334 STRATE AND NAUMANN CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 8, No. 4Table 1. Sources of Lower Intestinal Hemorrhage Source Frequency Endoscopic treatment Painless hematocheziaa Other commentsDiverticulosis 30%–65% Yes Yes Large volume, intermittent bleedingAngiodysplasia 4%–15% Yes Yes Occult blood loss more common than acuteHemorrhoids 4%–12% Yes Yes Can result in signiﬁcant hemorrhageIschemic colitis 4%–11% No No Mild bleeding with diarrheaColitis, other 3%–15% Sometimesb No Mild bleeding with diarrheaNeoplasia 2%–11% Sometimes YesPostpolypectomy 2%–7% Yes Yes Can be delayed 3–4 weeksRectal ulcer 0%–8% Yes Yes Anticoagulants and poor functional status are associated with bleeding118Dieulafoy lesion Rare Yes Yes Usually located in the rectumRectal varices Rare Sometimesc Yes Usually stigmata of chronic liver diseaseNOTE. Data from references.2,8,10,14,15,36,117a The abdominal examination can help differentiate inﬂammatory disorders such as ischemic colitis, which present with tenderness but generallyresult in mild blood loss from vascular disorders such as diverticula, which produce no tenderness but signiﬁcant blood loss (hence thedistinction painless hematochezia).36bRadiation proctopathy is amenable to endoscopic therapy. Ulcers with stigmata of hemorrhage also can be treated.cBanding or sclerotherapy for rectal varices is possible but transjugular intrahepatic portosystemic shunt procedures more commonly arerecommended.of patients depending on the deﬁnition of the bleeding source, in patients undergoing colonoscopy within 12 hours of ad-patient selection criteria, and timing of colonoscopy (Table mission (1 of 171 colonoscopies).14,15 Although polyethylene2).8,13–17 The diagnostic yield of colonoscopy is higher than glycol bowel preparation is a balanced salt solution, ﬂuidradiographic tests, which require active bleeding at the time of overload, congestive heart failure, and electrolyte abnormal-the examination, and ﬂexible sigmoidoscopy, which visualizes ities have been reported in patients with underlying comor-only the left colon.7,17 In published series, endoscopic therapy is bidites.10,20 Aspiration pneumonia is a potential risk withapplied in 10% to 40% of patients undergoing colonoscopy for rapid, high-volume purges, particularly in patients with al-LIB and immediate hemostasis is achieved in 50% to 100% of tered mental status. Bowel preparation is not believed tothese cases.8,10,13–15,18 dislodge clots or precipitate bleeding. Colonoscopy with endoscopic therapy for LIB appears to be More controversy exists regarding whether colonoscopysafe. In a 1998 review of 13 studies (1561 patients), the overall improves major clinical outcomes in LIB. Jensen et al15 com-complication rate was 1.3%.19 These complications included pared 2 sequential prospective cohorts of patients with se-bowel perforation (5 patients), congestive heart failure (4 vere diverticular hemorrhage who underwent colonoscopypatients), worsened bleeding (2 patients), and septicemia (1 within 6 to 12 hours of admission after aggressive bowelpatient). Of the perforations, 2 were noted to be secondary to preparation. Rebleeding (0% vs 53%; P .005) and surgeryendoscopic therapy (1 neodymium:yttrium-aluminum-garnet (0% vs 35%; P .03) were signiﬁcantly less common in[Nd-Yag] laser and 1 polypectomy). In 4 more recent studies patients undergoing urgent colonoscopy with endoscopicof colonoscopy after colon purge for all sources of LIB, there therapy compared with urgent colonoscopy without therapy,were 2 complications out of 664 patients (0.3%) (Table respectively. As in peptic ulcer disease, stigmata of recent2).8,14 –16 Both complications were perforations, one after hemorrhage were predictive of rebleeding, with active bleed-biopsy of a cecal ulcer and one after biopolar electrocautery ing having the highest risk (67%) followed by nonbleedingof a cecal angiodysplasia.8,14 The complication rate was 0.6% visible vessels (50%) and adherent clots (43%). No complica-Table 2. Colonoscopy in Lower Intestinal Bleeding Diagnosis, Deﬁnitive diagnosis, Endoscopic therapy, Complications, Study Patients, n Mean timing, h n (%) n (%) n (%) n (%)Jensen et al,15 2000 121 12 121 (100) 107 (88)a 10 (37)b 0Angtuaco et al,13 2001 39 24 29 (74) 3 (8) 3 (8) —Schmulewitz et al,8 2003 415 46 369 (89) — 42 (10) 1 (0.2)Smoot et al,16 2003c 78 18 78 (100) 38 (49) 7(9) 0Strate and Syngal,17 2003 144 25d 128 (89) 62 (43) 14 (10) —Green et al,14 2005 50 7 48 (96) 21 (42) 17 (34) 1 (2)Total 847 773 (91) 231 (53) 93 (12) 2 (0.3)NOTE. Studies since 2000 of colonoscopy after colon purge in LIB were included.a Fourteen patients had upper (9) or small bowel (5) sites.bTherapy only reported for 27 patients with diverticular bleeding.cDiverticular bleeding only.dMedian time of colonoscopy.
April 2010 MANAGEMENT OF ACUTE LOWER INTESTINAL BLEEDING 335Table 3. Endoscopic Treatment of Diverticular Bleeding Endoscopic treatment modality Patients, n Early rebleeding, n (%) Late rebleeding, n (%) Complications, n (%)Banding45 4 0 0 0Thermal contact15,21,47,48,58 17 2 (12) 0 0Epinephrine16,21,46,50–53,56 20 3 (15) 1 (5) 0Thermal contact plus injection14–16,21,55 25 6 (24) 4 (16) 0Endoclip16,41,42,49,54,57,59 71 0 12 (17) 0Total 137 11 (8) 17 (12) 0tions were reported. This study highlights the promise of patients.23 Traditionally, colonoscopy has been performed elec-colonoscopy, particularly when performed early in the course tively after bleeding has stopped owing to fear of increasedof severe diverticular bleeding. However, it also raises a complications, need for colon preparation, and lack of provennumber of issues, including whether the results can be gen- beneﬁt. Recent studies have suggested that performing colonos-eralized to practices without experienced bleeding teams and copy shortly after presentation is advantageous, but studiesto other sources of bleeding. The use of historical controls comparing this approach with delayed colonoscopy are lim-also may have inﬂuenced the results. Other reports of endo- ited.8,14,15,17scopic therapy for diverticular bleeding have been inconsis- The primary indication to perform early colonoscopy, astent. Early rebleeding has been reported in 0% to 38% of with UGIB, is to identify and treat bleeding sources. The avail-patients, and late rebleeding has been reported in 0% to able evidence suggests that earlier colonoscopy results in more18%.14,21 In reviewing the 137 cases of endoscopic therapy for deﬁnitive diagnoses and therefore more opportunities for ther-diverticular bleeding reported in the literature, early rebleed- apeutic intervention.10,14,15,24 Urgent colonoscopy generally re-ing occurred in 8% and late rebleeding in 12% (Table 3). fers to colonoscopy performed within 12 hours of admis- In 2005, Green et al14 published the ﬁrst randomized con- sion,14,15 but other studies have achieved good results using atrolled trial in LIB. In this study, 100 patients with severe LIB more lenient time window of 24 hours.24 In a retrospectivewere randomized to colonoscopy within 8 hours or to standard study, earlier colonoscopy, analyzed as a continuous variable,of care, which included elective colonoscopy in all patients and was associated with signiﬁcantly more diagnostic and therapeu-tagged red blood cell scan followed by angiography if positive in tic interventions.17 Endoscopic therapy was used successfully inpatients with ongoing bleeding (36 patients). A deﬁnitive source 29% of colonoscopies performed within 12 hours of admission,of bleeding was identiﬁed signiﬁcantly more often in the urgent 13% of those performed in 12 to 24 hours, 4% in 24 to 48 hours,colonoscopy arm (42% vs 22%; odds ratio, 2.6; P .03). There and 0% in colonoscopies performed after 48 hours.17 However,were no statistical differences in rebleeding (22% vs 30%), sur- this was an unadjusted analysis and patients most likely to havegery (14% vs 12%), mortality (2% vs 4%), blood transfusions (4.2 stigmata may have been selected preferentially for early exami-vs 5.0 units), and length of stay (5.8 vs 6.6 days) between the nations. Indeed, most studies of urgent colonoscopy have en-colonoscopy and standard-of-care arms, respectively, including rolled only patients with signiﬁcant hemorrhage,14,15 and aa subanalysis of patients receiving interventions. However, there speciﬁc time interval is probably less important than the pres-was a general trend in favor of colonoscopy. Importantly, this ence of signiﬁcant or ongoing hemorrhage. In one study, thestudy, similar to