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1. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 1 6 LOWER GASTROINTESTINAL BLEEDING Michael J. Rosen, M.D., and Jeffrey L. Ponsky, M.D., F.A.C.S. Approach to Lower GI Bleeding Lower gastrointestinal bleeding is defined as abnormal hemor- the nature and duration of the bleeding, including stool color and rhage into the lumen of the bowel from a source distal to the liga- frequency. The patient should also be asked about any associated ment of Treitz. In the majority of cases, lower GI bleeding derives symptoms of potential significance (e.g., abdominal pain, changes from the colon; however, the small bowel is identified as the source in bowel habits, fever, urgency, tenesmus, or weight loss), as well of bleeding in as many as one third of cases,1,2 and the upper GI as about relevant past medical events (e.g., previous GI bleeding tract is identified as the source in as many as 11% of patients pre- episodes, injuries, surgical procedures, peptic ulcer disease, senting with bright-red blood per rectum.3 inflammatory bowel disease [IBD], and abdominal or pelvic irra- Lower GI bleeding is more common in men than in women. diation). Any complicating comorbid conditions (e.g., heart or The incidence rises steeply with advancing age, exhibiting a liver disease and clotting disorders) should be investigated. A com- greater than 200-fold increase from the third decade of life to the prehensive review of medications—in particular, nonsteroidal ninth. This increase is largely attributable to the various colonic anti-inflammatory drugs (NSAIDs) and anticoagulants—is disorders commonly associated with aging (e.g., diverticulosis and mandatory.12 angiodysplasia).4-6 The exact incidence of lower GI bleeding is not The physical examination should include determination of pos- known, because there is no standardized technique for localizing tural vital signs so that intravascular volume status can be accu- it. Several investigators, however, estimate the incidence to be in rately estimated. A drop in the orthostatic blood pressure greater the range of 20 to 27 cases per 100,000 adults.4,7 A 1997 survey than 10 mm Hg or an increase in the pulse rate greater than 10 of GI bleeding from the American College of Gastroenterology beats/min indicates that more than 800 ml of blood (> 15% of the found that lower GI hemorrhage accounted for 24% of all GI total circulating blood volume) has been lost. Marked tachycardia bleeding events.8 Another study published the same year found and tachypnea in association with hypotension and depressed that 0.7% of 17,941 discharges from a Veterans Affairs hospital mental status indicates that more than 1,500 ml of blood (> 30% were for patients who had had lower GI bleeding.9 of the total circulating blood volume) has been lost. A complete The basic components of management are (1) initial hemody- abdominal examination, including digital rectal examination and namic stabilization, (2) localization of the bleeding site, and (3) anoscopy, should be performed. site-specific therapeutic intervention. There are many conditions Laboratory evaluation should include a complete blood count, that can cause lower GI hemorrhage [see Discussion, Etiology of measurement of serum electrolyte concentrations, a coagulation Lower GI Bleeding, below]; accordingly, successful localization profile (prothrombin time and partial thromboplastin time) [see depends on timely and appropriate use of a variety of diagnostic 1:4 Bleeding and Transfusion], and typing and crossmatching. tests. Despite the abundance of diagnostic modalities available, A nasogastric tube should be placed for gastric lavage. If lavage attempts to localize the source of the hemorrhage fail in as many yields positive results (i.e., the aspirate contains gross blood or so- as 8% to 12% of patients.10,11 Once the bleeding site is localized, called coffee grounds), esophagogastroduodenoscopy (EGD) is the appropriate therapeutic intervention must be carried out as indicated [see 5:18 Gastrointestinal Endoscopy]. An aspirate that expeditiously as possible. contains copious amounts of bile is strongly suggestive of a lower Lower GI bleeding can be acute and life-threatening, chronic, GI source of bleeding, and the workup proceeds accordingly [see or even occult. In what follows, we focus on severe, life-threaten- Investigative Studies, below]. The choice is less clear-cut with a ing hematochezia, reviewing the wide array of possible causes of clear aspirate. In the absence of bile, such an aspirate cannot rule lower GI bleeding and outlining the diagnostic and therapeutic out a duodenal source for the bleeding. Accordingly, there is modalities available for treating this difficult clinical problem. some degree of latitude for clinical judgment: depending on the overall clinical picture, the surgeon may choose either to perform EGD to rule out a duodenal bleeding source or to proceed with Initial Evaluation and colonoscopy on the assumption that the source of the bleeding is Resuscitation in the lower GI tract. Initial evaluation of a pa- Resuscitative efforts should begin immediately, with the aim of tient with lower GI bleeding maintaining the patient in a euvolemic state. Two large-bore should include a focused his- peripheral intravenous catheters should be inserted and isotonic tory and physical examination, I.V. fluid administered. A Foley catheter should be placed to facil- to be carried out simultane- itate monitoring of intravascular volume status. Whether and in ously with resuscitation. Of what form to administer blood products is determined on an indi- particular importance in tak- vidual basis, with appropriate weight given to the presence or ing the history is to ascertain absence of comorbid conditions, the rate of blood loss, and the
