Gastro-Intestinal Bleeding Hashmi UGIB The incidence of

1
Gastro-Intestinal Bleeding

• Hashmi

2
UGIB

• The incidence of upper gastrointestinal bleeding
  (UGIB) is approximately 100 cases per 100,000
  population per year.
• Bleeding from the upper GI tract is approximately
  4 times as common as bleeding from the lower GI
  tract and is a major cause of morbidity and
  mortality
• Mortality rates from UGIB are 6-10 overall
• The use of various endoscopic techniques, medical
  therapies, and visceral angiography has
  progressively diminished the role of surgery in
  the emergent management of UGIB
• Of patients who develop UGIB, 3-15 require a
  surgical procedure
• Fallah MA, Prakash C, Edmundowicz S Acute
  gastrointestinal bleeding. Med Clin North Am 2000
  Sep 84(5) 1183-208

3
Signs Symptoms

• History and physical examination findings in
  acute UGIB at presentation
• Hematemesis - 40-50
• Melena - 70-80
• Hematochezia - 15-20
• Syncope - 24
• Dyspepsia - 18
• Epigastric pain - 41
• Heartburn - 21
• Diffuse abdominal pain - 10
• Dysphagia - 5
• Weight loss - 12
• Jaundice - 5.2
• Peter DJ, Dougherty JM Evaluation of the patient
  with gastrointestinal bleeding an evidence based
  approach. Emerg Med Clin North Am 1999 Feb
  17(1) 239-61

4
Differential diagnoses for UGIB

• Gastric ulcer
• Duodenal ulcer
• Esophageal varices
• Gastric varices
• Mallory-Weiss tear
• Esophagitis
• Neoplasm

• Hemorrhagic gastritis
• Dieulafoy lesion
• Angiodysplasia
• Hemobilia
• Pancreatic pseudocyst
• Pancreatic pseudoaneurysm
• Aortoenteric fistula

5
Prognostic Indicators

• Factors include
• Age
• heart rate
• systolic blood pressure
• orthostatic changes in blood pressure or pulse
  rate
• Anticoagulants
• cool extremities
• Syncope
• signs of shock such as ongoing brisk hematemesis
  or maroon or bright-red stools, which requires
  rapid blood transfusion.

• The American Society for Gastrointestinal
  Endoscopy (ASGE) grouped patients with UGIB
  according to age and correlated age category to
  risk of mortality. The ASGE found a mortality
  rate of
• 3.3 for those aged 21-31 years
• 10.1 for those aged 41-50 years
• 14.4 for those aged 71-80 years

6
Shock

• American College of Surgeons Committee on Trauma,
  1997
• Class 1 Class 2 Class 3 Class 4
• Blood Loss, mL lt750 750-1500 1500-2000 gt2000
• Blood Loss, lt15 15-30 30-40 gt40
• Pulse Rate, bpm lt100 gt100 gt120 gt140
• Blood Pressure Normal Normal Dec Dec
• Respiratory Rate Normal or Inc Dec Dec Dec
• Urine, mL/h gt35 30-40 20-30 14-20
• CNS/MS Slightly anxious Mildly
  anxious Anxious/conf lethargic
• Fluid 3-for-1 rule Crystalloid Crystalloid bloo
  d blood

7
Shock

• Rebleeding after initial nonsurgical
  intervention
• 2 of patients without shock
• 18 with isolated tachycardia
• 48 with shock
• Mortality
• 8 for patients with SBP more than 100 mm Hg
• 17 for SBP of 80-90 mm Hg
• 30 for SBP less than 80 mm Hg
• 13.6 with orthostatic changes
• Schiller KF, Truelove SC, Williams DG
  Haematemesis and melaena, with special reference
  to factors influencing the outcome. Br Med J 1970
  Apr 4 2(700) 7-14

8
Shock

• Effect of Number of Packed Erythrocyte
  Transfusions on Need for Surgery and Mortality
  from UGIB
• Number of Units Transfused /24hr Need for
  Surgery, Mortality Rate,
• 0 4 4
• 1-3 6 14
• 4-5 17 28
• gt5 57 43
• Larson G, Schmidt T, Gott J, et al Upper
  gastrointestinal bleeding predictors of outcome.
  Surgery 1986 Oct 100(4) 765-73

