverticulosis in vegetarians is one third that of a to each mesenteric side of the two control population eating a conventional diet (28). antimesenteric tenia (14). Bleeding results from Another impressive observation is the fact that arterial rupture into the diverticular sac at this only humans whose diets contain lower penetration sites of nutrient vessels (21,22). vegetable fiber than those of the other herbivores Rupture did not occur circumferentially but develop colonic diverticula (14). A low-fiber diet always asymmetrically toward the diverticulum may reduce the amount of fecal residue and itself, resulting in LGI hemorrhage rather than prolong fecal transit time with increased colonic bleeding into the peritoneal cavity (14). Although muscle contraction, producing segmentation of erosion of the vessel may be the result of the bowel into short compartments with elevated stercoral trauma, it is not caused by inflammation intraluminal pressure (14). Over time, abnormally (23,24). Significant diverticular bleeding occurs in high pressure causes formation of pulsion only 3% to 5% of patients with diverticulosis (3). diverticula of the sort described above. It is not a cause of occult bleeding and Moreover, Wynne-Jones (29) has suggested that is rarely associated with significant diverticulosis is the result of elevated intraluminal bleeding. pressure probably due to reluctance of western people to the pass flatus in public. Colonic diverticula occur most often in the distal colon. Ninety percent of patients with Angiodysplasia diverticulosis have involvement of the sigmoid Angiodysplasias, also referred to as vascular colon, whereas only 15% in the and ectasias of the colon or arteriovenous (14). However, despite this malformations, are the most commonly seen difference, 50% to 70% of bleeding diverticula vascular abnormalities of the gastrointestinal occur in the right colon (25). Even though it has tract (14). This vascular entity does not relate to not been clearly demonstrated yet, the reason for other less common vascular lesions such as this is suggested to be that right-sided diverticula hemangiomas, congenital arteriovenous

121 Rasim Gençosmanoglu, et al

malformations, and the telengiectasias of the (32). Several cases of massive LGI bleeding Osler-Weber-Rendu syndrome. have been reported (33). Sigmoidoscopy and biopsy are essential for diagnosis. Conservative Angiodysplasias are specific mucosal vascular treatment is generally indicated initially and ectasias that develop as a degenerative process surgical therapy may be considered in selected of aging and result from the chronic low-grade cases (31). However, transanal excision is of obstruction of submucosal veins. Normal uncertain benefit and the lesions may recur in intermittent distension of the cecum and right almost half of the patients (34). colon causes recurrent obstruction to venous outflow where veins penetrate the muscularis Colonic Varices propria layer of the colonic wall. According to Colonic varices were reported as a source of another less widely accepted theory, they result bleeding in 0.07% of cases in an adult-autopsy from the chronic hypoxia or hypoperfusion of the series (31). In almost all cases, Gl bleeding is mucosa (3). intermittent, but in most cases it is massive (35,36). The most common location is the A concept of the development of vascular rectosigmoid area (31). The most common cause ectasias, proposed by Boley and co-workers of colonic varices is due to (30), explains their exclusive occurrence in the in most cases, and portal vein right colon with Laplace’s law. The right colon obstruction in the remainder (35). However, has the largest luminal diameter and the highest numerous other causes of colonic varices have resting wall tension, so that the pressure been described, including congestive heart difference between the bowel lumen and the failure with chronic passive congestion, peritoneal cavity is highest at this site of the mesenteric vein thrombosis, postoperative intra­ colon. Repeated episodes of colonic distension abdominal adhesions, and chronic cause transient increases in both intraluminal with splenic vein thrombosis (37). Colonoscopy pressure and size, and result in increased wall and angiography are the primary diagnostic tools tension. This increase causes an obstruction of for detecting colonic varices. They can be submucosal venous outflow. visualized by visceral angiography with a sensitivity of 95%; however, bleeding from The prevalence of angiodysplasia is associated varices is rarely demonstrated, because of the with aging. It can be found in more than 25% of dilution of the contrast medium in the venous asymptomatic individuals over age 60 (30). It phase (35,38). In colonoscopy, colonic varices occurs with equal frequency in men and in appear as serpiginous bluish collapsible women (14). structures (31,35).