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 2 Patient presents with acute lower GI bleeding Resuscitate as necessary. Simultaneously, take history (nature and duration of bleeding, associated symptoms, past medical history, complicating comorbid conditions, medications) and perform physical exam (postural vital signs, complete abdominal exam). Order laboratory tests (CBC, serum electrolytes, coagulation profile, and typing and crossmatching). Place NG tube for gastric lavage. NG aspirate contains gross blood NG aspirate is clear Perform esophagogastroduodenoscopy (EGD). Duodenal source cannot be ruled out. Use clinical judgment: depending on clinical picture, either (1) look for upper GI source (e.g., with EGD) (see left) or (2) proceed with colonoscopy (see right). Colon is adequately visualized on Colonoscopy identifies bleeding source colonoscopy, but no bleeding source is apparent Examine ileum; if no active bleeding is noted, perform EGD. Lesion is amenable to endoscopic therapy Treat endoscopically (e.g., with fulguration, vasoconstrictors, or clips). Surgical therapy is indicated Endoscopic Endoscopic therapy succeeds therapy fails Bleeding site was localized preoperatively Perform segmental resection. Bleeding site was not localized preoperatively Treat surgically. General criteria: Attempt to localize bleeding site intraoperatively > 4 units of blood/24 hr needed for (e.g., with EGD, colonoscopy, enteroscopy). hemodynamic stability; bleeding continues for 72 hr; rebleeding occurs within 1 wk. Bleeding site cannot be localized Bleeding site is localized intraoperatively intraoperatively Perform subtotal colectomy. Perform segmental resection.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 3 Approach to Lower GI Bleeding NG aspirate contains copious bile Perform colonoscopy. Bleeding volume is such that colonoscopy is not feasible or, if attempted, is ineffective Perform selective mesenteric arteriography, guided (if feasible and desired) by radiolabeled RBC scanning. Consider helical CT scanning. Lesion is amenable to angiographic therapy Treat with vasopressin infusion (initially, 0.4 U/min, then 0.2 U/min). (Transcatheter embolization is an alternative.) Vasopressin fails Vasopressin succeeds
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 4 degree of hemodynamic stability. Severe hemodynamic instability ed. Depending on the indication and on the technique employed, may necessitate monitoring in the intensive care unit. the diagnostic yield from push enteroscopy has ranged from 13% to 78%.19 Typically, yields are highest (40% to 60%) in patients with significant GI hemorrhage. Investigative Studies RADIOLABELED RED BLOOD CELL SCANNING A number of diagnostic techniques are available for de- Radionuclide scanning is highly sensitive for lower GI hemorrhage: termining the source of lower it is capable of detecting bleeding at rates as slow as 0.1 to 0.4 GI hemorrhage, the most use- ml/min.20 Two imaging tracers, both labeled with technetium-99m ful of which are colonoscopy (99mTc), are currently available for radionuclide scanning in this [see 5:18 Gastrointestinal Endos- setting: 99mTc-labeled sulfur colloid (99mTc-SC) and 99mTc-labeled copy], radionuclide scanning, red blood cells (RBCs). 99mTc-SC requires no preparation time computed tomography, and and can be injected immediately into the patient; however, its rapid angiography (in the form of absorption into the liver and the spleen can often hinder accurate selective mesenteric arteriography). The goal of these tests is to localization of overlying bleeding sites.9 At our institution, we pre- locate the site of bleeding accurately so that definitive therapy can fer to use 99mTc-labeled RBCs. This agent requires some prepara- be properly directed. Which diagnostic test is chosen for a specific tion time, but it has a much longer half-life than 99mTc-SC does, it patient depends on several factors, including the hemodynamic sta- is not taken up by the liver and spleen, and it can be detected on bility of the patient, the bleeding rate, the comorbid conditions pres- images as long as 24 to 48 hours after injection [see Figure 1].21,22 ent, and the local expertise available at the physician’s hospital. One study directly compared these two techniques and found 99mTc-labeled RBC scanning to have an accuracy of 93%, com- COLONOSCOPY pared with an accuracy of only 12% for 99mTc-SC scanning.23 Several large series that evaluated the diagnostic utility of colo- The high sensitivity of 99mTc-labeled RBC scanning—80% to noscopy in patients with lower GI