9
NGT

• The ASGE performed a study comparing NGT aspirate
  findings to the endoscopic findings of the
  bleeding source
• 15.9 of patients with a clear NGT aspirate
• 29.9 of patients with coffee-ground aspirate
• 48.2 of patients with red blood aspirate
• Effect of the Color of the Nasogastric Aspirate
  and of the Stool on UGIB Mortality Rate
• Nasogastric Aspirate Color Stool Color Mortality
  Rate,
• Clear Brown or red 6
• Coffee-ground Brown or black 8.2 Red 19.1
• Red blood Black 12.3 Brown 19.4 Red
  28.7
• Kupfer Y, Cappell MS, Tessler S Acute
  gastrointestinal bleeding in the intensive care
  unit. The intensivist's perspective.
  Gastroenterol Clin North Am 2000 Jun 29(2)
  275-307

10
Endoscopy

• Incidence rate in patients with UGIB
• Duodenal ulcer - 24.3
• Gastric erosion - 23.4
• Gastric ulcer - 21.3
• Esophageal varices - 10.3
• Mallory-Weiss tear - 7.2
• Esophagitis - 6.3
• Duodenitis - 5.8
• Neoplasm - 2.9
• Marginal ulcer - 1.8
• Esophageal ulcer - 1.7
• Silverstein FE, Gilbert DA, Tedesco FJ, et al
  The national ASGE survey on upper
  gastrointestinal bleeding. II. Clinical
  prognostic factors. Gastrointest Endosc 1981 May
  27(2) 80-93

11
Endoscopy

• Various techniques currently available for
  achieving hemostasis
• Injection of vasoactive agents
• Epinephrine (constriction vs. tamponade)
• Injection of sclerosing agents
• Ethanol, Polidocanol, Sodium Tetradecyl Sulfate
  (thrombosis, inflammation, necrosis, perforation)
• Bipolar electrocoagulation-Thermal probe
  coagulation
• Isolate, compress, tamponade
• Band ligation
• Laser photocoagulation
• NdYAG - heat vessel coagulation (non-contact)
• Argon plasma coagulator
• Application of hemostatic materials, including
  biologic glue
• Stabile BE, Stamos MJ Surgical management of
  gastrointestinal bleeding. Gastroenterol Clin
  North Am 2000 Mar 29(1) 189-222

12
PUD

• Peptic ulcer disease (PUD) remains the most
  common cause of UGIB. In a literature review
  involving more than 10,000 patients with UGIB,
  PUD was responsible for 27-40 of all bleeding
  episodes
• Ulcer Characteristics and Correlations
• Ulcer Prevalence Rebleeding Surgery Mortali
  ty
• Clean base 42 5 0.5 2
• Flat spot 20 10 6 3
• Clot 17 22 10 7
• Vessel 17 43 34 11
• Bleeding 18 55 35 11
• Consider surgical options if failed 2 attempts of
  endoscopy, failed angiographic embolization,
  hemorrhage not responsive to resuscition,
  perforation, obstruction, or malignancy
• Corson JD, Williamson RCN, eds Surgery. London,
  UK Mosby-Year Book 2001

13
PUD Duodenal

• The operative treatment options for a bleeding
  duodenal ulcer historically include vagotomy,
  gastric resection, drainage procedures, and
  repair of the duodenal bleed
• The gastroduodenal artery is ligated both
  proximally and distally to the arterial bleeding
  site. The third suture is a horizontal mattress
  placed to control hemorrhage from the transverse
  pancreatic branch of the gastroduodenal artery
• The 3 most common operations performed for a
  bleeding duodenal ulcer are
• Truncal vagotomy and pyloroplasty with suture
  ligation of the bleeding ulcer
• Truncal vagotomy and antrectomy with resection or
  suture ligation of the bleeding ulcer
• Proximal (highly selective) gastric vagotomy with
  duodenostomy and suture ligation of the bleeding
  ulcer
• Operation Recurrence PGS Mortality
• HSV 10 5 0.1
• Truncal VP 7 20-30 lt1
• Truncal VA w/B-1/2 1 30-50 0-5
• Truncal VA w/R-n-Y 5-10 50-60 0-5
• Operation Antral Innervation Liquid
  Emptying Solid Emptying
• HSV Preserved Fast Normal
• Truncal Vagotomy Divided Fast Slow
• Truncal VP Divided Fast Fast
• Truncal VA Divided Fast Fast