Hemorrhage from angiodysplasia is usually Portal Colopaty subacute and recurrent; however, 15% of cases Portal colopaty can occur in patients with portal present with massive hemorrhage (14). The hypertension and those associated ectasia-like nature and degree of bleeding often varies in a lesions in the colon may be associated with acute single patient from one episode to another. In LGI bleeding (31). Kozarek et al. (39) recently more than 90% of cases, bleeding stops reported a series including 10 cases, 70% of spontaneously (5,9). those having mucosal abnormalities resembling multiple vascular ectasias. Less Frequent Causes of LGI Bleeding

Solitary Rectal Ulcer Syndrome Small Bowel Diverticula Solitary rectal ulcer is a chronic benign condition Although diverticular disease is rarely seen in the characterized by single or multiple shallow ulcers small intestine, it has been reported as a source surrounded by a hyperemic margin and located of massive LGI bleeding in more than 50 cases in the majority of the cases on the anterior or (31). It is first described in 1794 and the cause is anterolateral rectal wall. It was first described by unknown (31). Jejunal diverticulosis is Cruveilheir in 1842 (31). The major symptoms of considered as an acquired abnormality of the solitary rectal ulcer syndrome are rectal bleeding, small bowel, the diagnosis of which is difficult the passage of mucus per rectum, and tenesmus because neither the symptoms nor the physical

122 Acute lower Gl bleeding

findings are specific (40). Patients present most made by angiography, surgical resection of the often with massive acute rectal bleeding (41). affected segment is the treatment of choice. When it is Identified preoperatively as the source of LGI bleeding, segmentary jejunal resection is Colitis the treatment of choice (41). Lower gastrointestinal bleeding can be due to inflammatory bowel disease, infectious colitis, or Meckel’s Diverticulum (10). If severe colitis is Meckel's diverticulum, located within 100 cm of encountered during urgent colonoscopy for the ileocecal valve on the antimesenteric border, hematochezia, the risk for perforation should be is the most common congenital anomaly of the remembered and the endoscopic procedure . It occurs in 2% of the should be ended following the biopsy of the normal population and remains mostly inflammatory area. Acute major hemorrhage is asymptomatic throughout life. Gastrointestinal uncommon in inflammatory bowel disease (1- bleeding Is the most common complication in the 5%), accounting for 0% to 6% of all symptomatic cases (31). Bleeding due to hospitalizations for Crohn’s disease and 1.4% to Meckel’s diverticulum usually occurs in 4.2% for (47-49). However, most childhood; however, it may be present in adults. cases are due to Crohn’s disease, without a Meckel’s diverticulum contains heterotopic predilection for site of involvement. The presence gastric and pancreatic mucosa so that it can of an endoscopically treatable lesion is produce acid and pancreatic exocrine enzymes. uncommon, and surgery is required in less than Acid can cause ulceration within the diverticulum half of the cases during the Initial hospitalization. and pancreatic enzymes can also contribute to Recurrent hemorrhage is not rare, and for these ulceration and bleeding. Intussusception due to cases surgery may be the most appropriate invagination of the diverticulum is accepted as treatment. Pardi et al. (47) have given this another mechanism for bleeding in patients who recurrent bleeding rate as much as 57%. For do not have any heterotopic gastric or pancreatic patients with ulcerative colitis, the progressive mucosa. (42). The preoperative diagnosis of severity of bleeding may be an important Meckel’s diverticulum may be difficult; however, indication for surgery (colectomy); in Crohn’s in patients with massive LGI bleeding, the lesion disease, patients with ileocolic location of the can be identified with a focal extravasation of disease are more likely to have severe intravenous contrast by angiography. hemorrhage, and may require resection as a Scintigraphy using 99mTc pertechnetate, which result (49). accumulates in the gastric mucosa, may show the image of Meckel’s diverticulum. When the Colorectal Tumors diagnosis is established, a segmentary ileal Colorectal tumors very rarely cause massive LGI resection containing the diverticulum should be bleeding. If any focal bleeding site Is present, performed. endoscopic treatment may be given. Surgical resection is the radical modality in patients with Dieulafoy Lesion of the Colon and uncontrollable bleeding. Small Intestine Dieulafoy lesion in the stomach is well described as a cause of massive upper Gl bleeding. DIAGNOSIS Recently, even though very rarely, Dieulafoy lesion of the colon has been described (43-45). The LGI bleeding is often intermittent. The Barbier et al. (43), Ma et al. (44), and Richards et identification of the source is usually difficult, al. (45) reported five cases in total with massive sometimes even impossible, if the bleeding is not bleeding from a submucosal artery. Angiography active. is a helpful diagnostic tool in such cases. Colonoscopy cannot identify the lesion because Colonoscopy of massive bleeding (31). On the other hand, Colonoscopy is the first step of the diagnostic Dieulafoy-like lesions causing acute LGI bleeding assessment in patients with acute LGI bleeding. in the small bowel have also been reported (46). Anoscopy and sigmoidoscopy can be performed The pathogenesis of the lesion remains as initial examinations, if colonoscopy is not unknown. When the differential diagnosis is 123 Rasim Gençosmanoglu, et al