most dealing with LIB, was underpowered to yield of colonoscopy increased from 20% to 85% when per-detect a clinically important and statistically signiﬁcant differ- formed during active bleeding versus electively.25 Other studiesence in major outcomes and therefore cannot be used to con- have shown a high yield when repeat colonoscopy is performedclude the equivalence of these interventions. In addition, it has promptly for recurrent bleeding.26 It is noteworthy that in thebeen criticized for insufﬁcient colon preparations (64% were fair randomized trial by Green et al,14 no stigmata of hemorrhageto poor),22 did not use current state-of-the-art endoscopic or were found in patients undergoing elective colonoscopy after aangiographic therapy, and was published 10 years after com- positive tagged red blood cell scan (the average time to colonos-pletion of the study. copy in this group was 38 hours). Large-scale, multicenter, randomized trials ultimately are Prompt colonoscopy also offers an opportunity to identifyneeded to determine the best strategy for patients with LIB. In low-risk patients and, therefore, to reduce the need for hospi-the meantime, the existing, albeit imperfect, literature can be talization and costs of care. Several studies have found thatused to address a number of important issues regarding time to colonoscopy is a strong predictor of length of stay aftercolonoscopy in LIB, including the relative importance of timing adjustment for other factors including comorbid illness.8,17of intervention versus colonic preparation, the prevalence of Overall, this appears to be the result of early diagnosis inhigh-risk stigmata, the optimal endoscopic treatment modality, low-risk patients rather than therapeutic interventions.17and the overall impact of endoscopic hemostasis in the colon. Length of hospital stay is a major determinant of costs in gastrointestinal bleeding and, therefore, earlier colonoscopy Timing of Colonoscopy likely translates into decreased costs of care.7,27 In a retrospec- Early endoscopy is the standard of care in UGIB, al- tive, informal cost analysis, urgent colonoscopy was associatedthough the optimal time frame has yet to be deﬁned. Early with an average savings of $10,065 per patient compared withintervention allows identiﬁcation and treatment of bleeding emergency angiography and elective colonoscopy.28 However,sources, reduces the need for blood transfusion and length of this large savings likely reﬂects other trends in care includinghospital stay, and facilitates the triage of high- and low-risk length of hospital stay and the use of surgery.
336 STRATE AND NAUMANN CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 8, No. 4 Taken together, the evidence suggests that colonoscopy mata of recent hemorrhage are seen on average in 17% ofshould be performed within 12 to 24 hours in most patients patients.34 Studies of all sources of LIB report stigmata in 8%with LIB—a goal that usually accommodates colon preparation to 35% of patients.13,14,17 However, yields at the upper end ofand the availability of the endoscopy suite. In patients with this range reﬂect highly selected patients who are recruitedsigns of severe bleeding, colonoscopy close to the time of over a long period.15 The timing of colonoscopy, quality ofbleeding after a rapid bowel preparation is likely to have the colon preparation, selection of patients with severe or ongo-highest yield. However, as in UGIB, an optimal time threshold ing bleeding, and experience and diligence of the endoscopisthas not been determined, and it is unclear how faster timing are factors that impact the yield of colonoscopy in LIB.affects major clinical outcomes such as rebleeding and mortal- Risk-stratiﬁcation tools that aid in the selection of patientsity. who are most likely to have stigmata of hemorrhage and to beneﬁt from urgent interventions are also likely to improve Colon Preparation the utility of urgent colonoscopy. Adequate colon preparation is an important compo-nent of colonoscopy for LIB. Early studies of unprepped Risk Stratiﬁcationcolonoscopy for LIB report low completion rates between 55% One of the major difﬁculties in the management of LIBand 70%.29 –31 In addition, blood and stool in the colon may is predicting the likelihood of severe bleeding and the need forincrease the risk of perforation and impair the identiﬁcation of hemorrhage control based on the initial clinical presentation.stigmata of hemorrhage. In the study of urgent colonoscopy by Risk stratiﬁcation is particularly important in LIB because di-Jensen et al,15 procedures were performed within 1 hour of stool agnostic and therapeutic interventions are time- and resource-clearing after 5 to 6 liters of polyethylene glycol were given over intensive and often entail risk and inconvenience (ie, bowel3 to 4 hours, often via nasogastric tube. This meticulous atten- preparation) for the patient. Furthermore, 75% of patients willtion to preparation likely contributed to the exemplary results, stop bleeding spontaneously and are unlikely to beneﬁt fromand, in general, shortening the time to colonoscopy should not aggressive interventions. In UGIB, there have been dozens ofcome at the expense of the bowel preparation. Ideally, colonos- attempts to predict the risk of poor outcome and the need forcopy is performed within 1 to 2 hours of stool clearing. The use endoscopic interventions.5 The systematic application of suchof promotility agents, such as metoclopramide, may facilitate tools can reduce resource use, mainly through early discharge,the preparation and prevent nausea, but this has not been without deleterious effects on other clinical outcomes.35studied formally.28 Aspiration precautions should be followed Recently, 3 risk-stratiﬁcation tools have been developed spe-during rapid colon cleansing. Water jet or syringe irrigation ciﬁcally for LIB.5,36 –38 Hemodynamic instability, ongoing hema-should be used to clear remaining blood and stool and a tochezia, and comorbid illness consistently have been associ-large-channel therapeutic colonoscope can be helpful. Addi- ated with poor outcome, and parallel ﬁndings in UGIB. Studiestional preparation may not be necessary for recurrent bleeding also have shown that patients who bleed while hospitalized foronce the colon has been cleansed because active bleeding in this another process have a particularly poor prognosis.2,39 Otherinstance may improve localization.32 A successful rapid colon risk factors identiﬁed in one or more studies are listed in Tablepreparation requires coordination of the medical, nursing, and 4. Strate et al36,37 developed and validated a simple predictionpharmacy staff and the cooperation of the patient. rule for severe bleeding based on 7 independent risk factors Flexible sigmoidoscopy and anoscopy can be performed early (tachycardia, hypotension, syncope, a nontender abdomen, rec-in the evaluation of LIB to evaluate and treat left-sided or tal bleeding within 4 hours of presentation to the hospital,anorectal lesions without the need for a full colon preparation. aspirin use, and 2 major comorbid conditions). The numberThis may be of particular use in patients with a high likelihood of risk factors predicted the risk of severe or recurrent hemor-of a distal source. However, the yield of this approach in the rhage as well as the need for blood transfusions, surgery, andliterature has been quite low ( 10%),7,25,33 and most patients death.37 Patients with 4 or more risk factors (17% of patients)ultimately will require a full colonoscopy to exclude proximal were in the highest risk group (80% chance of severe or ongoingpathology. Stigmata of Recent Hemorrhage Table 4. Risk Factors for Poor Outcome in Lower Intestinal Bleeding The main indication for performing urgent interven-tions and meticulous colon preparations is to identify and treat Hemodynamic instability5,36–38stigmata of recent hemorrhage or active bleeding. However, the Hypotension, tachycardia, orthostasis, syncope Ongoing bleeding5,36–38identiﬁcation of stigmata in the colon is difﬁcult. The large Blood on rectal examination, hematochezia, rectal bleeding withinsurface area of the colon, residual stool and blood, intermittent 4 hours of presentationbleeding, and multiple potential lesions (eg, diverticulosis) are Age5complicating factors. In addition, only about half of LIB is from Comorbid illness5,36,37endoscopically treatable sources, such as diverticulosis and an- Secondary bleeding (bleeding while hospitalized for another process)2,39giodysplasia (Table 1).2,8,17 Other sources, including ischemic Anticoagulation or antiplatelet medication5,36,37colitis and inﬂammatory bowel disease, tend to result in diffuse History of diverticular disease or angiodysplasia5injury. Furthermore, more than one third of patients will have Nursing home resident5more than one potential source such as diverticulosis and Nontender abdominal examination5,36,37hemorrhoids.24 Anemia (hematocrit 35%)38 Abnormal creatinine level5 The incidence of stigmata of recent hemorrhage in LIB is Abnormal white blood cell count5unknown. In prospective trials of peptic ulcer disease, stig-