14
PUD - Gastric

• Five types of gastric ulcers occur, based on
  their location and acid-secretory status
• Type 1 gastric ulcers are located on the lesser
  curvature of the stomach at or near the incisura
  angularis. These ulcers are not associated with a
  hypersecretory acid state
• Type 2 ulcers represent a combination of 2 ulcers
  that are associated with a hypersecretory acid
  state. The ulcer locations occur in the body of
  the stomach in the region of the incisura. The
  second ulcer occurs in the duodenum
• Type 3 ulcers are prepyloric ulcers. They are
  associated with high acid output and are usually
  within 3 cm of the pylorus
• Type 4 ulcers are located high on the lesser
  curvature of the stomach and are not associated
  with high acid output
• Type 5 ulcers are related to the ingestion of
  NSAIDs or aspirin. These ulcers can occur
  anywhere in the stomach

15
PUD - Gastric

• A bleeding gastric ulcer is commonly managed by
• wedge resection of the ulcer only
• truncal vagotomy and pyloroplasty with a wedge
  resection of the ulcer
• antrectomy with wedge excision of the proximal
  ulcer
• distal gastrectomy to include the ulcer with or
  without truncal vagotomy
• a distal gastrectomy that includes the ulcer with
  a gastroduodenostomy or a gastrojejunostomy
  reconstruction
• A vagotomy is added to manage type 2 or type 3
  gastric ulcers
• These ulcers arise in the pyloric/prepyloric area
  and are associated with acid hypersecretion
  physiology
• Patients who are hemodynamically stable with
  intermittent bleeding requiring blood
  transfusions should undergo a truncal vagotomy
  and distal gastric resection to include the ulcer
  for type 1, 2, and 3 ulcers
• In patients who present with life-threatening
  hemorrhage and a type 1, 2, or 3 ulcer
• biopsy and oversew
• excision of the ulcer in combination with a
  truncal vagotomy and a drainage procedure

16
PUD - Gastric

• Patients with type 4 ulcers usually present with
  hemorrhage. The left gastric artery should be
  ligated, and a biopsy should be performed on the
  ulcer. Then, the ulcer should be oversewn through
  a high gastrotomy
• Type 4 ulcer operations
• Pauchet, Shoemaker Procedure
• 2-5cm from Cardia
• Distal gastrectomy, extend resection along lesser
  curvature, Billroth I
• Csendes Procedure
• Less than 2cm from GE Jxn
• Subtotal Gastrectomy, Roux-en-Y
  Esophagogastrojejunostomy
• Kelling-Madlener Procedure
• Less than 2cm from GE Jxn
• Less aggressive
• Antrectomy, Billroth I, Truncal Vagotomy, /-
  Wedge Resection
• Rebleeding rates for the procedures that keep the
  ulcer range from 20-40
• Cameron JL, ed Current Surgical Therapy. 8th ed.
  St. Louis, Mo Mosby-Year Book 2004

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18
Portal HTN

• Variceal bleeding is one of the most alarming
  life-threatening complications of cirrhosis.
• Sixty percent of patients with cirrhosis develop
  esophageal varices
• Thirty percent of these patients bleed from their
  varices within 2 years of their diagnosis
• 50 bleed at some point during their lifetime
• The mortality rate for variceal bleeding is
  30-50, which is much higher than any other cause
  of UGIB
• The presence of portal vein pressure greater than
  10 mm Hg defines portal hypertension.
• Normal portal venous pressure ranges from 5-10 mm
  Hg
• Portal blood flow rate of approximately 1 L/min
  through the hepatic sinusoids
• Portal hypertension can be classified according
  to the anatomic location within the portal system
  that is the site for increased resistance to
  portal flow
• presinusoidal, sinusoidal, and postsinusoidal
• Corson JD, Williamson RCN, eds Surgery. London,
  UK Mosby-Year Book 2001

