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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Lower gastrointestinal tract bleeding: a problem based approach

, M.D. and , M.D., FACS.

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Acute lower gastrointestinal tract bleeding (LGIB), or hemorrhage that originates distal to the ligament of Treitz occurs with an annual incidence of 20.5 to 27 cases per 100,000 adults (1, 2). Male sex, advanced age, the presence of diverticulosis and angiodysplasia appear to be significant risk factors for LGIB. As the small bowel is rarely the source of LGIB with a reported incidence of 0.7% to 0.9% (1, 3), this review will focus upon acute colonic sources of LGIB.

Clinical presentation

McGuire and Haynes reviewed the literature from 1956 to 1971 and found 473 cases of massive lower GI bleeding (4). More than three-fourths of patients were successfully treated nonoperatively with a 22% rebleeding rate but only a 3% mortality. One hundred and three of four hundred and seventy-three (22%) underwent operations, 28 of the 62 (45%) hemicolectomies rebled and nine of the 62 (15%) died. Only three of 34 (9%) patients undergoing subtotal colectomy died and none rebled. McGuire recently reviewed the natural history of 79 patients with 108 episodes of acute lower GI bleeding (5). Bleeding stopped spontaneously in 76% but 24% required emergency surgery. In the 66 patients with lower gastrointestinal bleeding who required no more than three units blood transfusion over a 24 hour period, 98.5% stopped spontaneously. When greater than three units were transfused in a 24 hour time period, 25 of 42 (60%) patients needed emergency surgery. Patients with acute LGIB can demonstrate a decrease in hemoglobin as well as changes in hemodynamics (50%), orthostatic changes (30%), syncope (10%), or cardiovascular collapse (9%) (2).

History and physical examination

Information such as a prior history of peptic ulcer disease, diverticulosis, aortic vascular surgery, radiation therapy, use of medications such as non-steroidal anti-inflammatory and anti-coagulants, or recent endoscopy with biopsy may indicate the origin of bleeding. Diagnostic and resuscitative manuevers must occur simultaneously if hemodynamic instability is present. Initial laboratories should include complete blood count, type and crossmatch, platelet count and coagulation parameters. Digital rectal examination with stool guaiac is a routine part of the physical examination in the initial evaluation of all patients with gastrointestinal bleeding as 80% will have blood per rectum.

Diagnosis and therapeutics

Exclusion of an upper gastrointestinal source of bleeding per rectum including nasogastric tube aspiration and/or upper endoscopy is mandatory prior to evaluation of potential lower gastrointestinal tract sources. Aspiration of the nasogastric tube excludes all but a small percentage of upper GI sources (6). Sigmoidoscopy/anoscopy has been routinely performed early in the course of evaluation of LGIB to rule out anorectal sources of hemorrhage. Colonoscopy permits examination of the entire colon and potential therapeutic interventions in LGIB. The diagnostic yield for colonoscopy is related to the rate of bleeding and the ability to obtain an adequate bowel preparation. Overall diagnostic yield for a total of 1561 patients undergoing urgent colonoscopy in acute LGIB was 68%, with an incomplete procedure rate of 2%, and a reported complication rate of 1.3%. Endoscopic techniques to control hemorrhage have typically been attempted far less frequently in LGIB than in UGIB with reported rates of utilization of 27% and 51% respectively (6). When colonoscopy is non diagnostic, unavailable or incomplete the workup of acute lower GI bleeding after exclusion of upper GI bleeding, may include some form of nuclear medicine scan. If results of these scans demonstrate acute hemorrhage then selective angiography is indicated. The diagnostic inaccuracy of 20% in pooled data from tagged red blood cell scanning in localization of acute LGIB has led to the recommendation that surgical resection cannot be solely based on the results of nuclear scans (8). Even in cases where a positive TRBC scan was noted, a wide range (7–61%) of angiograms were noted to be abnormal (9). Segmental colectomy may subsequently be planned in those patients in whom site of bleeding is demonstrated by angiogram and when there is clinical evidence of ongoing hemorrhage.