bleeding found this modality to 98%—is well attested, but there is considerable disagreement in be moderately to highly accurate, with overall diagnostic yields rang- the literature with regard to its specificity in identifying the ing from 53% to 97% [see Table 1].3,13-17 Those studies that report- anatomic site of bleeding.24-27 For example, on one hand, a 1996 ed morbidity found colonoscopy to be safe as well, with an aver- study found radiolabeled RBC scanning to be 97% accurate for age complication rate of 0.5%. Colonoscopy has both a higher localizing bleeding in 37 patients undergoing surgical resection27; diagnostic yield and a lower complication rate than arteriography on the other hand, a 1990 study reported a 42% rate of incorrect in this setting and thus would appear to be a more attractive initial resection when surgical therapy was based solely on this modali- test in most circumstances.3,18 An argument has been made—one ty.26 In 2005, one group retrospectively reviewed 127 bleeding with which we agree—that colonoscopy should be considered the scans in an effort to identify factors that might predict a positive procedure of choice for structural evaluation of lower GI bleeding scan.28 The investigators found that tagged RBC scans were 48% and that arteriography should be reserved for patients with mas- accurate in localizing bleeding sites later confirmed by sive, ongoing bleeding in whom endoscopy is not feasible or endoscopy, surgery, or pathologic evaluation. Multivariate analy- colonoscopy fails to reveal the source of the hemorrhage.12 sis demonstrated that both the number of units of blood trans- The merits of colonic purging have been extensively debated in fused in the 24 hours preceding the scan and the lowest record- the literature.3,11,14 Although no firm conclusion has been reached, ed hematocrit differed significantly between patients with positive we feel that adequate colonic purging can improve both the diag- scans and those with negative scans. However, the clinical signif- nostic yield and the safety of colonoscopy. Given the absence of icance of a positive scan was unclear in this study, in that the rate any definitive data suggesting that colonic purging either reacti- of endoscopy was not significantly different between patients who vates or increases bleeding,12 it is our practice to administer an oral had positive scans and those who did not. purge after the patient has been adequately resuscitated. To date, no prospective, randomized trials have compared If the entire colon has been adequately visualized and no source radionuclide scanning with colonoscopy as the initial diagnostic for the bleeding has been identified, the ileum should be intu- procedure for patients with lower GI hemorrhage. In our view, bated; fresh blood in this region suggests a possible small bowel source. If no active bleeding is observed in the ileum, upper GI endoscopy should be performed to rule out an upper GI bleed- Table 1 Diagnostic Accuracy of Colonoscopy in ing site. Localizing Source of Lower GI Hemorrhage When colonoscopy and routine upper GI endoscopy fail to locate a bleeding source, push enteroscopy may be helpful. This Study No. of Patients Diagnostic Yield (%) procedure can be carried out in several ways. It can be performed purely endoscopically with a pediatric colonoscope.This approach Richter13 78 70 (90%) generally requires a high level of skill on the part of the endos- copist, in that the lack of retroperitoneal attachments of the small Jensen3 80 68 (85%) intestine makes endoscopic navigation extremely challenging. In Rossini14 409 311 (76%) most cases, only the proximal 150 cm of the small intestine can be evaluated in this way. Alternatively, push enteroscopy can be per- Goenka15 166 141 (85%) formed in the operating room at the time of exploratory laparoto- Ohyama16 345 307 (89%) my. The surgeon can manually “milk” the small bowel over the scope to evaluate its distal portion. In addition, an enterotomy can Chaudhry17 85 82 (97%) be made, and the scope can be passed in both a retrograde and an Total 1,163 979 (84%) antegrade fashion so that the entire small intestine can be evaluat-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 5 CT evaluation of GI bleeding has several noteworthy advan- tages: the scanners typically are readily available, mobilization of special teams or units is not required, the scans can be completed rapidly in the emergency department, and bowel preparation is unnecessary. In one experimental study, CT scanners were able to detect arterial bleeding at rates as low as 0.07 ml/min, which sug- gests that CT scanning is more sensitive than angiography for this purpose.30 In addition, CT scans are noninvasive and carry little morbidity. Unfortunately, like radionuclide scanning, CT has no therapeutic capability. A 2003 study of 19 patients with GI hemorrhage compared triphasic helical CT evaluation with colonoscopy and surgery for localization of bleeding sites.30 In this series, five patients had small bowel bleeding sites, and 14 had colonic sites. Helical CT scanning correctly identified four of the five small bowel lesions and 11 of the 14 colonic lesions.These findings, though