19
Portal HTN

• Causes and Sites of Block for Portal Hypertension
• Pre-sinusoidal
• Extrahepatic ? Congenital, Umbilical sepsis,
  Trauma, Hypercoagulation state, Malignant
  occlusion
• Intrahepatic ? Schistosomiasis, Congenital
  hepatic, Fibrosis, Primary Biliary Cirrhosis
• Sinusoidal Cirrhosis
• Post-sinusoidal Hepatic veins, Budd-Chiari
  syndrome, Venoocclusive disease
• 4 well-recognized collateral vascular systems
• the esophageal submucosal venous plexus
• the coronary vein of the stomach
• the umbilical system caput medusae
• the hemorrhoidal system
• North Italian Endoscopic Club for the Study and
  Treatment of Esophageal Varices (1998)
• Study revealed that the risk of the first
  variceal bleed may be predicted based on variceal
  size, the presence of red wales/cherry spots, and
  a Child-Pugh score greater than or equal to 8
  points

20
Portal HTN

• Child-Pugh Classification
• Parameter 1 Point 2 Points 3 Points
• Bilirubin lt2 2-3 gt3
• Albumin gt3.5 2.8-3.5 lt2.8
• Increase in PT 1-3 4-6 gt6
• Ascites None Slight Moderate
• Encephalopathy None Mild Moderate
• In addition to the Child-Pugh classification
  system, the model for end-stage liver disease
  (MELD) score has been used to predict outcomes
• MELD score calculation (0.957 x log(e)
  (creatinine mg/dl)0.378 x log(e) (bilirubin
  mg/dl) 1.120 x log(e) (INR) 0.643)x10
• Correlation between the portal-hepatic vein
  gradient (PHVG) and the risk for bleeding when
  the PHVG was greater than 12 mm Hg
• Garcia-Tsao G, Groszmann RJ, Fisher RL, et al
  Portal pressure, presence of gastroesophageal
  varices and variceal bleeding. Hepatology 1985
  May-Jun 5(3) 419-24

21
Portal HTN

• Treatment strategies
• pharmacologic therapy
• endoscopic therapy
• tamponade
• decompressive therapy (radiologic and surgical)
• liver transplantation

22
Portal HTN

• Pharmacological Splanchnic Vasoconstriction,
  Decrease Portal Flow
• Vasopressin and Nitroglycerine
• Octreotide
• Beta-blockers include Propranolol and Nadolol
• In Europe, a newly developed prodrug called
  terlipressin has been used that has advantages
  over vasopressin
• Terlipressin has a longer half-life with a
  biphasic vasoconstriction profile
• First has systemic vascular effects that are then
  steadily converted into a more effective
  vasoconstriction of the splanchnic bed
• Recombinant coagulation factor VII is a synthetic
  coagulation factor that is currently used to
  treat acute bleeding episodes in patients with
  hemophilia
• Patients in end-stage liver disease lose the
  synthetic capacity to produce these coagulation
  factors, most notably factor VII
• Replacing factor VII in cirrhotics may aid in
  controlling acute variceal hemorrhage
• A recent double-blind trial has shown increased
  success at controlling bleeding endpoints in more
  severe cirrhotics (classes B and C) treated with
  factor VII compared to placebo
• Bosch J, Thabut D, Bendtsen F Recombinant factor
  VIIa for upper gastrointestinal bleeding in
  patients with cirrhosis a randomized,
  double-blind trial. Gastroenterology 2004 Oct
  127(4) 1123-30
• Vargas HE, Gerber D, Abu-Elmagd K Management of
  portal hypertension-related bleeding. Surg Clin
  North Am 1999 Feb 79(1) 1-22