April 2010 MANAGEMENT OF ACUTE LOWER INTESTINAL BLEEDING 337bleeding) and would be the most appropriate targets for urgent moderate pressure.14,15 This technique appears to be safe (oneinterventions. Patients with 1 to 3 risk factors (designated as cecal perforation reported in the recent literature),14 but shouldmoderate risk) had a 43% chance of severe or recurrent bleeding be used cautiously in the right colon, in the dome of diverticula,and also may warrant urgent interventions. However, the ability and in the presence of mucosal defects. In experimental canineof the rule to aid in risk stratiﬁcation is limited by the fact that models, electrocoagulation was safe for mucosal lesions even atthe moderate-risk group comprised 78% of the population. high settings, but not for ulcers in which colon thickness wasVelayos et al38 identiﬁed hematocrit less than 35%, abnormal compromised.43 In the presence of active bleeding, epinephrinevital signs after 1 hour, and gross blood on initial rectal exam- (dilution, 1:10,000 or 1:20,000) can be injected in 1- to 2-mLination as independent predictors of ongoing or recurrent aliquots in 4 quadrants around the lesion. Injection not onlybleeding. Ongoing or recurrent bleeding occurred in 79% of helps to clear the ﬁeld of active bleeding, but it also can be usedpatients with 3 risk factors, 54% of patients with 2 risk factors, to better expose stigmata from within a diverticulum (con-17% of patients with 1 risk factor, and 0% in patients with no versely injection distal to a lesion can hamper access).32 Argonrisk factors. Fifty-two percent of patients had 2 or 3 risk factors plasma coagulation is particularly useful for diffuse lesionsand these patients are reasonable candidates for urgent inter- such as radiation proctopathy and large or multiple angiodys-ventions. Das et al5 developed and validated an artiﬁcial neural plasia.44 Band ligation also has been used in diverticular hem-network to predict the risk of death, rebleeding, and need for orrhage and for other focal lesions.45intervention. This tool was highly accurate in predicting these In reviewing the 137 cases in the literature (including ab-outcomes, particularly in the external validation group (97%, stract form) of endoscopic treatment of diverticular bleeding,93%, and 94%, respectively). In addition, the negative predictive hemostasis was achieved in 92% of all cases and no complica-values for these outcomes were greater than 98% in the internal tions were reported (Table 3).14 –16,21,26,41,42,46 –59 Four patientsand external validation cohorts, suggesting that this artiﬁcial were treated successfully with endoscopic band ligation. Of 20neural network could be used to triage low-risk patients to cases treated with epinephrine injection alone, 15% experiencedoutpatient management. Overall, the artiﬁcial neural network early rebleeding. Forty-two patients received thermal contactmodels appear to outperform prediction rules developed using therapy plus/minus epinephrine injection for active bleeding.standard logistic regression techniques. The requirements for The early rebleeding rate in this group was 19% and was highlyspeciﬁc software and data entry currently limit their clinical inﬂuenced by one study of 13 patients in which 5 (38%) expe-application, but, with the widespread use of computerized med- rienced rebleeding.21 A total of 71 cases treated with endoscopicical records, neural networks are likely to become more clini- clipping have been reported with 100% success, suggesting thatcally applicable. Further studies are needed to determine pro- this is a very effective modality for diverticular bleeding. Latespectively the impact of prediction rules on clinical outcomes recurrent bleeding has been reported in 25% of all patients withand to validate the results in larger diverse settings. Perhaps the diverticular hemorrhage after 4 years of follow-up.2 Late recur-bigger task will be the routine application of risk stratiﬁcation rent bleeding occurred in 17 of the reported 137 patients (12%)in clinical practice, something that has proven difﬁcult even in treated endoscopically for diverticular bleeding. However, recur-UGIB.40 rent bleeding is often a delayed phenomenon49 and patient follow-up varied substantially in these studies. It is also unclear Endoscopic Hemostasis Techniques how the treatment of one diverticulum affects recurrent bleed- ing given the presence of many diverticula in the colon. Although endoscopic hemostasis in the colon appearsto be effective, the optimal technique has not been delineated.The armamentarium for endoscopic hemostasis in the colon Radiologic Management Optionsparallels that of UGIB and includes injection therapy (eg, epi-nephrine or saline), thermal contact (heater probe, bipolar elec- There are a number of radiographic strategies used introcoagulation, or monopolar electrocoagulation), argon plasma the management of severe LIB including angiography, radionu-coagulation, endoscopic clipping devices, and band ligation. In clide scintigraphy (tagged red blood cell scanning), and com-contrast to UGIB, in which numerous trials (albeit many rela- puted tomography. These tests typically are reserved for pa-tively small) and meta-analyses have investigated endoscopic tients with very brisk bleeding who cannot be stabilized forhemostasis techniques, data in LIB are based largely on small colonoscopy or for ongoing bleeding of obscure etiology. Theynonrandomized trials or retrospective case series. In addition, it can be particularly useful in brisk bleeding because there is nois difﬁcult to compare the efﬁcacy of endoscopic treatment for need for bowel preparation. Radiographic modalities are ofdifferent bleeding sources because of differences in the need for limited use in more routine scenarios because they requireendoscopic therapy and in the natural history of bleeding. In active bleeding at the time of examination for diagnosis andgeneral, the type and location of the lesion, experience of the treatment. Similar to the literature for colonoscopy, studiesendoscopist, and presence of coagulation defects should evaluating radiographic modalities for the management of LIBguide the therapeutic modality. A second technique can be often are limited by small sample sizes, variable inclusion cri-tried if the ﬁrst attempt fails. teria, and a paucity of prospective randomized trials. In addi- Endoscopic clipping is touted as a safer alternative to ther- tion, there are very few head-to-head comparisons with colonos-mal contact methods.26,41,42 Endoclips can be applied directly to copy. The performance of these modalities continues tothe stigmata, to feeder vessels, or used to oppose the sides of improve as technologic advances are made.small diverticula or postpolypectomy defects.26,32 Care must betaken not to traumatize or partially clip a vessel. Electrocautery Angiographyin the colon should be performed using moderately low power Angiography is the only radiographic modality that cansettings (10 –15 W) in 1- to 3-second bursts with light to be both diagnostic and therapeutic. Bleeding rates of at least 0.5