preliminary, suggest that CT is a potentially valuable evaluation method in certain cases of GI bleeding. Perhaps CT scanning can eventually replace radionu- clide scanning, which is often inaccurate. One potential drawback to the use of CT in this setting is the excessive dye load if angiog- raphy is employed as well. Figure 1 99mTC-labeled RBC scan demonstrates collection of tracer at hepatic flexure. ANGIOGRAPHY Selective Mesenteric however, given that radionuclide scanning (unlike colonoscopy Arteriography and angiography) has no therapeutic intervention capabilities, its Selective mesenteric arteri- best use is in patients with non–life-threatening lower GI bleeding ography is somewhat less sen- as a prelude and a guide to mesenteric angiography after active sitive than radionuclide scan- hemorrhage has been confirmed. ning for lower GI hemorrhage: COMPUTED TOMOGRAPHY bleeding must be occurring at a rate of at least 1.0 to 1.5 With the ongoing improvements in high-speed abdominal ml/min to be detectable with CT scanning, there has been growing interest in the evaluation this test.31 The procedure in- of GI bleeding with CT.29 Helical CT scanners can provide volves percutaneous placement of a transfemoral arterial catheter direct or indirect evidence of the source of GI bleeding. Typical for evaluation of the superior mesenteric, inferior mesenteric, and findings that can facilitate localization of bleeding sites include celiac arteries. A positive test result is defined as extravasation of spontaneous hyperdensity of the peribowel fat, contrast enhance- contrast into the lumen of the bowel [see Figure 2]. Once the bleed- ment of the bowel wall, vascular extravasation of the contrast ing vessel has been localized angiographically, the area must be medium, thickening of the bowel wall, polyps, tumors, and vas- marked so that it can be successfully identified intraoperatively; cular dilatation. this is commonly accomplished by infusing methylene blue into the bleeding artery [see Figure 3].32,33 In several large series [see Table 2], the overall diagnostic yield of arteriography ranged from 27% to 67%.27,34-38 The complication rate for arteriography performed for lower GI bleeding ranges from 2% to 4%.2,38 Reported complications include contrast aller- gy, renal failure, bleeding from arterial puncture, and embolism from a dislodged thrombus.12 Unlike radionuclide scanning, arteriography provides several therapeutic options, including vasopressin infusion and emboliza- tion of bleeding vessels. Nonetheless, given that arteriography has a lower diagnostic yield and a higher complication rate than colonoscopy does, it is reasonable to attempt colonoscopy first in patients with lower GI hemorrhage and to reserve angiography for patients in whom the volume of bleeding is such that colonoscopy would be neither safe nor accurate. Provocative Angiography for Continued Obscure Bleeding In a minority of patients, obscure bleeding persists despite neg- ative findings from endoscopy, mesenteric arteriography, and radio- labeled RBC scanning.This obscure bleeding presents a consider- Figure 2 Angiographic study documents extravasation of contrast able diagnostic challenge, which some investigators have proposed into small bowel. addressing by means of so-called provocative angiography.39,40
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 6 hematochezia and diverticulosis in a prospective series of 121 pa- tients.47 In this series, none of the patients treated endoscopically with epinephrine injections, bipolar coagulation, or both required surgery and none experienced recurrent bleeding episodes. A 2001 study from another group, however, reported high rates of recurrent bleeding episodes in both the early and the late post- treatment periods.48 In the absence of prospective, randomized tri- als, it is difficult to draw definitive conclusions about the utility of endoscopic therapy in treating diverticular hemorrhage. Angiodysplasias resulting in GI hemorrhage typically are amen- able to endoscopic treatment. That these lesions are frequently found in the right colon makes perforation a concern; this compli- cation is reported in approximately 2% of patients.49 Good success rates have been reported with both injection and thermal meth- ods.50 In one series, endoscopic fulguration was successful in 87% of patients, and no rebleeding episodes occurred over a 1- to 7- year follow-up period.50 Bleeding from multiple telangiectatic lesions in the distal colon resulting from radiation injury can be treated with thermal contact probes, lasers, or noncontact devices Figure 3 Intraoperative examination of the bowel is aided by such as the argon plasma coagulator.51 injection of methylene blue dye, which facilitates localization of the Postpolypectomy hemorrhage can often be successfully treated bleeding site and thereby helps direct surgical resection. by endoscopic means. Methods used include simple resnaring of the stalk while pressure is maintained52; electrocauterization, with or without epinephrine injection; endoscopic band ligation; and placement of metallic clips. For patients whose bleeding is attrib- Provocative angiography involves the use of short-acting