Management of Lower GI bleed

8/9/2019 Management of Lower GI bleed

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Management Of LowerGastrointestinal Bleed

Megat Mohd Azman AdzmiKhoo Yimei Teo Yi Yan

Muhammad Hassanuddin


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De nition Lower gastrointestinal bleeding is

blood loss from the gastrointestinaltra t of re ent onset emanating froma lo ation distal to the ligament of

Treitz resulting in instabilit! of "italsigns# anemia# and$or need for bloodtransfusion%


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Aetiolog!


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Aetiolog! Di"erti ular diseases&M'( ) in elderl!

males% Angiod!s*lasia Anore tal diseases ) in middle aged

males% 'ar inoma$*ol!*s 'olitis ) is hemi # infe ti"e# radiation +n,ammator! bowel disease &+BD(

Me -el.s di"erti ulum ) in hildhood%


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Aetiolog! /n ommon auses

0ari es &1e tal( +ntussus e*tion 2olitar! re tal ul er Aorto enteri stulae 0as ulitis 32A+D indu ed ul er# olitis

2mall intestinal auses 0as ular e tasias Tumors

/4451 G+ 2O/1'5 should alwa!s be e6 luded in all

*atients with massi"e lower G+ bleeding%


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2igns and s!m*toms The lini al *resentation of LG+B "aries with theanatomi al sour e of the bleeding# as follows7 Maroon stools# with LG+B from the right side of the

olon Bright red blood *er re tum with LG+B from the left

side of the olon Melena with e al bleeding

Howe"er# *atients with u**er G+ bleeding and right8sided oloni bleeding ma! also *resent with bright redblood *er re tum if the bleeding is bris- and massi"e%


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2igns and s!m*toms

The *resentation of LG+B an also "ar!de*ending on the etiolog!% A !oung*atient with infe tious or noninfe tious&idio*athi ( olitis ma! *resent withthe following7 9e"er Deh!dration Abdominal ram*s Hemato hezia


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A**roa h 'onsideration

The management of LG+B has :om*onents# as follows7

1esus itation and initial assessment Lo alization of the bleeding site Thera*euti inter"ention to sto*

bleeding at the site


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1esus itation and +nitial Assessment

+nitial resus itation in"ol"es establishing large8bore +0a ess and administration of normal saline% Besidesordering routine laborator! studies &eg# om*leteblood ell &'B'( ount# ele trol!te le"els# and

oagulation studies(# blood should be t!*ed and ross8mat hed% The ;


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1esus itation and +nitial Assessment

2igns of hemod!nami om*romisein lude *ostural hanges with d!s*nea#ta h!*nea# and ta h! ardia%

An orthostati dro* in s!stoli blood*ressure of more than ?< mm Hg or anin rease in heart rate of more than ? and oil migration in :> of *atients%

The o"erall :%


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Complications of SuperselectiveEmbolization

1osen-rantz et al re*orted : ases ofoloni infar tion%

One *atient died following segmental

ole tom!# and the other *atientsre"ealed full8thi -ness bowel wall inFur! inthe rese ted s*e imen%

+ntestinal is hemia and infar tion ha"ealso been re*orted%

To *re"ent this om*li ation# *erformembolization be!ond the marginal arter!

as lose as *ossible to the bleeding *oint


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Complications of SuperselectiveEmbolization

The rele"an e of surger! after embolization ofgastrointestinal and abdominal surger! was alsostudied in ;


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5ndos o*i thera*ies Ad"antages of u**er or lower endos o*i e"aluation is that

it *ro"ides a ess to thera*! in *atients with G+ bleeding%

5ndos o*i ontrol of bleeding an be a hie"ed using the

thermal modalities or s lerosing agents% Absolute al ohol#morrhuate sodium# and sodium tetrade !l sulfate an beused for s lerothera*! of u**er and lower G+ lesions%

5ndos o*i e*ine*hrine inFe tion is ommonl! usedbe ause of its low ost# eas! a essibilit! and low ris- of

om*li ations% An additional hemostati method su h asli*s or thermoregulation is needed to *re"ent subse uent

bleeding%


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5ndos o*i thera*ies 5ndos o*i thermal modalities su h as laser

*hoto oagulation# ele tro oagulation# heater *robe analso be used to arrest hemorrhage%

5ndos o*i ontrol of hemorrhage is suitable for G+*ol!*s and an ers# arterio"enous malformations#mu osal lesions# *ost*ol!*e tom! hemorrhage#endometriosis# and oloni and re tal "ari es%

4ost*ol!*e tom! hemorrhage an be managed b!ele tro oagulation of the *ol!*e tom! site bleedingwith either snare or hot bio*s! for e*s or b!e*ine*hrine inFe tion%