available. The examination via sigmoidoscopy of actively bleeding cases with a 100% success rate the , rectum, sigmoid colon, and for complete hemostasis without any recurrence. descending colon for mucosal abnormalities and Chaudhry et al. (53) performed a total of 126 mass lesions with sigmoidoscopy may confirm a urgent unprepared in 85 patients distal colonic source. The timing of colonoscopy with LGI bleeding and correctly identified the within 6-12 hours of admission requires an out of source of bleeding in 97% of the patients. Of hours endoscopy service, which in our country is these sources 91% were colonic and 9% were in not universally available. It requires the presence the small bowel. It was concluded that diagnostic of a trained endoscopist for accurate diagnosis and therapeutic capability with colonoscopic and effective intervention plus a well-qualified intervention to control active hemorrhage is assistant and other facilities. especially appealing. They also believe that the pattern, amount, and location of blood in the In patients with a large volume LGI bleeding that unprepared colon all give clues as to source and stops, the colon can be prepared before type of bleeding. Machicado and Jensen (54) colonoscopy. In patients with active bleeding, evaluated 100 patients with acute LGI bleeding however, visualization is difficult and the risk of by urgent colonoscopy and found a definitive perforation may be increased (3). It is conceivable colonic lesion in 74% of cases. Angiodysplasia that a large volume purge may exacerbate LGI accounted for 30% of total or 41% of all colonic bleeding in some patients (50,51). Potential bleeding sites in their series. Urgent colonoscopy problems in voluminous bowel preparation was proved cost-effective rather than medical, include clinically significant fluid retention, which angiographic, and surgical management of the occurred in 4% of the patients (16). patients with severe ongoing hematochezia.