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Portal HTN

• Endoscopy
• Endoscopic sclerotherapy
• Endoscopic variceal banding ligation
• Comparison of sclerotherapy with variceal banding
  found significantly lower mortality rates,
  variceal rebleeding, esophageal perforation, and
  stricture formation with variceal banding therapy
• Native cyanoacrylate is a liquid tissue adhesive
  used frequently in Europe
• Blood mixes with the adhesive agent and rapidly
  polymerizes into a hard glue. The cyanoacrylate
  then plugs the lumen of the varix and creates
  hemostasis
• Cyanoacrylate is 90 successful in achieving
  hemostasis in patients with acute bleeding from
  either gastric or esophageal varices
• Cerebral stroke from anomalous right-to-left
  shunts, fatal pulmonary embolization, portal vein
  embolization, splenic infarction, and
  retrogastric abscess have all been reported in
  the literature
• D'Amico G, Pagliaro L, Bosch J The treatment of
  portal hypertension a meta-analytic review.
  Hepatology 1995 Jul 22(1) 332-54
• Laine L, Cook D Endoscopic ligation compared
  with sclerotherapy for treatment of esophageal
  variceal bleeding. A meta-analysis. Ann Intern
  Med 1995 Aug 15 123(4) 280-7
• Sarin SK, Agarwal SR Gastric varices and portal
  hypertensive gastropathy. Clin Liver Dis 2001
  Aug 5(3) 727-67

24
Portal HTN

• Tamponade Sengstaken-Blakemore tube and the
  Minnesota tube (3 vs 4 lumen)
• Esophageal balloon gastric balloon that are
  inflated to produce a tamponade effect
• Major complications
• Esophageal rupture
• Tracheal rupture
• Duodenal rupture
• Respiratory tract obstruction
• Aspiration
• Hemoptysis
• Tracheoesophageal fistula
• Jejunal rupture
• Thoracic lymph duct obstruction
• Esophageal necrosis
• Esophageal ulcer
• Minor complications
• Nasopharyngeal bleeding

25
Portal HTN

• TIPS Transjugular Intrahepatic Portosystemic
  Shunt
• Placement of a TIPS reduces the outflow hepatic
  resistance, lowers portal pressure, and diverts
  portal blood flow from gastroesophageal
  collaterals through the stent
• Stent is dilated to approximately 10-12 mm in
  diameter. Once the stent is in proper position,
  pressures are measured in the portal vein, the
  stent, and the right atrium
• Decrease of the PHVG to less than 12 mm Hg
• Portal-to-atrial pressure gradient to less than
  12 mm Hg
• Controls variceal bleeding in more than 90 of
  patients
• Rebleeding rate is 16-30 at 1-year follow-up,
  and this is most commonly related to stenosis of
  the intrahepatic shunt or obstruction of the
  stent
• Shunt dysfunction occurs in approximately 50-60
  of patients at 6 months
• Doppler ultrasound imaging and re-dilation has
  increased the 1-year patency rate to 83-85
• Hepatic encephalopathy is 25-35, but this can
  usually be managed with protein restriction and
  lactulose
• Sanyal AJ, Freedman AM, Shiffman ML, et al
  Portosystemic encephalopathy after transjugular
  intrahepatic portosystemic shunt results of a
  prospective controlled study. Hepatology 1994
  Jul 20 46-55

26
Portal HTN

• Surgery
• decompression of the high-pressure portal venous
  system into a low-pressure systemic venous system
• devascularization of the distal esophagus and
  proximal stomach
• Portacaval shunt
• Mesocaval shunt
• Interposition graft
• Distal splenorenal (ie, Warren) shunt
• Esophagogastric devascularization, esophageal
  transaction, and reanastomosis
• Liver transplantation
• Splenectomy (for splenic vein thrombosis)

27
Portal HTN

• Shunt
• bleeding control rate greater than 90
• difference between shunts is the incidence of
  encephalopathy and the risk of worsening ascites.
  
• Encephalopathy
• 10-15 of patients after a selective shunt
  (DSRS-Warren)
• 10-20 after a partial shunt (H-graft
  interposition graft)
• 30-40 after a total shunt (portocaval)
• The mortality rate of all the different shunts is
  approximately 5
• Sugiura procedure (modified) - gastroesophageal
  devascularization
• ligation of venous branches entering the distal
  esophagus and the proximal stomach from the level
  of the inferior pulmonary vein
• splenectomy
• vagotomy and pyloroplasty
• left gastric vein and the paraesophageal
  collateral veins are preserved to permit
  portoazygous collateralization, which inhibits
  future varix formation
• Japanese series reported a low mortality rate
  (4-12), with effectiveness in the prevention of
  recurrent bleeding (1.5-16)
• Futagawa S, Sugiura M, Hidai K, Shima F
  Emergency esophageal transection with
  paraesophagogastric devascularization for
  variceal bleeding. World J Surg 1979 Jul 16
  3(2) 229-34
• Corson JD, Williamson RCN, eds Surgery. London,
  UK Mosby-Year Book 2001