338 STRATE AND NAUMANN CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 8, No. 4to 1 cc per minute can be detected with angiography.60 Success- success and fewer complications, most notably bowel infarc-ful localization of bleeding is highly dependent on the rate of tion. Embolization is feasible in approximately 82% of patientsbleeding at the time of the examination.61,62 A systolic blood with positive angiograms in the setting of LIB.70 Failure topressure 90 mm Hg and a requirement of at least 5 units of achieve superselective positioning is most commonly the resultpacked red blood cells within a 24-hour period have been of vasospasm, tortuosity, or stenosis.71 In a review of 20 studiesshown to predict a positive angiography.63 Angiography was using current superselective techniques, immediate hemostasispositive in approximately 85% of patients with both of these was achieved in 96% of patients and rebleeding within 30 dayscriteria compared with 15% in more stable patients. Overall, occurred in 22% (Table 5).72–90 Studies suggest that diverticularpositive examinations are reported in 25% to 70% of cases in the bleeding may be more amenable to embolization therapy thanliterature.25,61,64 – 66 This wide range is likely a reﬂection of non- other sources of bleeding, such as angiodysplasia.62,63 In a meta-standardized patient selection and angiographic technique. analysis of embolization as ﬁrst-line therapy for LIB, emboliza- Provocative angiography with vasodilators, anticoagulants, tion successfully controlled diverticular bleeding in 85% at 30and thrombolytic agents has been studied as a means of in- days versus 50% in nondiverticular bleeding (P .01).91 Nocreasing the sensitivity of angiography. Studies using provoca- study has shown the superiority of any one of the 3 agents usedtive techniques in patients with obscure bleeding report an for embolization—microcoils, polyvinyl alcohol particles, andoverall yield of about 30% with few complications.67– 69 How- gelfoam. However, polyvinyl alcohol particles can be injectedever, the number of reported cases is small and the risk ofserious complications is high. Therefore, technical expertise and upstream of a bleeding site when superselective positioning iscareful patient selection are required to achieve good results not possible. Gelfoam allows for recanalization over days toand minimize complications. weeks, but rarely is used. Historically, angiographic intervention for LIB involved the The potential for serious complications is a major limitationinfusion of vasoconstrictors, such as vasopressin. This tech- to the use of angiography in LIB, particularly in the elderly andnique often was used to stabilize a patient before surgical in patients with comorbid illness. In reviewing the 338 patientsresection of the culprit segment rather than as a deﬁnitive undergoing superselective embolization for LIB, minor compli-intervention because rebleeding occurred in up to 50% and cations were seen in 26% and major complications were seen inserious complications developed in 10% to 20%.61,62 Techno- 17% (Table 5). The most common major complication waslogic advances in coaxial microcatheters and embolic materials bowel infarction. Other complications include contrast allergieshave enabled the embolization of speciﬁc distal arterial and nephrotoxicity, hematomas, thromboses, and vascular dis-branches. Superselective embolization has resulted in increased sections.72–90Table 5. Angiography With Embolization in Acute Lower Intestinal Bleeding Immediate Patients/patients hemostasis,a Early rebleeding,b Minor complications,c Major complications,d Study embolized, n n (%) n (%) n (%) n (%)Guy et al, 199282 9/9 9 (100) 3 (33) 3 (33) 3 (33)Gordon et al, 199781 17/14 13 (93) 2 (15) 4 (31) 2 (15)Lederman et al, 199885 7/7 6 (86) 1 (17) 1 (17) 0 (0)Nicholson et al, 1998119 38/13 12 (92) 2 (17) 4 (33) 1 (8)Bulakbasi et al, 199973 10/9 9 (100) 3 (33) 7 (78) 0 (0)Evangelista and Hallisey, 200078 17/17 15 (88) 2 (13) 3 (20) 1 (7)Luchtefeld et al, 200086 48/16 13 (81) 1 (8) 6 (46) 1 (8)Bandi et al, 200172 48/35 33 (94) 11 (33) 9 (27) 8 (24)Funaki et al, 200179 27/25 25 (100) 3 (1) 3 (12) 3 (12)Defreyne et al, 200176 11/11 11 (100) 1 (9) 0 (0) 1 (9)Patel et al, 200188 10/10 10 (100) 2 (20) 1 (10) 1 (10)DeBarros et al, 200275 27/27 27 (100) 6 (22) 2 (7) 6 (22)Kuo et al, 200384 22/22 22 (100) 3 (14) 4 (18) 0 (0)Gady et al, 200380 10/10 10 (100) 3 (30) 0 (0) 4 (40)Burgess and Evans, 200474 15/15 14 (93) 8 (57) 10 (71) 6 (43)Waugh et al, 200490 33/27 26 (96) 6 (23) 7 (27) 3 (12)Neuman et al, 200587 23/23 23 (100) 5 (22) 11 (48) 3 (13)Silver et al, 200589 77/11 10 (91) 1 (10) 2 (20) 6 (60)d’Othee et al, 200677 19/17 17 (100) 5 (29) 6 (35) 4 (24)Kickuth et al, 200883 71/20 20 (100) 2 (10) 2 (10) 2 (10)Total 539/338 325 (96) 70 (22) 85 (26) 55 (17)a Immediate hemostasis calculations were limited to those patients who were embolized.bEarlyrebleeding was deﬁned as bleeding within 30 days of initial embolization. Calculations were limited to patients who were embolized andachieved hemostasis.cMinor complications did not require surgery or result in death among those embolized with immediate hemostasis; late rebleeds were excludedbecause a majority were unrelated to the index procedure.dMajor complications required surgery or resulted in death among those embolized with immediate hemostasis.
April 2010 MANAGEMENT OF ACUTE LOWER INTESTINAL BLEEDING 339 Studies comparing colonoscopy and angiography in the Table 6. Nuclear Scintigraphy in Lower Intestinal Bleedingmanagement of LIB are limited. As mentioned earlier, there has Total Positive Localization Accuracy ofbeen only one randomized controlled trial comparing colonos- scans, scans, conﬁrmed,a positive scans,copy with tagged red blood cell scan followed by angiography if Study n n (%) n (%) n (%)positive.14 This trial found colonoscopy to be a superior diag-nostic test, but was underpowered for other major outcomes. In Zink et al, 200899 41 19 (46) 17 (89) 6 (35)a prospective study, 22 patients with severe hematochezia un- Czymek et al, 20 8 (40) 8 (100) 8 (100)derwent both angiography and panendoscopy.10 Ultimately, 17 200894were found to have colonic sources. Only 14% had a deﬁnitive Lee et al, 200896 22 9 (41) 4 (44) 3 (75)diagnosis made by angiography compared with 86% with pan- Brunnler et al, 92 67 (73) 30 (45) 20 (67) 200893endoscopy. Endoscopic therapy was used in 39% compared with Olds et al, 127 49 (39) 42 (86) 23 (55)1% with angiography. Complications occurred in 9% of angiog- 200598raphies compared with 4% of colonoscopies. Other retrospective Levy et al, 200397 40 28 (70) 28 (100) 18 (64)studies have found colonoscopy to have a better diagnostic and Gutierrez et al, 105 42 (40) 23 (55) 22 (96)therapeutic yield than angiography.7,25,92 In all of these studies, 199895angiography relied on vasopressin infusion, not embolization. Total 447 222 (50) 152 (68) 100 (66)It is important to note that most patients who undergo angiog- NOTE. Table includes studies since 1998.raphy will require elective colonoscopy to conﬁrm the bleeding a Scanlocalization conﬁrmed by endoscopy, angiography, or surgery.source and exclude neoplasia. In practice, angiography probably is used more often thancolonoscopy for patients with severe bleeding. In one retrospec- examinations decreased (9.6% to 3.6%) and the conﬁdence oftive, single-center study, patients with hemodynamic instability reported ﬁndings improved.102were more likely to undergo angiography, whereas logistical Despite its sensitivity for bleeding and safety, the role offactors (time of day and day of week) and postpolypectomy radionuclide scintigraphy in LIB remains controversial. Therebleeding were predictive of urgent colonoscopy.92 The fact that have been no randomized trials of angiography with and with-angiography can be performed without a bowel preparation is out radionuclide scanning. Some studies show an increase inlikely to factor signiﬁcantly into management decisions. How- the diagnostic yield of angiography when performed after aever, in this study, the median times from admission to early positive scan (22% to 53% in one study)103; whereas other stud-initial procedure were similar in patients undergoing angiogra- ies have found no difference.62,104,105 Likewise, the ability ofphy (14 hours) versus colonoscopy (17 hours),92 drawing atten- nuclide scanning to accurately localize bleeding before surgicaltion to the fact that angiography, especially when preceded by resection is debatable.105–107 A signiﬁcant disadvantage of radio-a nuclear medicine scan, also may take time to orchestrate. In nuclide scintigraphy is the lack of therapeutic possibilities. Thethe absence of data from large randomized trials, the choice of delay between a positive scan and subsequent angiography orintervention in patients with massive bleeding generally is colonoscopy may decrease therapeutic opportunities owing toguided by institutional expertise. However, in patients who can the intermittent nature of LIB. Therefore, if radionuclide scin-be stabilized for bowel preparation, colonoscopy appears to be tigraphy is to be used in LIB, care should be coordinated so thatthe most efﬁcient and safest strategy. a positive scan is followed closely by angiography. Radionuclide Scintigraphy