It was formerly thought that urgent colonoscopy The small intestine is a potential origin of for severe hematochezia is dangerous, and often hemorrhage in patients with unexplained LGI non-diagnostic and impractical. Recent progress, bleeding. Belaiche et al. (55) performed lower however, in the development of instruments and tract video push enteroscopy for diagnosis of techniques has overcome the limitations of small intestine disorders causing possible urgent colonoscopy. The procedure is also hemorrhage in 54 patients and found little help. It feasible with adequate prior colonic cleaning. was concluded that performing a second Ohyama et al. (52) retrospectively analyzed 345 colonoscopy was more appropriate. patients who underwent urgent colonoscopy for acute LGI bleeding within 24 hours after a Martinez et al. (56) performed intraoperative bleeding episode and found the overall endoscopy (IOE) in 58 patients with several diagnostic accuracy for bleeding site detection as colorectal disorders such as , 89.1%. Endoscopic hemostasis was performed diverticulitis, IBD, or LGI bleeding. They found in 48 cases with 66.7% (32 cases) permanent that in 10% of cases IOE changed the extent of hemostasis success. It was concluded that the surgical procedure without any additional urgent colonoscopy for massive LGI bleeding complication rate related to IOE. IOE may be was a safe and useful procedure. Jensen et al. used in patients with acute LGI bleeding (15) prospectively studied the role of urgent undergoing emergency surgery without exact colonoscopy in the diagnosis and treatment of preoperative diagnosis for both differential 121 patients with severe hematochezia and diagnosis and determining the adequate border diverticulosis. A sulphate purge was applied to of surgical resection. the patients to clean the bowel and colonoscopy was performed within 6-12 hours after High accuracy, safety, and therapeutic capability hospitalization. Definite signs of diverticular make colonoscopy the initial diagnostic test of hemorrhage were identified in 27 (22%) patients. choice for acute LGI bleeding. In the first 73 patients, the policy for actively bleeding diverticulosis was to perform Radionuclide Scanning hemicolectomy. In the last 48 patients, however, Technetium sulfur colloid scintigraphy and this was changed to endoscopic treatment in Technetium-labelled red blood cells (TRBC) similar circumstances. It was performed in 10 scintigraphy are the two radionuclide techniques

124 Acute lower Gl bleeding

used for localization of source causing LGI the bleeding is moderate or intermittent, a bleeding (3). The former technique, which uses a positive TRBC scintigraphy may be used to radiopharmaceutical that is rapidly cleaned from predict the likelihood of a positive angiogram the intravascular space by the reticuloendothelial demonstrating the site of bleeding while a system (RES), can show an extravasation into negative scan may avoid potential morbidity in the lumen when the bleeding rate is over 0.5 patients who might not benefit from an mL/min (3). It is removed from the circulation in 5 angiogram. to 10 minutes so that this technique requires the patients be actively bleeding during the few Angiography minutes the agent is in the blood (57,58). The Selective angiography is a sensitive diagnostic patient must be actively bleeding during this time method for evaluating major LGI bleeding. If the in order for the bleeding to be detected, and arterial bleeding rate is higher than 0.5 mL/min, bleeding sites, which overlap with the liver or extravasation of contrast material may be seen spleen, can be obscured. The latter technique, (3). Angiography does not require bowel where autologous red blood cells are labelled in preparation and gives precise anatomic vitro with technetium and injected into the patient, localization. Moreover, infusion of vasopressin offers a clear advantage over the sulfur colloid and transcatheter embolization can be issued scan with Its longer intravascular duration. with this technique. Its disadvantages include a Abdominal image can be obtained at 5-minute requirement of active bleeding and a relatively intervals for the first 30 minutes and every few high complication rate (9%) (61). The most hours for up to 24 hours (58). Tagged-erythrocyte common complications related to angiography scintigraphy has been reported to detect are arterial thrombosis, embolization, and renal bleeding rates as low as 0.05 to 0.01 mL/min failure (16). (59) .

Nicholson et al. (57) studied 41 patients with TREATMENT acute LGI bleeding and identified a definitive bleeding site in 30 (73%) patients by either The main approach to definitive therapy is colonoscopy, arteriography, or laparotomy. In 29 colonoscopic, angiographic, or surgical. Acute LGI of the 30 patients (sensitivity 97%), TRBC episodes stop spontaneously in almost 80% of scintigraphy could localize the bleeding site with cases so that most patients require elective the 83% specificity rate and 94% positive therapy. However, if the active bleeding site is predictive value. Contrarily, Hunter and Pezim identified by colonoscopy or angiography, (60) give the sensitivity rate of TRBC scanning as endoscopic hemostasis or angiographic 26% for localizing the bleeding site in 203 embolization should be performed. Urgent therapy patients with LGI bleeding. should be initiated in patients with recurrent or ongoing bleeding who have required more than 3 TRBC scintigraphy can only localize the bleeding units of blood (3,21). If the patient requires more to an area of the abdomen. Although this seems than 6 units of blood to replace the blood loss and a disadvantage, it can be used to determine maintains the cardiovascular instability, surgical which patients are bleeding sufficiently to therapy should be considered (4). undergo angiography and it also allows for more selective angiographic studies in such cases. Endoscopic Treatment Rantis et al. (58) gave the sensitivity and Endoscopic therapy includes the use of specificity of TRBC scintigraphy in detecting LGI sclerotherapy, thermal heater probes, bleeding as 84.6% and 70.4%, respectively. electrocoagulation (monopolar cautery, bipolar They conclude that a negative scan is highly circumactive probe, argon beam coagulator), and predictive so that a patient will not need laser (neodymium-YAG) (1). Electrocoagulation therapeutic intervention for bleeding during can be successfully applied for bleeding colonic hospitalization. diverticula; however, the risk of perforation is higher with this method (62). On the other hand, If the bleeding is profuse, there is no need for a efforts at endoscopic control of diverticular screening examination and one should proceed hemorrhage may precipitate more significant directly to angiography or surgery. If, however,

