Lower And Obscure Gastrointestinal Bleeding Luis S. Marsano, MD Professor of Medicine University of Louisville and Louisville VAMC June 2012 Acute Lower Gastrointestinal Bleed Magnitude of the Problem • Incidence: 20/100,000 persons • Mortality: 3.6% (23% if starts in hospital) • Mean Age: 63‐77 • Source of Hematochezia: – 76% colon – 11% above Ligament of Treitz – 9% small bowel – 6 % unknown Etiology of Lower GI Bleeding Zuckerman G et al. Gastrointest Endosc 1999;49:228 • Diverticulosis: 33% • Colon Ca or polyps: 19% • Colitis (IBD, infectious, ischemic, radiation, vasculitis, etc.): 18% • Angiodysplasia: 8% • Other intestinal lesions (post‐polypectomy, Ao‐ enteric fistula, stercoral ulcer, etc.): 8% • Ano‐rectal: 4% • Unknown: 16% Heater Probe in Colonoscopy (Inject “Pillow” before burn; tattoo after) Lesion Probe Pressure Energy Pulses/ Site Ulcer 10 Fr Moderate 15 J 2 Stalk 10 Fr Moderate 15-20 J 2 Diverticuli 10 Fr Moderate 15 J 2 Cancer 10 Fr Moderate 20 J 2 Angiodys 7-10 Fr Light 10 J 1 plasia BICAP in Colonoscopy (Inject “Pillow” before burn; tattoo after) Lesion Probe Pressure Energy Time/ Site Ulcer 10 Fr Moderate 20 W 2 sec Stalk 10 Fr Moderate 20 W 2 sec Diverticuli 10 Fr Moderate 20 W 2 sec Cancer 10 Fr Moderate 20 W 2 sec Angiodys 7-10 Fr Light 15 W 1 sec plasia Common Causes of Lower Gastrointestinal Bleed Diverticular Bleed • Frequency: Occurs in 3‐15% of patients with diverticulosis • Causes 30‐50% of massive hematochezia. • Cause: Erosion of artery in dome of diverticulum. • Presentation: Painless maroon or red bleed • Location: Right colon 50‐90% (< 25% of tics are in this region) • Course: – Persistent bleed in 20% – Stops spontaneously in 75‐80% (90% of those needing < 4U PRBC); – 25% rebleed @ 4y • Treatment: – Endoscopic treatment (injection, BICAP, Heater Probe, banding, clip); if fails: – Arteriography + Intra‐arterial vasopressin is successful in 90%. Transcatheter embolization causes intestinal infarction in 20%. – Surgery: in 18% of those needing transfusion. Has 10% mortality. Blind segmental resection should not be done. Angiodysplasia of Colon • Prevalence in screening colonoscopy is 0.8%; – multiple in 40‐60%; – 20% have them in more than 1 portion of GI tract (eg: colon & SB). • Frequency of bleed: – Less than 10% of angioectasia patients bleed; – once they bleed, up to 50% rebleed. • Age: 2/3 are > 70 y old. • Presentation: – acute hemorrhage in 45%; – low grade blood loss in 55%. • Location: May have multiple lesions. – More frequent in Cecum (37%) & – Rt. Colon (17%), – Transverse and descending (7% each) – Sigmoid (18%) & – Rectum (14%) Angiodysplasia of Colon • Associations: – CKD (20‐30% of bleeds), – valvular heart dz., specially aortic stenosis (Heyde S.); • Ao valve replacement decreases bleeding risk. – von Willebrand, – latent acquired von Willebrand (eg: Aortic Stenosis or LVAD), – CREST, – HHT. • Diagnosis: – Endoscopy: Precautions; May “blanch” with narcotics, tense insufflation, or anemia. Can use Naloxone 0.4‐0.8 mg once in cecum, but has risk. Hemoclip is good choice if anticoagulation will be needed. – Angiography – CT angiography (yield 70‐100% as angiography) • Treatment: only if bleeding or in unexplained Fe deficiency. – Endoscopic; if fails, – Angio + intra‐arterial vasopressin (90% success). – Thalidomide 25 mg QID for refractory, transfusion dependent patients. – Octreotide 50 mcg SQ BID or Octreotide‐LAR monthly IM. Classification of Angiectasias LOCATION SIZE (S) NUMBER (N) Gastric (G) Minute (S1) = < 2 mm Unique (N1) = 1 Duodenal (D) Intermediate (S2) = 2 –5 Multiple (N2) = 2 ‐ 10 mm Jejunal (J) Large (S3) = > 5 mm Diffuse (N3) = > 10 Ileal (I) Colonic (C) Example: D‐ S3‐N3 Ischemic Colitis • Due to: – low flow state, – vasospasm, – small vessel dz., or – Occlusion (arterial or venous). • Types: – 85% non‐gangrenous; – 15% gangrenous. • Middle‐age or elderly patient. • Associations: Atherosclerosis, Ao surgery, DM, critical illness, hypotension, “pressors”, pseudoephedrine, IBS, COPD, constipation. • Symptoms: – abdominal cramps and tenderness over affected bowel (usually left side) followed with hematochezia. (Small bowel ischemia gives mid‐abdomen pain). – Usually bloody diarrhea dominates over pain, except in Isolated Right Colonic Ischemia (IRCI) where dominant symptom is pain. – Predictive factors: Age > 60, Hemodialysis, Hypertension, Hypoalbuminemia, Diabetes, Constipation induced medication. Spectrum and Pattern of Ischemic Colitis • Reversible • Right sided: 25.2% – Intramural hemorrhage, – More abdominal pain than colopathy. bloody diarrhea – Transient segmental colitis – More CAD, AF, ESRD – Stricture – Cause found in 22% • Irreversible – Males > females – Gangrenous infarction – Worse prognosis (LOS, – Persistent segmental colitis