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UGIB

• Mallory-Weiss
• 15 of acute upper GI hemorrhage
• Kenneth Mallory and Soma Weiss first described
  the syndrome in 1929
• Linear tear in the mucosa of the gastric cardia
• Result from forceful vomiting, retching,
  coughing, or straining
• Rapid increase in the gradient between
  intragastric and intrathoracic pressures
• Boerhaave syndrome represents a full-thickness
  transmural laceration with perforation of the
  esophagus
• Mallory-Weiss tear bleeding spontaneously ceases
  in 50-80 of patients
• Endoscopic treatment
• Dieulafoy lesion
• first described in 1896 by French surgeon Paul
  Georges Dieulafoy
• 2-5 of acute UGIB episodes
• is a vascular malformation - large submucosal
  vessel that has protruded through a mucosal
  defect
• Angiodysplasia
• 2-4 of bleeding lesions
• abnormal dilation of mucosal and submucosal
  vessels
• dilated, thin-walled vascular channels that
  appear macroscopically as a cluster of cherry
  spots

31
LGIB

• The passage of maroon stools or bright red blood
  from the rectum is usually indicative of massive
  lower GI hemorrhage
• Lower GI hemorrhage can be due to numerous
  conditions, including
• Diverticulosis
• Anorectal diseases
• Carcinomas
• Inflammatory bowel disease (IBD)
• Angiodysplasias

32
LGIB

• In the first half of the 20th century, large
  intestinal neoplasms were believed to be the most
  common cause of lower GI bleeding
• In the 1950s, lower GI hemorrhage was commonly
  attributed to diverticulosis
• In this period, surgical treatment consisted of
  blind segmental bowel resections, with
  disappointing results
• Patients who underwent blind segmental bowel
  resection suffered from a prohibitively high
  rebleeding rate (up to 75), morbidity (up to
  83), and mortality (up to 60)

33
LGIB

• 1954 - flexible endoscope
• 1965 - full-length colonoscope
• 1965 - selective mesenteric angiography
• 1960/70s mesenteric angiography suggested that
  angiodysplasias and diverticulosis were the most
  common reasons for lower GI bleeding
• 1972 - superselective embolization of the
  mesenteric vessels
• 1973-1974 - vasopressin infusion
• 1980s - endoscopic control of bleeding with
  thermal modalities or sclerosing agents
• 1980s - nuclear scintigraphy detect hemorrhage
  at rates as low as 0.1 mL/min

34
LGIB

• Mortality rate for massive lower GI hemorrhage
  ranges from 0-21
• Department of Veterans Affairs' (VA) databases
  for a 4-year period to study the incidence and
  etiology of lower GI bleeding
• They found that less than 1 of 5.1 million
  hospital admissions were for lower GI hemorrhage
• Estimated an annual incidence rate of 20.5
  patients per 100,000 (24.2 in males vs 17.2 in
  females)
• GI bleeding increased more than 200-fold from the
  third to the ninth decades of life.
• Vernava AM, Longo WE, Virgo KS A nationwide
  study of the incidence and etiology of lower
  gastrointestinal bleeding. Surg Res Commun 1996
  18 113-120

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LGIB

• LOWER GI HEMORRHAGE
• Diverticular Disease 60
• Diverticulosis/diverticulitis of small intestine
• Diverticulosis/diverticulitis of colon
• IBD 13
• Crohn disease of small bowel, colon or both
• Ulcerative colitis
• Noninfectious gastroenteritis and colitis
• Benign Anorectal Diseases 11
• Hemorrhoids
• Anal fissure
• Fistula-in-ano
• Neoplasia 9
• Malignant neoplasia of small intestine
• Malignant neoplasia of colon, rectum, and anus
• Coagulopathy 4
• Arteriovenous malformations (AVM) 3