anticoag- utable to benign anorectal causes, endoscopic therapy may include ulant agents (unfractionated heparin, vasodilators, thrombolytics, epinephrine injection, sclerosant injection, or band ligation of or combinations thereof) in association with angiography. Once internal hemorrhoids.53 the bleeding point has been localized, methylene blue is injected and the patient is immediately brought to the OR for surgical ANGIOGRAPHIC THERAPY treatment.To date, unfortunately, little has been published on this Diagnostic use of angiog- technique, but it does appear to be a promising approach to this raphy in patients with lower difficult problem. GI bleeding can often be fol- lowed by angiographic thera- py.The two main angiograph- Management ic treatment options are intra- Although, in the majority of cases, lower GI bleeding stops arterial injection of vaso- spontaneously, in a significant number of cases, hemorrhage con- pressin and transcatheter tinues and necessitates therapeutic intervention. Treatment op- embolization. tions include endoscopic therapy, angiographic therapy, and sur- Vasopressin acts to control bleeding by causing arteriolar vaso- gical resection. constriction and bowel wall contraction.9 Once the bleeding site has been localized angiographically, the catheter is positioned in ENDOSCOPIC THERAPY When colonoscopy identi- fies a bleeding source, endo- scopic treatment may be an Table 2 Diagnostic Accuracy of Mesenteric option [see 5:18 Gastrointestinal Angiography in Localizing Source of Endoscopy]. Endoscopic mo- dalities used to treat lower GI Lower GI Hemorrhage bleeding include use of ther- mal contact probes,41,42 laser Study No. of Patients No. of Positive Angiograms (%) photocoagulation,43 electrocau- terization,44 injection of vaso- Pennoyer34 131 37 (28%) constrictors, application of metallic clips,45 and injection scle- rotherapy.46 The choice of a specific modality often depends on the Ng27 49 22 (45%) nature of the offending lesion and on the expertise and resources Rantis35 30 8 (27%) available locally. A 1995 survey of members of the American College of Gastroenterology found that endoscopic therapy was Leitman36 68 27 (40%) used in 27% of patients presenting with lower GI bleeding.8 Casarella37 69 46 (67%) Diverticular hemorrhage can be difficult to treat endoscopical- ly because of the high bleeding rate and the location of the bleed- Colacchio38 98 40 (41%) ing point within the diverticulum. In 2000, one group of investi- Total 445 180 (40%) gators reported their experience with endoscopic therapy for severe
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 7 the main trunk of the vessel. Infusion of vasopressin is initiated at zation therapy should be the first choice for angiographic treat- a rate of 0.2 U/min and can be increased to a rate of 0.4 U/min. ment of lower GI bleeding.65,66 Within 20 to 30 minutes, another angiogram is performed to SURGICAL THERAPY determine whether the bleeding has ceased. If the bleeding is under control, the catheter is left in place and vasopressin is con- Although there are no ab- tinuously infused for 6 to 12 hours. If the bleeding continues to be solute criteria for surgical controlled, infusion is continued for an additional 6 to 12 hours at treatment of lower GI bleed- 50% of the previous rate. Finally, vasopressin infusion is replaced ing, there are several factors— by continuous saline infusion, and if bleeding does not recur, the including hemodynamic sta- catheter is removed.54,55 tus, associated comorbidities, The vasoconstrictive action of vasopressin can have deleterious transfusion requirements, and systemic side effects, including myocardial ischemia, peripheral persistent bleeding—that are ischemia, hypertension, dysrhythmias, mesenteric thrombosis, instrumental in making an intestinal infarction, and death.9,36 Occasionally, simultaneous I.V. appropriate and timely deci- administration of nitroglycerin is necessary to counteract these sion whether to operate. In general, patients who require more than systemic effects. The reported success rate of vasopressin in con- 4 units of blood in a 24-hour period to remain hemodynamically trolling lower GI bleeding ranges from 60% to 100%, and the inci- stable, whose bleeding has not stopped after 72 hours, or who expe- dence of major complications ranges from 10% to 20%.56-58 rience rebleeding within 1 week after an initial episode should Rebleeding rates as high as 50% have been reported.57,58 undergo surgery.9 An alternative for patients with coronary vascular disease, If the patient’s hemodynamic status permits, surgical treatment severe peripheral vascular disease, or other comorbidities that should be undertaken after accurate localization of the bleeding prevent safe administration of vasopressin is transcatheter embo- site.When possible, directed segmental resection is the procedure lization. In this technique, a catheter is superselectively placed of choice: it is associated with rebleeding rates ranging from 0% to into the identified bleeding vessel and an embolizing agent (e.g., 14% and mortality rates ranging from 0% to 13%.10,36,67 Blind a gelatin sponge, a microcoil, polyvinyl alcohol particles, or a