Computed Tomography Radionuclide scintigraphy, or tagged red blood cell Until recently, computed tomography (CT) scanningscanning, often is used as a screening test before angiography has been of limited use in the evaluation of gastrointestinalbecause it is noninvasive and more sensitive (bleeding at a rate of bleeding. However, with the introduction of multidetector row0.05– 0.1 cc per minute can be detected).64 It also can be repeated CT (MDCT), it is being investigated as a potential diagnosticin the setting of intermittent bleeding. However, the ability of tool. MDCT markedly decreases scan time, which enables theradionuclide scanning to localize the bleeding source correctly accurate acquisition of arterial images, which can show contrastvaries widely in the literature in part because of differences in extravasation into any portion of the gastrointestinal tract.108the criteria used for conﬁrming the source and for patient Bleeding rates as low as 0.3 to 0.5 cc per minute have beenselection. In reviewing the 7 most recent studies of radionuclide detected in a swine model.109 Overall, in the 124 patients re-scanning for LIB (447 patients) in which radionuclide scintig- ported in the literature, the average yield of MDCT for LIB israphy ﬁndings were conﬁrmed by a different test, the accuracy 60%, with yields ranging from 25% to 95% (Table 7).93–99 Theof a positive test was 66% (Table 6).93–99 Localization appears to yield of MDCT is highest among patients with severe ongoingimprove when scans are positive within 2 hours of injection LIB.99,110 –114 General advantages of CT scanning include its(95%–100%) as opposed to later (55%– 65%).100 This likely re- wide availability and the added diagnostic yield of cross-sec-ﬂects the tendency of blood to spread both antegrade and tional imaging. The primary disadvantage of CT scanning, asretrograde in the colon. Subtraction scintigraphy also may with radionuclide scintigraphy, is its inability to deliver therapy.improve the accuracy of radionuclide scintigraphy. With this Other disadvantages include exposure to radiation, limited abil-technique, the initial frame is subtracted from subsequent im- ity to perform repeat scans, false-positive results generated fromages, theoretically improving visualization of the radionuclide metallic objects or sutures, contrast allergies, and potentiallabel by removing superimposed background structures.101,102 nephrotoxicity with intravenous contrast, particularly if CT isIn a retrospective study of 49 scans processed using both con- followed by angiography.108 Overall, 2 complications have beenventional and subtraction scintigraphy, the rate of false-positive reported in the literature.114 Both of these patients had pre-
340 STRATE AND NAUMANN CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 8, No. 4Table 7. MDCT in Lower Intestinal Bleeding Total scans, Positive scans, Bleeding site conﬁrmed,a Correct localization,b Complications, Study n n (%) n (%) n (%) n (%)Jaeckle et al, 2008111 17 16 (94) 16 (100) 16 (100) 0Zink et al, 200899 41 10 (24) 5 (50) 5 (100) 0Scheffel et al, 2007112 8 5 (63) 5 (100) 5 (100) 0Yoon et al, 2006114 19 16 (84) 16 (100) 16 (100) 2 (11)Sabharwal et al, 2005120 7 5 (71) 2 (40) 2 (100) 0Tew et al, 2004113 13 7 (54) 7 (100) 7 (100) 0Ernst et al, 2003110 19 15 (79) 15 (100) 15 (100) 0Total 124 74 (60) 61 (82) 66 (100) 2 (2)a Conﬁrmation of bleeding site by angiography, endoscopy, and/or surgery.bOf those patients who had conﬁrmation of the bleeding site.existing renal insufﬁciency secondary to diabetic nephropathy orrhage, but there are few data to guide this practice.6 Decision-and experienced contrast-induced nephrotoxicity requiring he- analysis models using population-based data call into questionmodialysis after MDCT followed by angiography. the practice of surgical resection after 2 episodes of diverticu- A recent study prospectively evaluated MDCT followed by litis.116 Complications of surgery for LIB are reported in asangiography in 26 consecutive patients presenting with acute many as 60% of patients,94 and the mortality rate is as high asmassive gastrointestinal bleeding.114 MDCT detected the extrav- 10%.115 Localization of the bleeding source before surgery isasation of contrast into the intestinal lumen in 16 of the 19 important to prevent the excess morbidity and mortality re-patients with lower GI sources. Bleeding was conﬁrmed in all 16 ported with blind subtotal colectomy and also to prevent re-cases by angiography (100%). When both upper and lower section of the incorrect segment of bowel.6sources were included, MDCT had a sensitivity of 91% and aspeciﬁcity of 99%. There were 2 false-negative examinations and Conclusions1 false-positive examination. Localization of the site of bleedingwas accurate in 100% of cases. As noted earlier, contrast-in- Colonoscopy is the preferred intervention for most pa-duced nephropathy was noted in 2 patients who had baseline tients with LIB owing to its high diagnostic yield, varied ther-increases in creatinine level. It is not clear whether MDCT has apeutic capabilities, and low complication rate. Based on thean impact on rebleeding rates, need for surgical intervention, or available literature, it appears that colonoscopy shortly aftermortality. Another study compared MDCT with radionuclide presentation can increase the identiﬁcation and treatment ofscintigraphy in 41 patients with LIB.99 MDCT identiﬁed 10 stigmata of hemorrhage and potentially reduce early rebleeding.cases (25%) of active bleeding and radionuclide scintigraphy However, the identiﬁcation of stigmata is probably as much aidentiﬁed 19 (46%). The yield of nuclear scintigraphy was higher function of ongoing or severe bleeding and meticulous colonbecause the test could be repeated in the event of intermittent preparation as it is the timing of the examination. Promptbleeding. There were discordant results in 13 cases—11 negative colonoscopy in all patients with LIB, regardless of endoscopicMDCT but positive scintigraphy and 2 positive MDCT but intervention, is likely to decrease hospital length of stay andnegative scintigraphy. Both techniques accurately identiﬁed the therefore the cost of care. The need for colon preparation, thelocation of bleeding although MDCT provided more detail and difﬁculty in performing prompt colonoscopy, and the relativeancillary ﬁndings. Although the data are encouraging, addi- infrequency of stigmata of hemorrhage in the colon are deter-tional studies are needed with larger sample sizes and stronger rents to the use of urgent colonoscopy in routine practice.end points to determine the appropriate role for MDCT in the Risk-stratiﬁcation tools that target high-risk patients as well asmanagement of LIB. system-based interventions that address logistical issues prom- ise to improve the utility of urgent interventions. Radiographic modalities, particularly angiography, play a complementary role Surgery in patients with massive bleeding who cannot be stabilized for Surgery generally is reserved for patients with life- colon preparation or who have eluded endoscopic diagnosisthreatening hemorrhage who have failed other management and/or treatment. While we await more deﬁnitive trials, it isoptions. Farrell and Friedman115 summarize the following in- reasonable to aim for colonoscopy within 12 to 24 hours ofdications for emergency surgery for severe LIB: hypotension and admission in most patients with LIB. With a thorough bowelshock despite resuscitation; continued bleeding ( 6 U packed preparation and meticulous technique, we just might ﬁnd thosered blood cells transfused) and lack of a diagnosis despite elusive stigmata of hemorrhage in the colon.thorough work-up of upper, midgut, and lower sources; activebleeding from a segmental gastrointestinal lesion that is ame- Referencesnable to cure or permanent hemostasis by surgery; and patient 1. Longstreth GF. Epidemiology of hospitalization for acute upperis a surgical candidate with a reasonable life expectancy. How- gastrointestinal hemorrhage: a population-based study. Am Jever, it usually is difﬁcult to make decisions based solely on Gastroenterol 1995;90:206 –210.criteria. Surgical consultation should be obtained early in the 2. Longstreth GF. Epidemiology and outcome of patients hospital-course of severe bleeding as a precautionary measure. Surgery ized with acute lower gastrointestinal hemorrhage: a population-also often is used in the setting of recurrent diverticular hem- based study. Am J Gastroenterol 1997;92:419 – 424.
