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Uncontrollable GI Bleed

Uncontrollable GI Bleed. Mamoun A. Rahman. Case 1. RT. 57 yrs-old lady BGhx: -Rectal cancer -Pre-operative adjuvant chemotherapy: 5FU based -low anterior resection Medications: - Losec 20 mg Od. Presentation. C/O: Lower abdominal pain for 3-4 days Admitted

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Uncontrollable GI Bleed

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  1. Uncontrollable GI Bleed Mamoun A. Rahman

  2. Case 1 • RT. • 57 yrs-old lady • BGhx: -Rectal cancer -Pre-operative adjuvant chemotherapy: 5FU based -low anterior resection • Medications: - Losec 20 mg Od

  3. Presentation • C/O: Lower abdominal pain for 3-4 days • Admitted • Next morning: PR bleeding, bright red • Weak and anxious • O/E: - Pale - Pulse: 98 - BP: 106/64 - Abdomen: stoma; soft, non tender. - DRE: clotted blood, nil active bleeding

  4. Lab results • Hb: 10.1 ALP: 141 • PCV: 0.30 GGT: 151 • WBC: 6.8 Bil: 3 • Urea: 4.7 • Cr: 95 • Na: 137 • K: 4.3

  5. Few hours later • Had another episode of PR bleed • Hb: 8.3 • PCV: 0.24 • Received 2 unit of RCC • Patient “stabilized” • PR bleeding continuing - pulse: 109 • CT angiography

  6. On arrival in X-Ray • Anxious • Tachypnoeic • Cold and clammy • Pulse: 125 • BP: 70/50 • Unstable

  7. Resuscitation by surgical team • O2 • Trendelenburg position • 3 IV lines • Received Hartmann’s solution and Gelofusin • Tranfusion with 2 units O –ve blood • ICU informed • Urgent angiography

  8. Bleeding in the pelvis Ruptured aneurysm branch of internal iliac artery Anterior branch of IIA embolized Angiography & embolization

  9. Post embolization • Transferred to ICU • Pulse: 144 • BP: 140/65 • Chest: course crepitations • Received Frusemide 40 mg • Remained stable, melaena only

  10. Case 2 • TY • 52 yrs-old lady • Background history: - Recurrent cholangitis - ERCP and stent

  11. C/O - Epigastric pain - Fever - Pale stool - Dark urine • O/E - Jaundiced - Temp: 41 - Tender RUQ • Lab results - Cholestatic picture

  12. USS • Cotracted, thick-walled GB, multiple stones • CBD: 14 mm, stones

  13. ERCP performed Sphincterotomy and CBD clearance Bleeding from sphincter site Adrenalin injected Continued to ooze

  14. Haematemesis Melaena Dizzy Pulse: 90 BP: 139/67 Hb:9.7 INR: 1.2 CT Angiogram: - ?Arterial haemorrhage at ampulla Post ERCP

  15. Bleeding from branches of GDA and Superior pancreaticodudenal artery Embolization performed with coil and gel foam SMA angiogram: normal Embolization

  16. Seen by team as a consult Vitals stable Hb: 6.6 INR: 1.37 Transfused 4 units of RCCs and 1 unit FFP IV fluids and Abx continued Repeat ERCP: - No further bleeding. Stent inserted Day 1 Post Embolization

  17. Post repeat ERCP • Remained asymptomatic • No further GI bleeding • Discharged with planned ERCP and Cholecystectomy in 6 weeks’ time

  18. Superselective embolization oflower GI hemorrhage

  19. Etiologies of Lower GI bleeding • Most common in the elderly • Variety of causes : - Diverticular disease (10% to 20% risk) - Neoplasia ( Ca colon causes 5% of major bleeding) Boley et al, Am J Surg 1979 - Angiodysplasia (right colon, <10% risk)

  20. Evaluation • Recurrent minor bleeding: colonoscopy • Severe but intermittent, stable patient: Tc-99M RBC scanning • Hemodynamically unstable patient: angiography • Helical CT: 80% accurate in some series Ernst et al, Eur Radiol 2003

  21. History • Rosch and Bookstein, early 1970s • Ischemic complications was13% to 33% • Throughout the 1980s it was a taboo • Dissatisfaction with vasoconstriction methods led renew interest in embolization in 1990s

  22. Coaxial Microcatheters • Range in size from 2.5 to 3 F • 5-French catheter may be used to select a first-order vessel • microcatheter can be advanced through this catheter more distally

  23. Superselective Catheterization • Distal arteries, close to bleeding points • Embolic material is deployed • It limits the segment of bowel at risk for ischemia

  24. Choice of embolic • Gel foam • Polyvinyl alcohol particles • Microcoils • some combination

  25. Published experience • Guy et al, 1992, reported 10 superselective embolization procedures in nine patients. All procedures were successful • Gordon et al, 1997: 17 cases of microcatheter embolization using microcoils, gel foam, and polyvinyl alcohol particles. Success rate was 76%. No bowel ischaemia

  26. Published experience • >100 successful embolization have been reported 1997 – 2002 • Clinical success ranged from 44% to 91% • Ischemic complications ranged from 0% to 6% Funaki et al, AJR, 2001 Bandi et al, J Vasc Interv Radiol, 2001

  27. Published experience • Tan et al, 2008. 265 patients underwent angiography for GI bleeding. • 32 ( 12%) had superselective embolization for lower GI hemorrhage • In 31 patients (97%) technical success was achieved • 7 had re-bleed • 1 had bowel ischaemia

  28. Limitations of embolization • Colonic bleeding is multifactorial - Diverticular bleed vs. Angiodysplasia • Patients who are not actively bleeding • Difficult vascular anatomy or severe atherosclerotic disease • “Symptomatic treatment”

  29. Summary • Minimally invasive techniques have replaced surgical resection as the initial therapies of choice • Superselective embolization and endoscopic treatment appear complementary

  30. Thank you

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