125 Rasim Gençosmanogiu, et al bleeding (1). The heater probe is preferred for transcatheter embolization in 17 patients with bleeding diverticula. In contrast, angiodysplasias angiographically demonstrated small intestinal or are readily treated with endoscopic measures. colonic bleeding. Bleeding was stopped in 13 of Acute hemorrhage can be controlled in up to 14 patients (93%) in whom embolization was 80% of cases with bleeding angiodysplasias, possible, and in 13 of 17 patients (76%) where although rebleeding may develop in up to 15%. there was an intention to treat. They did not Approaching the lesion from the perimeter, observe any clinically apparent bowel infarctions obliterating feeder vessels before cauterization of due to embolization. However, Cohn et al. (66) the central vessel, may avoid precipitating controversially reported a lower success rate with massive hemorrhage. The most common angiography for identification of bleeding sites in complications of endoscopic treatment include patients with LGI bleeding. In their series, 65 rebleeding and perforation (3). Postpolypectomy patients underwent 75 selective angiograms; bleeding, which develops in 1% to 2% of patients only 23 patients (35%) positive angiography after polypectomy during the following 2 weeks, findings and 14 of them (61%) required may easily be managed with endoscopic operations. Forty-two patients (65%) had approach. Electrocauterization by hot biopsy negative angiography findings and 8 of them forceps or re-snaring the remnant pedicle are (19%) required operations. Complications from appropriate methods for controlling the bleeding. angiography occurred in 7 patients (11%) in this series. The authors conclude that selective Angiographic Treatment angiography appears to add little clinically useful Angiographic injections of vasopressin and information in patients with acute LGI bleeding embolization are used for the treatment of and carries a relatively high complication risk. bleeding angiodysplasia and diverticula. In patients whose bleeding source is identified by Selective embolization can achieve temporary angiography, a trial of angiographic therapy may control of bleeding from angiodysplasias and be appropriate as a perioperative temporizing diverticula. This procedure may cause a colonic measure or as a definitive measure for high-risk infarction presented by severe abdominal pain surgical candidates (1). Intra-arterial and fever with the lack of collateral blood supply vasopressin is effective in 80-90% of cases; to the colonic wall. Therefore, embolization however, 50% of patients rebleed and should be restricted to patients who cannot complications can occur in 5% to 15% (1,21). tolerate surgery or as a temporizing measure in Complications include myocardial ischemia, massive bleeding in patients for whom a pulmonary edema, mesenteric thrombosis, and definitive surgical resection is imminent. hyponatremia (1). Transarterial vasopressin is used to achieve temporary control of bleeding Surgical Treatment before emergency definitive surgical resection. Blind and emergency segmental colectomy without adequate localization of the bleeding site Selective arterial embolization is a relatively safe in the surgical treatment of severe LGI bleeding and successful procedure in patients with carries 30% to 40% mortality rate and 33% of massive LGI bleeding. It is recommended for rebleeding rate (67). This surgical therapy was patients who failed intra-arterial vasopressin and widely used until the1970s, since then the are poor candidates for surgical resection. adoption of subtotal colectomy has reduced Luchtefeld et al. (63) reported 82% success rate operative mortality to 20% (67). However, it of transcatheter arterial embolizaton in stopping carries significantly higher perioperative bleeding in patients with LGI bleeding. morbidity. Moreover, diarrhea and rapid transit Ledermann et al. (64) performed superselective after total abdominal colectomy can also be microcoil embolization in 7 patients with massive debilitating conditions, especially for elderly LGI bleeding and stopped the bleeding patients (1). Nevertheless, recent advancements successfully. Embolization materials which they on endoscopic and angiographic techniques for used in their series were microcoils (2-4 mm), the definite localization of bleeding site in the microcoils and polyvinyl alcohol particles (355- preoperative period of patients with LGI bleeding 500 (pm), and microcoils and gelatine sponge again made segmental resections the surgical particles. Gordon et al. (65) performed treatment of choice.