36
LGIB

• Diverticulosis
• Approximately 50 of adults over the age 60 years
  have radiologic evidence of diverticulosis
• Most commonly located in the sigmoid and
  descending colon
• Bleeding originates from vasa rectae located in
  submucosa, which can rupture at the dome or the
  neck of the diverticulum
• Up to 20 of patients with diverticular disease
  experience bleeding
• In 5 of patients, bleeding from diverticular
  disease can be massive.
• Hemorrhage from diverticular disease stops
  spontaneously in 80 of patients
• Although diverticulosis is a left colonic
  condition, approximately 50 of diverticular
  bleeding originates from a diverticulum located
  proximal to the splenic flexure

37
LGIB

• Angiodysplasias
• Arteriovenous malformations located in the cecum
  and ascending colon
• Lesion affecting elderly persons older than 60
  years
• Composed of clusters of dilated vessels, mostly
  veins, in the colonic mucosa and submucosa
• Colonic angiodysplasias are believed to occur as
  a result of chronic, intermittent, low-grade
  obstruction of submucosal veins as they penetrate
  the muscular layer of the colon
• Angiographic findings are clusters of small
  arteries during the arterial phase of the study,
  accumulation of contrast media in vascular tufts
  and persistent opacification due to the late
  emptying of the draining veins
• If mesenteric angiography is performed at the
  time of active bleeding, extravasation of
  contrast media is visualized
• Angiodysplasia tends to cause slow but repeated
  episodes of bleeding
• Angiodysplasias can be easily recognized by
  colonoscopy as 1.5- to 2-mm red patches in the
  mucosa

38
LGIB

• IBD
• Ulcerative colitis causes bloody diarrhea in most
  cases.
• 50 of patients with ulcerative colitis,
  mild-to-moderate lower GI bleeding occurs, and
  approximately 4 of patients with ulcerative
  colitis have massive hemorrhage
• Lower GI bleeding in patients with Crohn disease
  is not as common as in patients with ulcerative
  colitis
• 1-2 of patients with Crohn disease may
  experience massive bleeding
• The frequency of bleeding in patients with Crohn
  disease is significantly more common with colonic
  involvement than with small bowel involvement
  alone
• Ischemic colitis
• Watershed areas, including the splenic flexure
  and the rectosigmoid junction
• Commonly observed after patients' sixth decade of
  life
• Ischemia causes mucosal and partial-thickness
  colonic wall sloughing, edema, and bleeding
• Abdominal pain and bloody diarrhea are the main
  clinical manifestations

39
LGIB

• Colorectal adenocarcinoma
• Third most common cancer in the United States
• Occult bleeding, and patients usually present
  with anemia and syncopal episode
• Bleeding due to colorectal carcinoma varies from
  5-20 in different series
• Postpolypectomy hemorrhage is reported to occur
  up to 1 month following colonoscopic resection.
  The reported incidence is between 0.2-3
• Postpolypectomy hemorrhage can be managed by
  electrocoagulation of the polypectomy
  site/bleeding with either snare or hot biopsy
  forceps or by epinephrine injection
• Benign anorectal disease
• Hemorrhoids, anal fissures, anorectal fistulas
• Intermittent rectal bleeding
• Patients who have rectal varices with portal
  hypertension may develop painless massive lower
  GI bleeding
• Discovery of benign anorectal disease does not
  exclude the possibility of more proximal bleeding
  from lower GI tract.

40
Radiology

• Nuclear Scintigraphy Sensitive (86) and can
  detect hemorrhage at rates as low as 0.1 mL/min,
  it is not highly accurate in locating the
  bleeding point
• Nuclear scintigraphy is reportedly 10 times more
  sensitive than mesenteric angiography in
  detecting ongoing bleeding
• The scintigraphic imaging suffers from a low
  specificity (50) due to its limited resolution
• 99m Sulfur colloid requires no preparation. This
  agent has a very short half-life (2.5-3.5 min)
  because it is rapidly cleared by the
  reticuloendothelial system
• Because it enhances the liver and spleen,
  bleeding from both the hepatic flexures and the
  splenic flexures may be obscured
• 99m Technetiumlabeled red blood cell scanning is
  the preferred technique because its half-life is
  longer. Images delayed up to 24 hours can be
  taken with labeled red blood cell scanning
• The sensitivity of the technetium scan is
  reportedly 20-95
• The bleeding site can be identified accurately
  when intraluminal accumulation of 99m
  technetiumlabeled red blood cells is observed
• Recently, cinematic technetium Tc 99m red blood
  cell scintigraphy (continous real-time scanning)
  has been described as a noninvasive alternative
  to mesenteric angiography
• Ng DA, Opelka FG, Beck DE Predictive value of
  technetium Tc 99m-labeled red blood cell
  scintigraphy for positive angiogram in massive
  lower gastrointestinal hemorrhage. Dis Colon
  Rectum 1997 Apr 40(4) 471-7