April 2010 MANAGEMENT OF ACUTE LOWER INTESTINAL BLEEDING 341 3. Lanas A, Garcia-Rodriguez LA, Polo-Tomas M, et al. Time trends ter? A systematic review. Arch Intern Med 2001;161: and impact of upper and lower gastrointestinal bleeding and 1393–1404. perforation in clinical practice. Am J Gastroenterol 2009;104: 24. Caos A, Benner KG, Manier J, et al. Colonoscopy after Golytely 1633–1641. preparation in acute rectal bleeding. J Clin Gastroenterol 1986; 4. Strate LL, Ayanian JZ, Kotler G, et al. Risk factors for mortality in 8:46 – 49. lower intestinal bleeding. Clin Gastroenterol Hepatol 2008;6: 25. Colacchio TA, Forde KA, Patsos TJ, et al. Impact of modern 1004 –1010, quiz 955. diagnostic methods on the management of active rectal bleed- 5. Das A, Ben-Menachem T, Cooper GS, et al. Prediction of out- ing. Ten year experience. Am J Surg 1982;143:607– 610. come in acute lower-gastrointestinal haemorrhage based on an 26. Yen EF, Ladabaum U, Muthusamy VR, et al. Colonoscopic treat- artiﬁcial neural network: internal and external validation of a ment of acute diverticular hemorrhage using endoclips. Dig Dis predictive model. Lancet 2003;362:1261–1266. Sci 2008;53:2480 –2485. 6. McGuire HH. Bleeding colonic diverticula. A reappraisal of nat- 27. Jiranek GC, Kozarek RA. A cost-effective approach to the patient ural history and management. Ann Surg 1994;220:653– 656. with peptic ulcer bleeding. Surg Clin North Am 1996;76:83– 7. Richter JM, Christensen MR, Kaplan LM, et al. Effectiveness 103. of current technology in the diagnosis and management of 28. Jensen DM, Machicado GA. Colonoscopy for diagnosis and lower gastrointestinal hemorrhage. Gastrointest Endosc treatment of severe lower gastrointestinal bleeding. Routine 1995;41:93–98. outcomes and cost analysis. Gastrointest Endosc Clin N Am 8. Schmulewitz N, Fisher DA, Rockey DC. Early colonoscopy for 1997;7:477– 498. acute lower GI bleeding predicts shorter hospital stay: a retro- 29. Chaudhry V, Hyser MJ, Gracias VH, et al. Colonoscopy: the initial spective study of experience in a single center. Gastrointest test for acute lower gastrointestinal bleeding. Am Surg 1998; Endosc 2003;58:841– 846. 64:723–728. 9. Thomas S, Wong R, Das A. Economic burden of acute divertic- 30. Ohyama T, Sakurai Y, Ito M, et al. Analysis of urgent colonos- ular hemorrhage in the U.S.: a nationwide estimate (abstr). copy for lower gastrointestinal tract bleeding. Digestion 2000; Gastroenterology 2004;126:A– 606. 61:189 –192. 10. Jensen DM, Machicado GA. Diagnosis and treatment of severe 31. Tada M, Shimizu S, Kawai K. Emergency colonoscopy for the diagnosis of lower intestinal bleeding. Gastroenterol Jpn 1991; hematochezia. The role of urgent colonoscopy after purge. Gas- 26(Suppl 3):121–124. troenterology 1988;95:1569 –1574. 32. Wong Kee Song LM, Baron TH. Endoscopic management of 11. Eisen GM, Dominitz JA, Faigel DO, et al. An annotated algorith- acute lower gastrointestinal bleeding. Am J Gastroenterol 2008; mic approach to acute lower gastrointestinal bleeding. Gastro- 103:1881–1887. intest Endosc 2001;53:859 – 863. 33. Al Qahtani AR, Satin R, Stern J, et al. Investigative modalities for 12. Zuccaro G. Management of the adult patient with acute lower massive lower gastrointestinal bleeding. World J Surg 2002;26: gastrointestinal bleeding. Am J Gastroenterol 1998;93:1202– 620 – 625. 1208. 34. Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med 13. Angtuaco TL, Reddy SK, Drapkin S, et al. The utility of urgent 1994;331:717–727. colonoscopy in the evaluation of acute lower gastrointestinal 35. Hay JA, Maldonado L, Weingarten SR, et al. Prospective evalu- tract bleeding: a 2-year experience from a single center. Am J ation of a clinical guideline recommending hospital length of Gastroenterol 2001;96:1782–1785. stay in upper gastrointestinal tract hemorrhage. JAMA 1997; 14. Green BT, Rockey DC, Portwood G, et al. Urgent colonoscopy for 278:2151–2156. evaluation and management of acute lower gastrointestinal 36. Strate LL, Orav EJ, Syngal S. Early predictors of severity in acute hemorrhage: a randomized controlled trial. Am J Gastroenterol lower intestinal tract bleeding. Arch Intern Med 2003;163:838 – 2005;100:2395–2402. 843. 15. Jensen DM, Machicado GA, Jutabha R, et al. Urgent colonos- 37. Strate LL, Saltzman JR, Ookubo R, et al. Validation of a clinical copy for the diagnosis and treatment of severe diverticular prediction rule for severe acute lower intestinal bleeding. Am J hemorrhage. N Engl J Med 2000;342:78 – 82. Gastroenterol 2005;100:1821–1827. 16. Smoot RL, Gostout CJ, Rajan E, et al. Is early colonoscopy after 38. Velayos FS, Williamson A, Sousa KH, et al. Early predictors of admission for acute diverticular bleeding needed? Am J Gastro- severe lower gastrointestinal bleeding and adverse outcomes: a enterol 2003;98:1996 –1999. prospective study. Clin Gastroenterol Hepatol 2004;2:485– 17. Strate LL, Syngal S. Timing of colonoscopy: impact on length of 490. hospital stay in patients with acute lower intestinal bleeding. 39. Strate LL, Ayanian JZ, Kotler G, et al. Risk factors for mortality Am J Gastroenterol 2003;98:317–322. in lower intestinal bleeding. Clin Gastroenterol Hepatol 2008; 18. Peura DA, Lanza FL, Gostout CJ, et al. The American College of 6:1004 –1010. Gastroenterology Bleeding Registry: preliminary ﬁndings. Am J 40. Bjorkman DJ, Zaman A, Fennerty MB, et al. Urgent vs. elective Gastroenterol 1997;92:924 –928. endoscopy for acute non-variceal upper-GI bleeding: an effec- 19. Zuckerman GR, Prakash C. Acute lower intestinal bleeding: part tiveness study. Gastrointest Endosc 2004;60:1– 8. I: clinical presentation and diagnosis. Gastrointest Endosc 41. Hokama A, Uehara T, Nakayoshi T, et al. Utility of endoscopic 1998;48:606 – 617. hemoclipping for colonic diverticular bleeding. Am J Gastroen- 20. Dominitz JA, Eisen GM, Baron TH, et al. Complications of terol 1997;92:543–546. colonoscopy. Gastrointest Endosc 2003;57:441– 445. 42. Simpson PW, Nguyen MH, Lim JK, et al. Use of endoclips in the 21. Bloomfeld RS, Rockey DC, Shetzline MA. Endoscopic therapy of treatment of massive colonic diverticular bleeding. Gastrointest acute diverticular hemorrhage. Am J Gastroenterol 2001;96: Endosc 2004;59:433– 437. 2367–2372. 43. Jensen DM, Machicado GA, Tapia J, et al. Comparison of argon 22. Jensen DM. Management of patients with severe hematoche- laser photocoagulation and bipolar electrocoagulation for endo- zia—with all current evidence available. Am J Gastroenterol scopic hemostasis in the canine colon. Gastroenterology 1982; 2005;100:2403–2406. 83:830 – 835. 23. Spiegel BM, Vakil NB, Ofman JJ. Endoscopy for acute nonva- 44. Kwan V, Bourke MJ, Williams SJ, et al. Argon plasma coagula- riceal upper gastrointestinal tract hemorrhage: is sooner bet- tion in the management of symptomatic gastrointestinal vascu-
