Uncontrollable GI Bleed

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Uncontrollable GI Bleed. Mamoun A. Rahman. Case 1. RT. 57 yrs-old lady BGhx: -Rectal cancer -Pre-operative adjuvant chemotherapy: 5FU based -low anterior resection Medications: - Losec 20 mg Od. Presentation. C/O: Lower abdominal pain for 3-4 days Admitted - PowerPoint PPT Presentation

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  • Uncontrollable GI BleedMamoun A. Rahman

  • Case 1RT.57 yrs-old ladyBGhx: -Rectal cancer -Pre-operative adjuvant chemotherapy: 5FU based -low anterior resection Medications: - Losec 20 mg Od

  • PresentationC/O: Lower abdominal pain for 3-4 daysAdmitted Next morning: PR bleeding, bright red Weak and anxiousO/E: - Pale - Pulse: 98 - BP: 106/64 - Abdomen: stoma; soft, non tender. - DRE: clotted blood, nil active bleeding

  • Lab resultsHb: 10.1 ALP: 141PCV: 0.30 GGT: 151WBC: 6.8 Bil: 3 Urea: 4.7Cr: 95Na: 137K: 4.3

  • Few hours laterHad another episode of PR bleedHb: 8.3PCV: 0.24Received 2 unit of RCC

    Patient stabilizedPR bleeding continuing - pulse: 109CT angiography

  • On arrival in X-RayAnxiousTachypnoeicCold and clammyPulse: 125BP: 70/50Unstable

  • Resuscitation by surgical teamO2Trendelenburg position3 IV linesReceived Hartmanns solution and GelofusinTranfusion with 2 units O ve bloodICU informedUrgent angiography

  • Angiography & embolizationBleeding in the pelvisRuptured aneurysm branch of internal iliac arteryAnterior branch of IIA embolized

  • Post embolizationTransferred to ICUPulse: 144BP: 140/65Chest: course crepitations

    Received Frusemide 40 mgRemained stable, melaena only

  • Case 2TY

    52 yrs-old lady

    Background history: - Recurrent cholangitis - ERCP and stent

  • C/O - Epigastric pain - Fever - Pale stool - Dark urineO/E - Jaundiced - Temp: 41 - Tender RUQLab results - Cholestatic picture

    Ur13.1Cr138Na135K4.4Cl110

    Hb11.6HCT36.1WBC4.7Neut3.78

    Bil113.9ALT131ALP270GGT278

    Amylase10CRP352

    PT11.6INR1.1

  • USS

    Cotracted, thick-walled GB, multiple stonesCBD: 14 mm, stones

  • ERCP performedSphincterotomy and CBD clearanceBleeding from sphincter siteAdrenalin injectedContinued to ooze

  • Post ERCPHaematemesisMelaenaDizzyPulse: 90BP: 139/67Hb:9.7INR: 1.2CT Angiogram: - ?Arterial haemorrhage at ampulla

  • EmbolizationBleeding from branches of GDA and Superior pancreaticodudenal arteryEmbolization performed with coil and gel foamSMA angiogram: normal

  • Day 1 Post EmbolizationSeen by team as a consultVitals stableHb: 6.6INR: 1.37Transfused 4 units of RCCs and 1 unit FFPIV fluids and Abx continuedRepeat ERCP: - No further bleeding. Stent inserted

  • Post repeat ERCPRemained asymptomaticNo further GI bleedingDischarged with planned ERCP and Cholecystectomy in 6 weeks time

  • Superselective embolization of lower GI hemorrhage

  • Etiologies of Lower GI bleedingMost common in the elderlyVariety of causes : - Diverticular disease (10% to 20% risk) - Neoplasia ( Ca colon causes 5% of major bleeding) Boley et al, Am J Surg 1979 - Angiodysplasia (right colon,
  • EvaluationRecurrent minor bleeding: colonoscopySevere but intermittent, stable patient: Tc-99M RBC scanningHemodynamically unstable patient: angiographyHelical CT: 80% accurate in some series Ernst et al, Eur Radiol 2003

  • HistoryRosch and Bookstein, early 1970sIschemic complications was13% to 33%Throughout the 1980s it was a tabooDissatisfaction with vasoconstriction methods led renew interest in embolization in 1990s

  • Coaxial MicrocathetersRange in size from 2.5 to 3 F5-French catheter may be used to select a first-order vesselmicrocatheter can be advanced through this catheter more distally

  • Superselective CatheterizationDistal arteries, close to bleeding pointsEmbolic material is deployed It limits the segment of bowel at risk for ischemia

  • Choice of embolicGel foamPolyvinyl alcohol particlesMicrocoilssome combination

  • Published experienceGuy et al, 1992, reported 10 superselective embolization procedures in nine patients. All procedures were successful

    Gordon et al, 1997: 17 cases of microcatheter embolization using microcoils, gel foam, and polyvinyl alcohol particles. Success rate was 76%. No bowel ischaemia

  • Published experience>100 successful embolization have been reported 1997 2002Clinical success ranged from 44% to 91%Ischemic complications ranged from 0% to 6% Funaki et al, AJR, 2001 Bandi et al, J Vasc Interv Radiol, 2001

  • Published experienceTan et al, 2008. 265 patients underwent angiography for GI bleeding.

    32 ( 12%) had superselective embolization for lower GI hemorrhage In 31 patients (97%) technical success was achieved7 had re-bleed1 had bowel ischaemia

  • Limitations of embolizationColonic bleeding is multifactorial - Diverticular bleed vs. Angiodysplasia

    Patients who are not actively bleeding

    Difficult vascular anatomy or severe atherosclerotic disease

    Symptomatic treatment

  • SummaryMinimally invasive techniques have replaced surgical resection as the initial therapies of choice

    Superselective embolization and endoscopic treatment appear complementary

  • Thank you