126 Acute lower Gl bleeding

Surgical therapy should be preferred In the be performed rather than a blind subtotal treatment of patients who have lost a large- abdominal colectomy. When the bleeding site is volume of blood (i.e. transfusion of greater than 6 localized, segmental resection is done. Because units of packed red blood cells, ongoing angiodysplastic and diverticular bleeds are transfusion requirement, persistent located in the right side, the right hemicolectomy hemodynamic instability) or who have recurrent is the most commonly performed segmental bleeding and have failed to respond to operation. In case of patient rebleeds where the endoscopic and angiographic therapy. It is also bleeding site cannot be localized, a subtotal considered for patients with angiodysplasia that colectomy may be performed. The overall are not controlled with endoscopic hemostatic mortality rate of surgery for acute LGI bleeding is attempts or those with numerous less than 5% (1,3,21). Bleeding is not the cause angiodysplasias making these techniques of death; rather, pneumonia, cardiovascular unfeasible (4,68). events, and renal failure lead to poor outcomes, primarily in elderly patients with recurrent Farner et al. (69) retrospectively analyzed 77 hemorrhage (1). Thorough timing of surgical patients with acute LGI bleeding who required management in LGI bleeding increases the surgical therapy. Fifty of these cases underwent success rate. limited colon resection (LCR) and total or subtotal colectomy was performed in the remaining 27 In conclusion, acute lower gastrointestinal cases. They found significantly more common bleeding, still a difficult clinical challenge, may recurrent bleeding in the LCR group (18% versus originate from any level of the gastrointestinal 4%) with similar morbidity and mortality rates and tract. If the bleeding is not ongoing, the concluded that total or subtotal colectomy should identification of the source may be difficult or be considered more often in the management of impossible, even with the combination of these patients. Parkes et al. (70) give the re­ available current diagnostic tools such as bleeding rate as 0% following subtotal colectomy scintigraphy, endoscopy, and angiography (Fig whereas 14% after segmental resection with 1). The latter two measures confer therapeutic positive angiography and as high as 42% with negative angiography.

Field et al (71) recommend total abdominal colectomy for control of massive LGI bleeding with the rational that hemodynamic instability sometimes does not allow extensive preoperative evaluation and the diagnostic procedures are not always available. Furthermore, in the case of more than one site being visualized as bleeding, or in the presence of widespread diverticulosis in a good-risk patient, wide resection should be necessary. However, Setya et al. (72) reported a very high mortality rate (33%) and morbidity occurrence (75%) following subtotal colectomy for the 12 cases with massive, unrelenting LGI bleeding similar to the results of Bender and co-workers’ (73). In the latter series with 49 total abdominal colectomies, the overall mortality was 27% but the authors stressed that if the blood loss was so extensive as to need 10 or more units of , the mortality rate parallel increased (45% versus 7%).

F ig .l ; Algorithm of approach to acute lower Every effort should be made to localize the gastrointestinal bleeding. source of bleeding so that a hemicolectomy can

127 Rasim Gertçosmanoglu, et al

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