The need for this myriad of diagnostic studies evolved from the premise that subtotal colectomy was to be avoided and that the benefits of segmental colectomy outweighed the risks of angiography and associated delay in surgical intervention. Subtotal colectomy was thought to be associated with a higher mortality rate and an increased incidence of disabling diarrhea than hemicolectomy. The view that subtotal colectomy with ileorectal anastamosis leads to a higher morbidity and mortality rates is certainly debatable. Early studies, predating current sophisticated critical care management, demonstrated a low mortality after subtotal colectomy for lower GI bleeding. Fazio et al. (10) reviewed 163 patients undergoing elective ileorectal anastamosis and found only a 1.2% leak rate and 1.9% operative mortality. A higher leak rate (28–33%) for ileorectal anastamosis, however, has been noted in the emergency setting (4). The surgeon must strongly consider fecal diversion, avoiding construction of a tenous anastamosis in hypoperfused patients undergoing any emergency colectomy, to minimize the risk for anastamotic dehiscence. It now appears that severe disabling diarrhea rarely occurs after subtotal colectomy with ileorectal anastamosis. Most patients’ bowel habits are relatively normal following subtotal colectomy, averaging 2 to 4 bowel movements per day after emergency or elective surgery for cancer, ulcerative colitis or acute lower GI bleeding. Preserving a length of remaining ileum, (greater than 15 cm), is critical to maintain normal bowel habits. The loss of the ileocecal valve appears to have little impact on stool volume or electrolyte composition or upon the number of bowel movement. Thus, subtotal colectomy, in the absence of extensive resection of the ileum, rarely causes difficulties with frequent defecation.

Angiography has been used to identify sites of intestinal bleeding for more than three decades supposedly to minimize the extent of colonic resection. In addition, the use of therapeutic angiography (vasopressin and embolization) has been thought to possibly minimize the need for operative intervention. While angiography does occasionally localize the origin of hemorrhage, studies are negative in more than one-half of patients requiring emergency operation (11). Furthermore, the angiogram can be misleading, showing only some of multiple bleeding site, leading to an inadequate segmental resection.

Surprisingly, selective angiography has been shown to be clinically beneficial in only 8%–28% of patients (12). Nath and colleagues reported that in only 10 of 49 patients evaluated, angiography led to a segmental resection (13). Similarly, Britt et al. found that just 11 of 40 patients undergoing angiography for lower GI bleeding received a segmental resection (14). Browder and co-workers reported that 8 of 50 patients had emergent operations but four of the eight underwent subtotal colectomy for multiple bleeding sites (15). Unfortunately, complication rates of angiography are not insignificant with reported overall rate of 9.3% (16). Major complications include femoral artery thrombosis, hematoma, contrast reactions, renal failure, and transient ischemic attacks (16). Furthermore, it is unclear how the delay in performing a definitive operative intervention may impact on the development of organ failure and death in these populations alternatively therapeutic angiography has been utilized with variable success to stop bleeding with vasoconstrictive agents and embolization. Angiography has also been used to induce an identify occult bleeding sites by employing anticoagulants, fibrinolytic agents, and vasodilators. In a review of 83 patients with intra-arterial infusion of vasopressin for colonic bleeding, it was found that 41% rebled. The long term consequences of angiographic control of hemorrhage are unknown, but the colon appears to be at increased risk of ischemia and colonic stricture after transcatheter embolization (17).

In summary, mortality rates for lower gastrointestinal bleedings are less than five percent and hemorrhage related deaths are actually infrequent (18). After resuscitation, placement of a nasogastric tube to exclude an upper gastrointestinal source, and screening anoscopy/sigmoidoscopy to rule out the presence of anorectal pathology is required. (Fig. 1) It is our preference to proceed to subtotal colectomy when transfusion requirements exceed three units. However, an acceptable alternative includes TRBC followed by angiography and possible segmental colectomy. A positive TRBC requires verification by angiography typically and subsequent attempt to halt hemorrhage with vasopressin infusion. If angiography is negative in the setting of a positive TRBC, provocative tests utilizing anti-coagulants or vasodilators may be attempted. If after these attempts no site is localized on angiography, subtotal colectomy is recommended. If no active bleeding is evident clinically (< 4 unit transfusion over 24 hours), whole gut lavage should be performed, and colonoscopy should be carried out (19). If no lesion is identified on colonoscopy and the patient continues to actively bleed total abdominal colectomy is recommended. Patients who have > 3 unit blood transfusion requirement during a 24 hour period should be considered to be immediate surgical candidates.

Figure 1. Diagnostic algorithm.

Figure 1

Diagnostic algorithm.

References

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Prakash C, Zuckerman GR, Aliperti G, Walden DT, Royal HD, Willis JR (1998) Prospective analysis of work-up of acute lower gastrointestinal hemorrhage: Can an optimal algorithm be designed? Gastrointest Endosc 47: AB102 .
Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6988

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