Surgery, and mortality) – Fulminant universal colitis – Consider CTA or MRA (acute • Other rare situations mesenteric ischemia). – Colitis simulating Cancer • Transverse: 10.2% – Colitis with distal obstruction • Left sided: 32.6% – Protein loosing enteropathy – Recurrent sepsis • Sigmoid/distal: 24.6% • Pancolitis: 7.3% Ischemic Colitis • Diagnosis: Clinical features plus: – X‐Ray: “thumbprinting” on colon in 30%; pneumatosis in advanced severe disease. – CT Scan: segmental wall edema; Necrosis if pneumatosis or portal venous air – Flex‐Sigm or colonoscopy; found most frequently on splenic flexure, descending, and sigmoid. Ischemic mucosa +/‐ ulcers. May have pseudomembranes. • Treatment: – IV fluid resuscitation + bowel rest, and antibiotics. – NGT for ileus. – Improve oxygenation and cardiac output. – Surgery (unprep) for intestinal gangrene. – Anticoagulation + hypercoagulability work‐up for acute mesenteric vein thrombosis. • Prognosis: – most improve in 1‐2 days, and resolve in 1‐2 weeks. – 20% develop chronic ischemic colitis with strictures, recurrent bacteremia, protein loosing enteropathy, bloody diarrhea and/or weight loss. May need resection. Radiation Colitis • Timing: – Acute: within 6 weeks of radiation, – Chronic: > 6 weeks; often 9‐14 months post‐radiation, up to 30 years. • Presentation: – Diarrhea, tenesmus and/or rectal pain, bleeding. – Less often obstructive symptoms from stricture, or incontinence. – Fistulas are uncommon. • Endoscopy: – friable pale mucosa and telangiectasias. – Biopsy over prostate could cause fistula. • Treatment: – Acute: Butyrate enemas. – Chronic: • Endoscopic: APC, BICAP, H‐P, Laser (65‐90% success). • Formalin Instillation. • Sucralfate enemas 2 gm in 20 mL saline or water BID. • Hyperbaric oxygen. • Mesalamine+Betamethasone Enema + oral Flagyl 400 mg BID Infectious Colitis • Frequently related to shiga toxin: – Shigella, Enterohemorrhagic E. Coli, Salmonella. – Also C. difficile, Klebsiella oxytoca, and campylobacter jejuni. • Less often: – CMV, Ameba, Mycobacterium avium, Yersinia. • Dx: Stool culture • Endoscopy: spotty colitis; Bx c/w ischemia Inflammatory Bowel Disease • Diarrhea and bleeding. • Tenesmus is frequent. • DX: Colonoscopy/sigmoidoscopy with compatible Bx and negative stool studies. Rectal Varices • Massive bleed is infrequent. • Painless hematochezia in patient with portal hypertension. • Need exam after volume resuscitation. • Treatment: – Banding or sclerotherapy. – May need TIPSS or non‐selective surgical shunt. Obscure‐Overt Gastrointestinal Bleeding Initial Evaluation Obscure‐Overt LGI bleed • Repeat EGD and Colonoscopy after – volume resuscitation, – correction of anemia, – perfect colon preparation, – without use of narcotics, (or with Narcan given before endoscope withdrawal). • If work‐up is non‐diagnostic: – Push‐Enteroscopy – Capsule Endoscopy – Balloon assisted, or Intra‐operative Enteroscopy Etiology of Mid GI Bleeding (Ampulla of Vater to TI) • Younger than 40 – Tumors (lymphoma, carcinoid, adenocarcinoma, polyposis) – Meckel’s – Dieulafoy – Crohn – Celiac disease • Older than 40 – Angiectasia (latent acquired von Willebrand, HHT, blue rubber bleb S.): 40% – NSAID enteropathy – Celiac disease • Uncommon – Hemobilia – Hemosuccus pancreaticus – Aortoenteric fistula – Kaposi, Ehlers‐Danlos, neurifibromatosis, Klippel‐Trenaunay‐Weber 1: Push Enteroscopy • Ideally with “Dedicated Video‐Enteroscope”, using an overtube – Spiral Enteroscopy with pediatric colonoscope as second choice. • Yield is highest when lesion is seen in initial 10% of total SB length as determined by capsule enteroscopy [Tlesion‐pylorus / Tcecum‐pylorus] </= 0.1 • Yield: – 26‐80% with dedicated enteroscope; – 13‐38% with colonoscope without overtube. • Has therapeutic capabilities. 2: Capsule Endoscopy • Needs good Small Bowel Prep. • Reeding rate </= 15 frames/sec • Experimental Yield: Dedicated Enteroscope vs. Capsule Enteroscopy – Beads at reach of enteroscope: 94% vs 53% – Beads in all small bowel: 37% vs 64% • Clinical Yield of Capsule: – Ongoing obscure‐overt bleed within 2 weeks: 92% – Ongoing obscure‐overt bleed after 2 weeks: 34% – Obscure‐overt bleed in past year: 13% – Obscure‐occult bleed: 44% 2: Capsule Endoscopy • Predictors of (+) capsule finding: – Through Hb < 10 g, – more than 1 bleeding episode, or – bleeding persisting > 6 months • Capsule vs Intraop Endoscopy: – yield 74 vs 76.6%, – Capsule: sensitivity = 95%, specificity = 75%, PPV = 95%, NPV = 86% • Management change: 37 to 66%; this led to resolution of bleeding in 65% 3: Intraoperative Enteroscopy (IOE) • Yield: 58‐88% of small bowel lesions. • IOE: Examination done “anterograde”, with dedicated enteroscope, with dimmed OR light. Lesions are marked when seen in the “way in”. • TI reached in > 90% •