342 STRATE AND NAUMANN CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 8, No. 4 lar lesions: experience in 100 consecutive patients with giography in patients with gastrointestinal hemorrhage of long-term follow-up. Am J Gastroenterol 2006;101:58 – 63. obscure origin. Am J Gastroenterol 2000;95:2807–2812.45. Farrell JJ, Graeme-Cook F, Kelsey PB. Treatment of bleeding 68. Malden ES, Hicks ME, Royal HD, et al. Recurrent gastrointesti- colonic diverticula by endoscopic band ligation: an in-vivo and nal bleeding: use of thrombolysis with anticoagulation in diag- ex-vivo pilot study. Endoscopy 2003;35:823– 829. nosis. Radiology 1998;207:147–151.46. Bertoni G, Conigliaro R, Ricci E, et al. Endoscopic injection 69. Ryan JM, Key SM, Dumbleton SA, et al. Nonlocalized lower hemostasis of colonic diverticular bleeding: a case report. En- gastrointestinal bleeding: provocative bleeding studies with in- doscopy 1990;22:154 –155. traarterial tPA, heparin, and tolazoline. J Vasc Interv Radiol47. Foutch PG, Zimmerman K. Diverticular bleeding and the pig- 2001;12:1273–1277. mented protuberance (sentinel clot): clinical implications, his- 70. Weldon DT, Burke SJ, Sun S, et al. Interventional management topathological correlation, and results of endoscopic interven- of lower gastrointestinal bleeding. Eur Radiol 2008;18:857– tion. Am J Gastroenterol 1996;91:2589 –2593. 867.48. Johnston JJ, Sones J. Endoscopic heater probe coagulation of 71. Peck DJ, McLoughlin RF, Hughson MN, et al. Percutaneous the bleeding colonic diverticulum. Gastrointest Endosc 1986; embolotherapy of lower gastrointestinal hemorrhage. J Vasc 32:168. Interv Radiol 1998;9:747–751.49. Kaltenbach T, Watson R, Shah JN, et al. Safety and efﬁcacy of 72. Bandi R, Shetty PC, Sharma RP, et al. Superselective arterial colonoscopy to treat diverticular bleeding—long-term outcomes embolization for the treatment of lower gastrointestinal hemor- of a large multicenter cohort. Gastrointest Endosc 2009; rhage. J Vasc Interv Radiol 2001;12:1399 –1405. 69:AB113. 73. Bulakbasi N, Kurtaran K, Ustunsoz B, et al. Massive lower50. Kim YI, Marcon NE. Injection therapy for colonic diverticular gastrointestinal hemorrhage from the surgical anastomosis in bleeding. A case study. J Clin Gastroenterol 1993;17:46 – 48. patients with multiorgan trauma: treatment by subselective em-51. Lara LF, Bloomfeld RS. Endoscopic therapy for acute diverticular bolization with polyvinyl alcohol particles. Cardiovasc Intervent hemorrhage. Gastrointest Endosc 2001;53:492. Radiol 1999;22:461– 467.52. Mauldin JL. Therapeutic use of colonoscopy in active diverticular 74. Burgess AN, Evans PM. Lower gastrointestinal haemorrhage bleeding. Gastrointest Endosc 1985;31:290 –291. and superselective angiographic embolization. Aust N Z J Surg53. Pardoll P, Neubrand S. Injection control of colonic hemorrhage 2004;74:635– 638. with hypertonic saline-epinephrine injection. Am J Gastroenterol 75. DeBarros J, Rosas L, Cohen J, et al. The changing paradigm for 1989;84:1193. the treatment of colonic hemorrhage: superselective angio-54. Patel C, Wong Kee Song LM, Buttar N, et al. Effectiveness of graphic embolization. Dis Colon Rectum 2002;45:802– 808. endoscopic hemoclipping for diverticular bleeding. Gastrointest 76. Defreyne L, Vanlangenhove P, De Vos M, et al. Embolization as Endosc 2006;63:AB200. a ﬁrst approach with endoscopically unmanageable acute non-55. Prakash C, Chokshi H, Walden DT, et al. Endoscopic hemosta- variceal gastrointestinal hemorrhage. Radiology 2001;218: sis in acute diverticular bleeding. Endoscopy 1999;31:460 – 739 –748. 463. 77. d’Othee BJ, Surapaneni P, Rabkin D, et al. Microcoil emboliza-56. Ramirez FC, Johnson DA, Zierer ST, et al. Successful endo- tion for acute lower gastrointestinal bleeding. Cardiovasc Inter- scopic hemostasis of bleeding colonic diverticula with epineph- vent Radiol 2006;29:49 –58. rine injection. Gastrointest Endosc 1996;43:167–170. 78. Evangelista PT, Hallisey MJ. Transcatheter embolization for57. Rino Y, Imada T, Iwasaki H, et al. Hemostasis of colonic diver- acute lower gastrointestinal hemorrhage. J Vasc Interv Radiol ticular bleeding with hemoclips under endoscopic control: report 2000;11:601– 606. of a case. Hepatogastroenterology 1999;46:1733–1735. 79. Funaki B, Kostelic JK, Lorenz J, et al. Superselective microcoil58. Savides TJ, Jensen DM. Colonoscopic hemostasis for recurrent embolization of colonic hemorrhage. AJR Am J Roentgenol diverticular hemorrhage associated with a visible vessel: a re- 2001;177:829 – 836. port of three cases. Gastrointest Endosc 1994;40:70 –73. 80. Gady JS, Reynolds H, Blum A. Selective arterial embolization for59. Yoshikane H, Sakakibara A, Ayakawa T, et al. Hemostasis by control of lower gastrointestinal bleeding: recommendations for capping bleeding diverticulum of the colon with clips. Endoscopy a clinical management pathway. Curr Surg 2003;60:344 –347. 1997;29:S33–S34. 81. Gordon RL, Ahl KL, Kerlan RK, et al. Selective arterial emboli-60. Steer ML, Silen W. Diagnostic procedures in gastrointestinal zation for the control of lower gastrointestinal bleeding. Am J hemorrhage. N Engl J Med 1983;309:646 – 650. Surg 1997;174:24 –28.61. Browder W, Cerise EJ, Litwin MS. Impact of emergency angiog- 82. Guy GE, Shetty PC, Sharma RP, et al. Acute lower gastrointes- raphy in massive lower gastrointestinal bleeding. Ann Surg tinal hemorrhage: treatment by superselective embolization 1986;204:530 –536. with polyvinyl alcohol particles. AJR Am J Roentgenol 1992;159:62. Pennoyer WP, Vignati PV, Cohen JL. Mesenteric angiography for 521–526. lower gastrointestinal hemorrhage: are there predictors for a 83. Kickuth R, Rattunde H, Gschossmann J, et al. Acute lower positive study? Dis Colon Rectum 1997;40:1014 –1018. gastrointestinal hemorrhage: minimally invasive management63. Abbas SM, Bissett IP, Holden A, et al. Clinical variables asso- with microcatheter embolization. J Vasc Interv Radiol 2008;19: ciated with positive angiographic localization of lower gastroin- 1289 –1296e2. testinal bleeding. Aust N Z J Surg 2005;75:953–957. 84. Kuo WT, Lee DE, Saad WE, et al. Superselective microcoil64. Alavi A, Ring EJ. Localization of gastrointestinal bleeding: supe- embolization for the treatment of lower gastrointestinal hemor- riority of 99mTc sulfur colloid compared with angiography. AJR rhage. J Vasc Interv Radiol 2003;14:1503–1509. Am J Roentgenol 1981;137:741–748. 85. Ledermann HP, Schoch E, Jost R, et al. Superselective coil65. Cohn SM, Moller BA, Zieg PM, et al. Angiography for preopera- embolization in acute gastrointestinal hemorrhage: personal tive evaluation in patients with lower gastrointestinal bleeding: experience in 10 patients and review of the literature. J Vasc are the beneﬁts worth the risks? Arch Surg 1998;133:50 –55. Interv Radiol 1998;9:753–760.66. Leitman IM, Paull DE, Shires GT 3rd. Evaluation and manage- 86. Luchtefeld MA, Senagore AJ, Szomstein M, et al. Evaluation of ment of massive lower gastrointestinal hemorrhage. Ann Surg transarterial embolization for lower gastrointestinal bleeding. 1989;209:175–180. Dis Colon Rectum 2000;43:532–534.67. Bloomfeld RS, Smith TP, Schneider AM, et al. Provocative an- 87. Neuman HB, Zarzaur BL, Meyer AA, et al. Superselective cath-