bal- segmental colectomy should never be performed: it is associated loon) is injected. Several small series found this technique to be with rebleeding rates as high as 75% and mortality rates as high as 90% to 100% successful at stopping bleeding.59-63 Equally im- 50%.68 If hemodynamic compromise and ongoing hemorrhage pressive was the finding that the rebleeding rates in these series make it necessary to perform surgical exploration before the bleed- were 0%. The complication rates of this procedure are generally ing site can be localized, every effort should be made to identify reasonable as well; however, intestinal infarction has been the source of bleeding intraoperatively before embarking on resec- reported.36,64 tion. Intraoperative options for bleeding-site localization include The use of small microcatheters and the ability to superselec- colonoscopy (to allow for this option, patients should always be tively embolize individual vessels have reduced the potential for placed in the lithotomy position), EGD, and transoral passage of ischemic perforation. It is possible that as more experience is a pediatric colonoscope for enteroscopy with simultaneous gained with these techniques, superselective embolization may intraperitoneal assistance for small bowel manipulation.9 If the replace catheter-directed vasoconstrictive therapy, thus obviating bleeding site still cannot be accurately localized, subtotal colecto- the potential deleterious systemic effects of vasopressin adminis- my is the procedure of choice. This procedure is associated with tration. Some researchers have suggested that with the exception mortality rates ranging from 5% to 33%,69,70 which underscores of cases of diffuse bleeding lesions or cases whose demands exceed the importance of accurate preoperative localization of bleeding the technical limitations of superselective catheterization, emboli- before surgical intervention. Discussion Etiology of Lower GI Bleeding cularis to supply the mucosa9; as the diverticulum expands, these As noted, lower GI bleeding has a wide array of possible causes vessels are displaced. A 1976 anatomic study of colonic specimens [see Table 3].9,71 Of these, diverticular disease is the most common, from patients with diverticular bleeding used angiography to accounting for 30% to 40% of all cases.72 Arteriovenous malfor- demonstrate that in all cases, the vasa recta overlying the divertic- mations (AVMs), though extensively described in the literature, ulum ruptured into the lumen of the diverticulum, not into the are considerably less common causes, accounting for 1% to 4% of peritoneum [see Figure 4].76 cases.73,74 Other significant causative conditions are IBD, benign It has been estimated that approximately 17% of patients with and malignant neoplasms, ischemia, infectious colitis, anorectal colonic diverticulosis experience bleeding, which may range from disease, coagulopathy, use of NSAIDs, radiation proctitis, AIDS, minor to severe and life-threatening.77 As many as 80% to 85% of and small bowel disorders. diverticular hemorrhages stop spontaneously.78 In one series, surgery was unlikely to be necessary if fewer than 4 units of packed DIVERTICULAR DISEASE RBCs were transfused in a 24-hour period, whereas 60% of The reported prevalence of colonic diverticulosis in Western patients receiving more than 4 units of packed RBCs in a 24-hour societies is 37% to 45%.75 The vast majority of colonic diverticula period required surgical intervention.5 The risk of a second bleed- are actually false diverticula (pseudodiverticula) that contain only ing episode is approximately 25%.3 Semielective surgical therapy serosa and mucosa [see 5:12 Diverticulitis]. They occur at weak is usually offered after a second diverticular bleeding episode points in the colonic wall where the vasa recta penetrate the mus- because once a second such episode has occurred, the risk that a
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 8 Table 3 Common Causes of Lower GI cytomegalovirus) can result in severe lower GI bleeding, but this Hemorrhage is a relatively rare occurrence. Increasing use of radiation therapy to treat pelvic malignancies Cause of Bleeding Frequency has led to a corresponding increase in the incidence of chronic radiation proctitis.87 Radiation therapy damages bowel mucosa, Diverticulosis 17%–40% resulting in the formation of vascular telangiectases that are prone to bleeding.88 From 1% to 5% of cases of acute lower GI bleeding Arteriovenous malformation 2%–30% from radiation-induced proctocolitis are severe enough to necessi- Colitis 9%–21% tate hospitalization.4,14 In a survey of patients with prostate cancer who underwent pelvic irradiation, 5% of the patients reported Neoplasia (including postpolypectomy bleeding) 7%–33% hematochezia daily.89 Initial therapy for clinically significant hema- Benign anorectal disease 4%–10% tochezia related to radiation proctitis should include some form of endoscopic treatment (e.g., argon-beam coagulation). Surgery Upper GI source 0%–11% should be reserved for unstoppable hemorrhage or other major Small bowel source 2%–9% complications, such as fistulas and strictures.87 NEOPLASIA third will follow exceeds 