Lower Gi Bleed 4611

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    LOWER GI BLEEDING

    4/6/11

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    LGIB

    Distal to ligament of Treitz

    Annual incidence rate of 20.5/100,000

    Male predominance

    Incidence of significant bleeding increases

    with age

    May suggest changes associated with the

    small intestine and colon

    Reflects the prevalence of diverticulosis and

    angiodysplasia in the elderly

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    LGIB

    May present as melena or hematochezia

    Melena typically suggests bleeding from a

    more proximal source (colon or small intestine)

    Hematochezia suggests left colonic, rectal, or

    anal sources

    Upper gastrointestinal hemorrhage may

    present with rectal bleeding given bloodscathartic effect and rapid intestinal transit (10-

    15% of cases)

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    LGIB

    Most often the intestinal bleeding resolvesspontaneously

    Once it resolves, investigations should begin to identifythe potential sources

    On occasion, the intestinal hemorrhage does notresolve Creates hemodynamic compromise

    Ongoing hemorrhage demands aggressive medicaland surgical management

    Oftentimes patients are plagued with significantcomorbidities that complicate their individualresuscitation

    Comorbidities must be considered in the diagnosticand therapeutic phases of the care plan

    Current increased patient exposure to antiplatelet

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    Etiology

    Diverticula

    Angiodysplasia

    Ischemic colitis

    Inflammatory bowel disease

    Intestinal tumors or malignancies

    NSAID-related nonspecific colitis

    Meckels diverticulum

    Anorectal diseases

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    Diverticular disease

    Outpouchings of the mucosa and submucosa

    through defects in the muscular layer of the

    bowel at sites of penetration of the vasa recta

    Thinning of the media in the vasa rectapredisposes to intraluminal rupture: focal injury

    may occur from trauma related to a fecalith

    incidence spans a range of 15% to 48% relatively rare event affecting only 4%17% of

    patients with diverticulosis

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    Diverticular disease

    Operative management is indicated when

    bleeding continues unabated and is not

    amenable to angiographic or endoscopic

    therapy Should be considered in patients with

    recurrent bleeding localized to the same

    colonic segment

    In a stable healthy patient, the operation

    consists of a segmental bowel resection

    (usually a right colectomy or sigmoid

    colectomy) followed by a primary anastomosis

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    Angiodysplasia

    Thin-walled arteriovenous communications

    located within the submucosa and mucosa of

    the intestine

    May be congenital or acquired, isolated ormultiple

    In the acquired form, distortions of the

    postcapillary venules may arise as adegenerative lesion associated with increases

    in intraluminal pressure

    Results in thickening and ectasia

    The vessels eventually entangle as tufts within

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    Angiodysplasia

    Colonoscopic criteria

    Mucosal surface

    contains a cherry red

    lesion that is typically flatGreater than 2 mm in

    size

    Have a fern-like

    appearance

    A central feeding vessel

    is not always visible

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    Occult Hemorrhage

    Occurs infrequently

    no more than 5% of all patients admitted with LGImassive hemorrhage

    Frequent recurrences create chronic anemic

    states in patients and require occasionaladmissions for transfusions

    May harbor angiodysplasias in the small intestineor right colon

    May benefit from small bowel contrastradiography or capsule endoscopy

    Elective angiography with cecal magnification mayreveal small angiodysplasias

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    Occult Hemorrhage

    If the hemorrhage recurs and investigations fail toreveal the source, a variety of provocativediagnostic angiographic studies have beendescribed

    Most studies prefer to incite bleeding using eitherheparin or thrombolytics

    Once the site of bleeding is identified, it may bedifficult to control without surgery

    Prepare and hold an operating room

    Once the location is identified, a superselectivecatheter is left in the distal artery

    During surgery, the surgeon can palpate thecatheter within the vessel and direct the surgical

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    Initial Assessment

    Establish IV access (large bore) and start IV fluids restore volume and replete red blood cell deficiencies

    Labs CBC, electrolytes, coags, type and cross

    All coagulopathies require reversal!