April 2010 MANAGEMENT OF ACUTE LOWER INTESTINAL BLEEDING 343 eterization and embolization as ﬁrst-line therapy for lower and surgical management of active lower gastrointestinal gastrointestinal bleeding. Am Surg 2005;71:539 –545. hemorrhage with technetium-labeled erythrocyte scintigraphy. 88. Patel TH, Cordts PR, Abcarian P, et al. Will transcatheter embo- Ann Surg 1996;224:29 –36. lotherapy replace surgery in the treatment of gastrointestinal 108. Jaeckle T, Stuber G, Hoffmann MH, et al. Acute gastrointestinal bleeding?. Curr Surg 2001;58:323–327. bleeding: value of MDCT. Abdom Imaging 2008;33:285–293. 89. Silver A, Bendick P, Wasvary H. Safety and efﬁcacy of superse- 109. Kuhle WG, Sheiman RG. Detection of active colonic hemorrhage lective angioembolization in control of lower gastrointestinal with use of helical CT: ﬁndings in a swine model. Radiology hemorrhage. Am J Surg 2005;189:361–363. 2003;228:743–752. 90. Waugh J, Madan A, Sacharias N, et al. Embolization for major 110. Ernst O, Bulois P, Saint-Drenant S, et al. Helical CT in acute lower gastrointestinal haemorrhage: ﬁve-year experience. Aus- lower gastrointestinal bleeding. Eur Radiol 2003;13:114 –117. tralas Radiol 2004;48:311–317. 111. Jaeckle T, Stuber G, Hoffmann MH, et al. Detection and local- 91. Khanna A, Ognibene SJ, Koniaris LG. Embolization as ﬁrst-line ization of acute upper and lower gastrointestinal (GI) bleeding therapy for diverticulosis-related massive lower gastrointestinal with arterial phase multi-detector row helical CT. Eur Radiol bleeding: evidence from a meta-analysis. J Gastrointest Surg 2008;18:1406 –1413. 2005;9:343–352. 112. Scheffel H, Pfammatter T, Wildi S, et al. Acute gastrointestinal 92. Strate LL, Syngal S. Predictors of utilization of early colonos- bleeding: detection of source and etiology with multi-detector- copy vs. radiography for severe lower intestinal bleeding. row CT. Eur Radiol 2007;17:1555–1565. Gastrointest Endosc 2005;61:46 –52. 113. Tew K, Davies RP, Jadun CK, et al. MDCT of acute lower 93. Brunnler T, Klebl F, Mundorff S, et al. Signiﬁcance of scintigra- gastrointestinal bleeding. AJR Am J Roentgenol 2004;182: phy for the localisation of obscure gastrointestinal bleedings. 427– 430. World J Gastroenterol 2008;14:5015–5019. 114. Yoon W, Jeong YY, Shin SS, et al. Acute massive gastrointes- 94. Czymek R, Kempf A, Roblick UJ, et al. Surgical treatment con- tinal bleeding: detection and localization with arterial phase cepts for acute lower gastrointestinal bleeding. J Gastrointest multi-detector row helical CT. Radiology 2006;239:160 –167. Surg 2008;12:2212–2220. 115. Farrell JJ, Friedman LS. Review article: the management of 95. Gutierrez C, Mariano M, Vander Laan T, et al. The use of lower gastrointestinal bleeding. Aliment Pharmacol Ther 2005; technetium-labeled erythrocyte scintigraphy in the evaluation 21:1281–1298. and treatment of lower gastrointestinal hemorrhage. Am Surg 116. Salem L, Veenstra DL, Sullivan SD, et al. The timing of elective 1998;64:989 –992. colectomy in diverticulitis: a decision analysis. J Am Coll Surg 96. Lee J, Lai MW, Chen CC, et al. Red blood cell scintigraphy in 2004;199:904 –912. children with acute massive gastrointestinal bleeding. Pediatr 117. Kanwal F, Dulai G, Jensen DM, et al. Major stigmata of recent Int 2008;50:199 –203. hemorrhage on rectal ulcers in patients with severe hematoche- 97. Levy R, Barto W, Gani J. Retrospective study of the utility of zia: endoscopic diagnosis, treatment, and outcomes. Gastroin- nuclear scintigraphic-labelled red cell scanning for lower gastro- test Endosc 2003;57:462– 468. intestinal bleeding. Aust N Z J Surg 2003;73:205–209. 118. Oku T, Maeda M, Ihara H, et al. Clinical and endoscopic fea- 98. Olds GD, Cooper GS, Chak A, et al. The yield of bleeding scans tures of acute hemorrhagic rectal ulcer. J Gastroenterol 2006; in acute lower gastrointestinal hemorrhage. J Clin Gastroenterol 41:962–970. 2005;39:273–277. 119. Nicholson AA, Ettles DF, Hartley JE, et al. Transcatheter coil 99. Zink SI, Ohki SK, Stein B, et al. Noninvasive evaluation of active embolotherapy: a safe and effective option for major colonic lower gastrointestinal bleeding: comparison between contrast- haemorrhage. Gut 1998;43:79 – 84. enhanced MDCT and 99mTc-labeled RBC scintigraphy. AJR Am J 120. Sabharwal R, Vladica P, Chou R, et al. Helical CT in the diagno- Roentgenol 2008;191:1107–1114. sis of acute lower gastrointestinal haemorrhage. Eur J Radiol100. Dusold R, Burke K, Carpentier W, et al. The accuracy of tech- 2006;58:273–279. netium-99m-labeled red cell scintigraphy in localizing gastroin- testinal bleeding. Am J Gastroenterol 1994;89:345–348.101. Currie GM, Towers PA, Wheat JM. A role for subtraction scintig- raphy in the evaluation of lower gastrointestinal bleeding in the Reprint requests athlete. Sports Med 2007;37:923–928. Address requests for reprints to: Lisa L. Strate, MD, MPH, Harbor-102. Currie GM, Towers PA, Wheat JM. Improved detection and lo- view Medical Center, 325 Ninth Avenue, Box 359773, Seattle, Wash- calization of lower gastrointestinal hemorrhage using subtrac- ington 98104. e-mail: firstname.lastname@example.org; fax: (206) 744- tion scintigraphy: clinical evaluation. J Nucl Med Technol 2007; 8698. 35:105–111.103. Gunderman R, Leef JA, Lipton MJ, et al. Diagnostic imaging and Acknowledgments the outcome of acute lower gastrointestinal bleeding. Acad The authors thank Jason A. Dominitz, MD, MHS, for reviewing a prior Radiol 1998;5(Suppl 2):S303–S305. version of this manuscript. Dr Dominitz is afﬁliated with the University104. Bentley DE, Richardson JD. The role of tagged red blood cell of Washington School of Medicine and the VA Puget Sound Health imaging in the localization of gastrointestinal bleeding. Arch Care System, Seattle, WA. There was no funding source for this Surg 1991;126:821– 824. assistance.105. Voeller GR, Bunch G, Britt LG. Use of technetium-labeled red blood cell scintigraphy in the detection and management of Conﬂicts of interest gastrointestinal hemorrhage. Surgery 1991;110:799 – 804. The authors disclose no conﬂicts.106. Hunter JM, Pezim ME. Limited value of technetium 99m-labeled red cell scintigraphy in localization of lower gastrointestinal Funding bleeding. Am J Surg 1990;159:504 –506. This project was funded by a grant from the Agency for Healthcare107. Suzman MS, Talmor M, Jennis R, et al. Accurate localization Research and Quality (K08 HS14062, to L.L.S.).