50%.79 In a series of 83 conservatively Significant GI bleeding from colorectal neoplasia [see 5:15 managed cases of diverticular disease, the predicted yearly recur- Adenocarcinoma of the Colon and Rectum] accounts for 7% to 33% rence rates were 9% at 1 year, 10% at 2 years, 19% at 3 years, and of cases of severe lower GI hemorrhage.3,11,14,36,90 Such bleeding is 25% at 4 years.4 believed to result from erosions on the luminal surface.91 One COLITIS report identified ulcerated cancers as the cause in 21% of cases of hematochezia.14 Adenomatous polyps are implicated in 5% to The broad term colitis includes IBD, infectious colitis, radiation 11% of cases of acute lower GI bleeding.7,8,14,92,93 Lower GI hem- colitis, and idiopathic ulcers. IBD, in turn, includes Crohn disease orrhage, either immediate or delayed, is the most common report- [see 5:11 Crohn Disease] and ulcerative colitis [see 5:13 Fulminant ed complication after endoscopic polypectomy, occurring in 0.2% Ulcerative Colitis]. Patients with IBD usually present with bloody diarrhea that is not life-threatening; however, 6% to 10% of to 6% of cases.3,4,94,95 Immediate postpolypectomy bleeding is patients with ulcerative colitis have lower GI bleeding severe believed to result from incomplete coagulation of the stalk before enough to necessitate emergency surgical resection,80,81 and 0.6% transection.52 Delayed bleeding has been reported as long as 15 to 1.3% of patients with Crohn disease have acute life-threatening days after polypectomy and is thought to be secondary to slough- lower GI bleeding.80,82 In one review, 50% of patients with intesti- ing of the coagulum; it is less common than immediate bleeding, nal hemorrhage from IBD experienced spontaneous cessation of occurring in only 0.3% of cases.14,52 bleeding.80 Approximately 35% of patients whose bleeding stops COAGULOPATHY without intervention will have another bleeding episode. Because of this high recurrence rate, semielective surgery is recommended Lower GI bleeding can be a presenting symptom both for pa- after the first episode of severe GI bleeding secondary to IBD. tients with iatrogenic coagulopathy from heparin or warfarin ther- Colitis caused by various infectious agents (e.g., Salmonella apy and for patients with a hematologic coagulopathy from throm- typhi,83,84 Escherichia coli O157:H7,85 Clostridium difficile,86 and bocytopenia [see 1:4 Bleeding and Transfusion]. It is unclear, howev- er, whether severe coagulopathy leads to spontaneous hemorrhage or whether it predisposes to bleeding from an existing lesion.96,97 In an early series of leukemic patients with thrombocytopenia and severe GI hemorrhage, 50% of bleeding patients had platelet counts lower than 20,000/mm3 without any identifiable mucosal lesions; fur- thermore, when the platelet count rose above 20,000/mm3, the incidence of bleeding decreased to 0.8%.96 The investigator con- cluded that severe thrombocytopenia led to spontaneous GI hem- orrhage. Other investigators subsequently challenged this conclu- sion, arguing that spontaneous bleeding from coagulopathy is in fact rare.98 In one report, the distribution of pathologic lesions in patients with GI bleeding who were taking heparin or warfarin was essentially equivalent to that in the general population.98 Regardless of what the precise relation between coagulopathy and GI hemor- rhage may be, a thorough investigation for an anatomic lesion is imperative in the workup of patients with lower GI bleeding even in the face of coagulopathy or thrombocytopenia. BENIGN ANORECTAL DISEASE Hemorrhoids, ulcer/fissure disease, and fistula in ano [see 5:17 Benign Rectal,Anal, and Perineal Problems] must not be overlooked as causes of GI hemorrhage: in one review comprising almost Figure 4 Shown is the appearance of a bleeding diverticulum on 18,000 cases of lower GI bleeding, 11% were attributable to ano- colonoscopy. rectal pathology. It is crucial to remember that identification of
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 9 lishes the diagnosis.111 During endoscopy, angiodysplasias appear as red, flat lesions about 2 to 10 mm in diameter, sometimes accompanied by a feeding vessel [see Figure 5].6,41,44,72 Typically, the bleeding caused by colonic AVMs is chronic, slow, and intermittent.9 Although these lesions can cause severe lower GI hemorrhage, they are a relatively uncommon cause: in most large series, they account for only about 2% of cases of acute bleeding.74,104 The bleeding stops spontaneously in 85% to 90% of cases,10 but it recurs in 25% to 85%.112 Accordingly, definitive sur- gical or colonoscopic treatment should be rendered once the lesion has been identified. COLONIC ISCHEMIA Acute lower GI bleeding can also be a presenting symptom of colonic ischemia. In several large series, colonic ischemia account- ed for 3% to 9% of cases of acute lower GI hemorrhage.4,7,8,14,92 Other vascular diseases reported as potential causes are poly- arteritis nodosa, Wegener granulomatosis, and rheumatoid vas- culitis.113,114 The resultant vasculitis can cause ulceration, necrosis, and ultimately hemorrhage.115 Figure 5 Shown is the appearance of an arteriovenous malforma- SMALL INTESTINAL SOURCES tion on