    NG tube placed will screen for the presence ofupper gastric sources for bleeding Kovacs and Jensen noted 17.9% of LGI hemorrhage

    presentations involved an upper gastrointestinalsource

    NG tube is effective in detecting prepylorichemorrhage

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    Evaluation

    Digital anorectal examination and anoscopy

    Rigid proctosigmoidoscopy will allow the

    examiner to evacuate the rectum of blood and

    clotsExcludes internal hemorrhoids, anorectal solitary

    ulcers, neoplasms, and colitis

    Colonoscopy and angiography offertherapeutic intervention

    Nuclear scanning is purely diagnostic

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    Evaluation

    subdivide patients into 3 general clinicalcategories

    minor and self-limited

    major and self-limited

    major and ongoing

    Major ongoing hemorrhage requires promptintervention with angiography or surgery

    Minor, self-limited may undergo colonic lavageand colonoscopy within 24 hours

    Major, self-limited need diagnostic tests todetermine if they require prompt therapy or

    observation

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    Radionuclide imaging

    Detects the slowest bleeding rates

    0.10.5 mL/min

    More sensitive than angiography

    Unfortunately cannot reliably localize the site ofhemorrhage

    The specificity of small bowel versus largeintestine bleeding does not reliably compare withangiography

    Two general techniques

    technetium sulfur colloid scans

    99mTc pertechnetate-tagged RBCs

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    Radionucleotide imaging

    Immediate positive blush (within the first 2

    minutes of scanning)

    highly predictive of a positive angiogram (60%)

    predictive for surgery in 24%

    If study did not demonstrate a blush

    highly predictive of a negative angiogram (93%)

    the need for surgery decreased to 7%

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    Colonoscopy

    If the patient appears stable with self-limited hemorrhage,colonoscopy is the preferred diagnostic study

    Major benefit depends on ability to provide a definitivelocalization of ongoing active bleeding and the potential fortherapy

    Many landmarks for colonoscopy may be obscured duringhemorrhage

    Once the endoscopist highlights a bleeding source, theregion requires a tattoo to mark the site

    If the hemorrhage continues and fails medical management,

    the tattoo assists in localizing the hemorrhage Therapeutic armamentarium i

    thermal agents such as heater probes, bipolar coagulation, andlaser therapy

    Injection therapy uses topical and intramucosal epinephrine

    Mechanical therapy includes endoscopically applied clips

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    Angiography

    Diagnostic and therapeutic

    Acute, major hemorrhage with ongoingbleeding requires emergency angiography

    Patients with an early blush during nuclearscintigraphy may benefit from therapeuticangiography

    May define a potential source for hemorrhage

    in occult and recurrent gastrointestinalhemorrhage

    Requires a hemorrhage rate of at least 1mL/min

    Yields range from 40% to 78%

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    Angiography

    Highly accurate localization provides for focused therapy

    Intraarterial vasopressin infusion

    0.2 U/min up to 0.4 U/min

    Systemic effects and cardiac impact may limit maximizing the dosage

    Controls bleeding in 91% of patients

    Bleeding may recur in up to 50% of patients Arterial embolization

    Superselective mesenteric angiography with microcatheters in the vasa recta

    Vessels as small as 1 mm

    Risk of intestinal infarctions of larger selective vessels may exceed 20%

    Provides immediate arrest of the bleeding

    Combination of agents to control bleeding Gelfoam pledgets, coils, and polyvinyl alcohol particles

    Arteriography also has complications

    arterial thrombosis, distant arterial emboli, and renal toxicity from dye

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    Operative therapy

    Few patients currently require surgical treatment

    Hemodynamically unresponsive to initial resuscitation

    Site of hemorrhage localized, but available therapeuticinterventions fail to control the bleeding

    Patient mortality increases with their transfusion requirements Once reaches 67 units and the hemorrhage re