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5ndos o*i thera*ies 4hoto oagulation using lasers su h as argon

laser or 3d7YAG laser%

Argon laser treatment is re ommended formu osal or su*er ial lesions# be ause theenerg! *enetrates onl! ? mm% 3d7YAG lasersare more useful for dee*er lesions# be ause

the! *enetrate :8 mm%

5ndos o*i thera*! for LG+B is a minimall!in"asi"e%


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5mergent surger! 5mergen ! surger! is re uired in about ? of

*atients with lower gastrointestinal bleeding &LG+B( inwhom non8o*erati"e management is unsu essful oruna"ailable%

Surgical indications 7 4ersistent hemod!nami instabilit! with a ti"e

bleeding

4ersistent# re urrent bleeding Transfusion of more than units *a -ed red bloods

ells in a ; 8hour *eriod# with a ti"e or re urrentbleeding


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2egmental bowel rese tion andsubtotal ole tom!

2egmental bowel rese tion following *re iselo alization of the bleeding *oint is a well8a e*tedsurgi al *ra ti e in hemod!nami all! stable *atients%

The *ro edure of hoi e in *atients who are a ti"el!bleeding from an un-nown sour e%

+ntrao*erati"e eso*hagogastroduodenos o*! &5GD(#

surgeon8guided enteros o*!# and olonos o*! ma!be hel*ful in diagnosing undiagnosed massi"e G+bleeding%


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4atients who are hemod!nami all! stable shouldha"e *reo*erati"e lo alization of the bleeding

whereas *atients who are hemod!nami all!unstable with a ti"e bleeding ma! undergoemergen ! e6*lorator! la*arotom! withintrao*erati"e endos o*!%

+n *atients who are hemod!nami all! stable# on ethe bleeding site is *reo*erati"el! lo alized# intra8arterial "aso*ressin is used as a tem*orizing

measure to redu e the bleeding before *atientsundergo segmental ole tom!% /sing thisa**roa h the o*erati"e morbidit! rate isa**ro6imatel! =% ># the mortalit! rate is around

?# and the rate of rebleed ranges from %


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+n *atients undergoing emergen !la*arotom!# e"er! attem*t should be made tolo alize the bleeding intrao*erati"el!# be ausea segmental ole tom! is *referred% +f thebleeding site is not lo alized# a subtotal

ole tom! is *erformed with an inherentmorbidit! rate of around : > and a mortalit!rate of about ??>8::>% +n unstable *atients#a two8stage *ro edure is *referred7 tem*orar!end ileostom! and dela!ed ileo*ro tostom!%

*osto*erati"e diarrhea an be a signi ant*roblem in elderl! *atients who undergosubtotal ole tom! and ileo*ro tostom!%


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4re8o*erati"e details A ute LG+B is a ommon lini al entit! and

is asso iated with signi ant morbidit! andmortalit! &?


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: maFor as*e ts in"ol"ed in managing LG+B7 Treat sho - Lo alization of the sour e of bleeding 9ormulating and inter"entional *lan

+nsert a nasogastri &3G( tube in all *atients% A lear bile8stained as*irate generall! e6 ludes bleeding *ro6imal to

the Treitz ligamentum% After initial resus itation#underta-e a sear h for the ause of the bleeding to*re isel! lo ate the bleeding *oint%

9ollowing a urate lo alization b! angiogram# bleeding

an be tem*oraril! ontrolled with either angiogra*hiembolization or "aso*ressin infusion to stabilize the*atient in anti i*ation of semi8urgent segmental bowelrese tion%


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2egmental bowel rese tion is *erformed in the ne6t ; 8 =hours following orre tion of the *atientNs *h!siologi*arameters# whi h in lude h!*otension# h!*othermia# a utehemorrhagi anemia# and de ient oagulation fa tors%

/se sele ti"e mesenteri embolization in high8ris- *atientsfor whom the o*erati"e management is asso iated with

*rohibiti"e ris- of morbidit! and mortalit!% +f mesenteriembolization is used# these *atients must be arefull!monitored for bowel is hemia and *erforation% An! e"iden eof ongoing bowel is hemia and$or une6*lained se*sisfollowing mesenteri embolization re uires e6*lorator!la*arotom! to rese t the a e ted bowel segment%

4erform subtotal ole tom! with ileo*ro tostom! in *atientswith multi*le e*isodes of non8lo alized LG+B or bilateral

sour es of oloni hemorrhage%


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+ntra8o*erati"e details 2urgi al inter"ention is re uired in onl! a small *er entage of

*atients with LG+B% The surgi al o*tion de*ends on whether thebleeding sour e has been a uratel! identi ed *reo*erati"el!C ifso# it is then *ossible to *erform segmental intestinal rese tion%