colonoscopy. Small intestinal sources account for 0.7% to 9% of cases of acute lower GI bleeding.3,4,116-118 About 70% to 80% of cases of small bowel hemorrhage are attributable to AVMs; other, less common a benign anorectal lesion does not eliminate the possibility of a causes are jejunoileal diverticula, Meckel’s diverticulum,119 neopla- more proximal cause of hemorrhage. In general, patients with hem- sia, regional enteritis, and aortoenteric fistulas [see Figure 6].90,120,121 orrhoids identified on physical examination should still undergo thorough endoscopic evaluation of the colon to rule out other pathologic conditions. Portal hypertension [see 5:10 Portal Hypertension], congestive heart failure, and splenic vein thrombosis can cause colonic or anorectal varices, which can result in massive lower GI hemor- rhage.99 The reported incidence of anorectal varices in patients with portal hypertension ranges from 78% to 89%.100,101 If local measures fail to control hemorrhage, some form of portosystemic shunting is indicated. COLONIC ARTERIOVENOUS MALFORMATIONS The term arteriovenous malformation includes vascular ectasias, angiomas, and angiodysplasias. AVMs are ectatic blood vessels seen in the mucosa and submucosa of the GI tract. They are degenerative lesions of the GI tract, occurring more frequent- ly with advancing age.9 In autopsy series, the reported incidence of colonic AVMs is 1% to 2%.102 In patients older than 50 years, the incidence of colonic AVMs is estimated to range from 2% to 30%.103-106 In healthy asymptomatic adults, the prevalence is esti- mated to be approximately 0.8%.107 Colonic AVMs are believed to derive from chronic colonic wall muscle contraction, which leads to chronic partial obstruction of the submucosal veins, causing the vessels to become dilated and tortuous. This process eventually renders the precapillary sphinc- ters incompetent, resulting in direct arterial-venous communica- tion.108,109 Colonic AVMs are most commonly found in the cecum.10 They have been associated with several systemic diseases, including atherosclerotic cardiovascular disease, aortic stenosis, chronic renal disease, collagen vascular disease, von Willebrand disease, chronic obstructive pulmonary disease, and cirrhosis of the liver; to date, however, no definite causal relationship to any of these conditions has been established.6,21,44,110 The diagnosis of a colonic AVM is made at the time of angiog- raphy or colonoscopy. During angiography, visualization of ectat- Figure 6 Shown are intraoperative specimens of small bowel ic, slow-emptying veins, vascular tufts, or early-filling veins estab- tumors causing lower GI hemorrhage.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 6 LOWER GASTROINTESTINAL BLEEDING — 10 Accurate localization of a bleeding site in the small intestine can be patients hospitalized for lower GI bleeding, benign anorectal dis- highly challenging: the length and the free intraperitoneal position ease was the cause.123 Other significant causes of lower GI hem- of the small bowel make endoscopic examination difficult, and the orrhage in this population are colonic histoplasmosis, Kaposi sar- nature of the overlying loops makes angiographic localization coma of the colon, and bacterial colitis.123,124 imprecise. For these reasons, the small intestine is usually left for NSAID USE last in the attempt to localize the source of lower GI bleeding and is examined only after sources in the colon, the upper GI tract, and The association between NSAID use and upper GI hemor- the anorectum have been ruled out.9 rhage is well known.125 Current data suggest that NSAIDs have a toxic effect on colonic mucosa as well.126 An epidemiologic study AIDS estimated the incidence of NSAID-associated large bowel bleed- The etiology of lower GI bleeding in patients with AIDS differs ing to be 7/100,000.127 A retrospective review found that patients from that in the general population.91 In AIDS patients, lower GI who had experienced lower GI bleeding were twice as likely to bleeding is caused predominantly by conditions related to the have taken NSAIDs as those who had not.128 NSAIDs have also underlying HIV infection. Cytomegalovirus colitis is the most been linked to diverticular hemorrhage: in one study, 92% of common cause of such bleeding in this population, occurring in patients with diverticular bleeding were taking NSAIDs.107 The 39% of cases.122 AIDS patients with hemorrhoids or anal fissures exact mechanism of NSAID-induced colonic injury is unknown; often experience significant bleeding as a result of HIV-induced nevertheless, heightened clinical awareness of this potential cause thrombocytopenia.122 A 1998 study reported that in 23% of AIDS of lower GI bleeding is warranted.91 References 1. Briley CA Jr, Jackson DC, Johnsrude IS, et al: Acute 15. Goenka MK, Kochhar R, Mehta SK: Spectrum of trointestinal hemorrhage. Dis Colon Rectum 40:471, gastrointestinal hemorrhage of small-bowel origin. lower gastrointestinal hemorrhage: an endoscopic study 1997 Radiology 136:317, 1980 of 166 patients. Indian J Gastroenterol 12:129, 1993 28. Olds GD, Cooper GS, Chak A, et al: The yield of 2. 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