MAJOR LOWER GASTRO-INTESTINAL BLEEDING

1. MAJOR LOWER GASTRO-INTESTINAL BLEEDING John Hartley The Academic Surgical Unit, University of Hull, Castle Hill Hospital, Hull, U.K.

2. Lower gastrointestinal bleeding Modes of Presentation • Occult or obscure bleeding Iron deficiency anaemia FOB’s positive • Overt bleeding – visible blood PR Intermittent – self limiting • Significant haemorrhage Large amounts frank blood Haemodynamic compromise

3. Lower GI Bleeding - Etiology Angiodysplasia • The Others • Neoplasms • Colitis • Ileal & Colonic varices • Meckels’ diverticulum • Haemorrhoids 40% 20% Others 40% Diverticulosis

4. Lower GI bleeding - Angiodysplasia • Acquired vascular ectasia • Degenerative • Elderly population • Multiple

5. Lower GI bleeding - Angiodysplasia • Uncommon in healthy individuals • Benign course with low risk of re-bleeding • Endoscopic therapy non- bleeding lesions not necessary Foutch PG et al. Am J Gastroenterol 1995

6. Lower GI bleeding – diverticular disease Non-inflamed tics Ruptured vasa recta

7. Lower GI bleeding – diverticular disease

8. Lower GI bleeding – diverticular disease • 50% of > 60 yrs • Up to 20% bleed • 5% massive • (mainly right side) • Non-inflamed • Recurs in 25% McGuire HH et al. Ann Surg 1972; 175: 847-855

9. Lower GI bleeding – diverticular disease Potential for therapeutic colonoscopy

10. Lower GI bleeding – cancer Major bleeding uncommon10 -21 % of significant bleeds

11. Lower GI bleeding – polyps Uncommon cause Of massive bleeding (<10%)

12. Lower GI bleeding – ischaemic colitis Abdo pain ++ Bleeding common Usually limited 21 of 311 pts with Major bleed Rossini et al. World J Surg 1989;13:190-192

13. Lower GI bleeding – the catch!! Adequate anorectal Examination MANDATORY

14. Lower GI bleeding - clinical • Bleeding per rectum 3-6 units transfusion within 24hrs Hb drop to < 10g • Blood – cathartic • Bright red or plum coloured • Usually painless • +/- signs of shock

15. Lower GI bleeding - clinical Management • Characterise • Resuscitate • Differentiate • Localise • (Treat)

16. Lower GI bleeding - clinical Resuscitation • Large bore cannulae • Volume and blood replacement • Blood products • Monitoring • 85% WILL STOP THEREAFTER

17. Diagnostic Sigmoidoscopy ☺ Scintiscans Colonoscopy Angiography ☺ Barium Enema Enteroclysis Operative Endoscopy Therapeutic Colonoscopy Electrocautery Laser Polypectomy Angiography ☺ Vasopressin Embolisation ☺ Major Lower GI Bleeding Endoscopic & Radiological Procedures

18. Lower GI bleeding - Management Resuscitation +ve (NG Aspirate) OGD -ve Proctoscopy & Sigmoidoscopy Colonoscopy Angiography Radionucleotide scan

19. Lower GI Bleeding - Bleeding Scans

20. Lower GI Bleeding - Bleeding Scans Tech. labelled red cell scan • Sensitivity 97% • Specificity 85% • 48 of 50 patients had bleeding site identified preop • One patient TAC for failure to localise • No postop bleeding Nicholson et al Br J Surg 1989;76:358-361.

21. Massive bleeding – acute colonoscopy An alternative view • Urgent prep via NG (1-2hrs) • Site identified in approx. 76% • Access for therapy85% will stop anyway ? best performed electively

22. Lower GI bleeding - clinical

23. Lower GI Bleeding - Angiography • Both diagnostic and therapeutic potential • Needs active bleeding • haemodynamically unstable patient • Highly operator dependant • Can be repeated • leave sheath in place • Embolise if source identified

24. Lower GI Bleeding Transcatheter coil embolotherapy • Extension of diagnostic angiography (Bookstein et al 1977) • Immediate haemostasis • Risk of colonic ischaemia and infarction (Bookstein et al 1982)

25. Colonic angiography and embolisation Superselective embolisation Avoid ischaemic complications

26. Mrs AB • 75 yrs • CVA 6yrs => dysphasic + hemiplegic • Admitted 10/7 pr bleed • normal UGI + LGI endoscopy => discharged • Readmitted pr bleed • bp 100/60 pulse 100 • resuscitated => bp 140-160 in lab

30. Angiography for major colonic bleeding Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

31. Lower GI Bleeding - Embolotherapy Results • 13 patients (8 female) • Mean age 81yrs (71-87 yrs) • Mean systolic BP 76 mmHg (unrecordable in 2 patients) • Mean Hb 7.1 g/dl(4-10 g/dl) • Mean transfusion vol. 6.0 units (2-8 units) Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

32. Lower GI Bleeding - Embolotherapy Summary • Bleeding point embolised in 13/38 patients (r = 1 for systolic BP < 100mmHg) • Embolisation achieved haemostasis in 11/13 patients • Ischaemic complications in 3 patients managed conservatively Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

33. Lower GI Bleeding - Embolotherapy • 26 pts, positive angiograms • Mean transfusion 7 units (+/- 1.43) • 16 pts attempted embolisation • Immediate haemostasis 14 pts (82%) • Rebleeding in 3 (one rpt embolisation) • 2 pts required surgery one colonic necrosis one for bleeding Luchtefeld MA et al. Dis Colon Rectum 2000;43:532-4.

34. Lower GI Bleeding - Coil embolotherapy In the emergency control of major colonic haemorrhage: • Safe • both early and late problems appear minimal • coils should be placed beyond marginal artery • Efficacious • Reduces the requirement for emergency surgery • complete cessation of bleeding in some • may permit planned surgery in others Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

35. Lower GI Bleeding -Surgery • Make sure the cause is not anorectal • haemorrhoids • rectal cancer or proctitis • Only one bite of the cherry! • total colectomy is the procedure of choice • avoid segmental colectomy unless definite cause • probably avoid primary anastomosis

36. Lower GI bleeding - surgery • Ensure cause not anorectal • Only one bite at cherry! • Avoid segmental colectomy unless definite cause • Probably avoid primary anastomosis

37. Major low GI bleeding • Unusual • Alarming !!! • Challenging: - diagnosis - management • Multidisciplinary approach - characterise - localise - treat