+f the bleeding sour e is un-nown# an u**er gastrointestinalendos o*! should be *erformed before an! surgi al e6*loration%

The abdominal a"it! is e6*lored through a midline "erti alin ision% The assistan e of a gastroenterologist or anothersurgi al endos o*ist or surgeon is re uired for intrao*erati"eendos o*i e"aluation% The olonos o*e is introdu ed# and thesurgeon assists its *assage% On8table oloni la"age and

olonos o*! ma! identif! the oloni sour e of bleeding%2urgeon8guided intrao*erati"e small bowel enteros o*! is also*erformed when no oloni sour e of bleeding is identi ed%


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'olonos o*i mani*ulation of the small bowel ma!ause iatrogeni mu osal tears and hematomas#

whi h ma! be mista-enl! identi ed as a sour e ofbleeding%

Another intrao*erati"e strateg! is to lam*segments of the bowel with non8 rushing intestinal

lam*s to identif! the segment that lls with blood%

+f the bleeding *oint annot be diagnosed throughintrao*erati"e *an8intestinal endos o*! ande6amination# and if e"iden e *oints to a olonibleeding# *erform a subtotal ole tom! with endileostom!%


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4ost8o*erati"e details H!*otension and sho - are the e"entual

onse uen es of blood loss# but thisde*ends on the rate of bleeding and the

*atientNs res*onse% 'lini al de"elo*ment of sho - ma!

*re i*itate m!o ardial infar tion#erebro"as ular a ident# and renal or

he*ati failure% Azotemia o urs in *atientswith gastrointestinal blood loss%


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'OM4L+'AT+O3 O9 LOI51GA2T1O+3T52T+3AL BL55D

Anemia 2ho - Kidne! failure 'om*li ations of blood transfusions

'om*li ations related to massi"e bloodtransfusions &greater than one blood "olumein ; hour( are h!*othermia# h!*o al emia#h!*er-alemia# dilutional thrombo !to*enia#and oagulation fa tor de ien ies%


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'om*li ation of surger!

The most ommon earl! *osto*erati"eom*li ations are intra8abdominal or anastomoti bleeding#

me hani al small bowel obstru tion &2BO(# intra8abdominal se*sis#lo alized or generalized *eritonitis#wound infe tion and$or dehis en e#Clostridium difcile olitis dee* "enous thrombosis &D0T(#*ulmonar! embolus &45(%


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T1A329/2+O3 9155 MA3AG5M53T

The management of lower G+ bleeding &LG+B( an behallenging in *atients who refuse transfusions of blood or

blood *rodu ts% Howe"er# transfusion8free management of G+bleeding ma! be e e ti"e with an a e*table mortalit! rate%

2tudied has been done in 5nglewood Hos*ital in whi h the!e6*erien e in managing *atients with gastrointestinalbleeding who do not a e*t blood8deri"ed *rodu ts ) most ofthem sur"i"ed

These results suggest that transfusion8free management ofgastrointestinal hemorrhage an be e e ti"e with mortalit!

om*arable with the general *o*ulation a e*ting medi all!indi ated transfusion%

Management of these *atients is hallenging and re uires adedi ated multidis i*linar! team a**roa h -nowledgeable inte hni ues of blood onser"ation%


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2ur"i"ing *atients were treated with e*oetin alfa&4ro rit( ) stimulate er!thro*oesis 8 on e dail! for@ da!s# +0 iron de6tran&*lasa "ol e6*ender(infusion on e dail! for ?< da!s# +0 foli a id dail!#

"itamin ' twi e dail!# as well as +M "itamin B?;inFe tion on e% These *atients also re ei"ed beta8blo -ers &to redu e the ardia wor-load( andsu**lemental o6!gen &?


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LO3G T51M MO3+TO1+3G 4osto*erati"e o e "isits e"er! ; wee-s are essential to ensure

*ro*er wound healing% /*on dis harge# a general diet abundant in fruits and "egetables

is re ommended% 4atients are instru ted to drin- 8= glasses of ,uid *er da!% 4s!llium seed *re*arationsa&dietar! bre( should also be started% +n reased le"els of *h!si al a ti"it! ma! *re"ent the *rogression

of di"erti ular disease As*irin and 32A+D use is asso iated with in reased ris- of

di"erti ular bleeding% The need for a follow8u* olonos o*! is determined b! a

re urren e of s!m*toms% Angiod!s*lasia is more li-el! to rebleed if untreated and ma!

re uire follow8u* inter"ention to lo alize and treat re urrentbleeding%

'olonos o*i ele tro oagulation is generall! su essful in su h

Management of Lower GI bleed

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