41
Radiology

• Indium In 111labeled scintigraphy remains
  underutilized because of a prolonged half-life of
  67 hours, more expensive than 99m technetium
  labeling
• Longer half-life of indium In 111labeled
  scintigraphy useful in locating intermittent
  bleeding
• Schmidt et al published a report on 6 patients in
  whom 99m technetium scanning was initially
  negative. Indium In 111labeled red cells located
  the site of bleeding in all patients
• Mesenteric Angiography bleeding at a rate of more
  than 0.5 mL/min
• Because of the intermittent nature of lower GI
  bleeding, the number of positive study findings
  is significantly less with this invasive
  diagnostic modality.
• Emergency angiography as an initial study is
  indicated in a highly selected group of patients
  with massive ongoing lower GI bleeding.
• Browder et al used 2 criteria's to triage
  patients for emergency angiography
• The criteria were at least 4 units of blood
  transfusion in the first 2 hours following
  hospital admission
• Systolic blood pressure of less than 100 mm Hg
  with aggressive resuscitation
• Fifty patients underwent emergency angiography,
  and bleeding was localized in 72 of patients
• Vasopressin infusion was successful in 91
• Patients with ongoing hemorrhage, emergency
  angiography, and vasopressin infusion have
  improved operative morbidity, mortality, and
  outcome
• Browder W, Cerise EJ, Litwin MS Impact of
  emergency angiography in massive lower
  gastrointestinal bleeding. Ann Surg 1986 Nov
  204(5) 530-6

42
Radiology

• Helical CT scan - extravasation of the contrast
  medium, contrast enhancement of the bowel wall,
  thickening of the bowel wall, spontaneous
  hyperdensity of the peribowel fat, and vascular
  dilatations are used to establish the bleeding
  site with helical CT
• Double-contrast barium enema examinations can be
  justified only for elective evaluation of
  unexplained lower GI bleeding.
• Do not use barium enema examination in the acute
  hemorrhage phase because it makes subsequent
  diagnostic evaluations, including angiography and
  colonoscopy, impossible
• Elective contrast radiography of the small bowel
  - enteroclysis

43
Radiological Treatment

• Vasoconstrictive Agents
• Vasopressin rebleeding rates fluctuated between
  27-71
• Vasopressin infusion was used in the acute event
  to stabilize patients prior to surgery
• If vasopressin infusion fails to control the
  hemorrhage, patients should undergo a segmental
  resection.
• Superselective Embolization
• Gelfoam, polyvinyl alcohol, microcoils,
  ethanolamine, and oxidized cellulose can be used
  as embolic agents
• Prevent complication, perform embolization beyond
  the marginal artery as close as possible to the
  bleeding point in the terminal mural arteries
• If terminal mural branches of the bleeding vessel
  cannot be catheterized, abort the procedure and
  immediately perform surgery.
• Rosenkrantz H, Bookstein JJ, Rosen RJ
  Postembolic colonic infarction. Radiology 1982
  Jan 142(1) 47-51

44
Endoscopic Treatment

• Colonoscopy
• First choice of diagnostic modality colonoscopy
  yields a diagnosis in 90 of the patients
• Provides opportunity for therapy at the same time
  
• Endoscopic Coagulation
• Heated probe or lasers such as NdYAG and argon
• Argon laser treatment is recommended for mucosal
  or superficial lesions because the energy
  penetrates only 1 mm
• NdYAG lasers are more useful for deeper lesions
  because they penetrate 3-4 mm
• Absolute alcohol, morrhuate sodium, and sodium
  tetradecyl sulfate can be used for sclerotherapy
• Hemorrhage was successfully arrested in 70 of
  patients, with a rebleeding rate of 15
• Parkes BM, Obeid FN, Sorensen VJ The management
  of massive lower gastrointestinal bleeding. Am
  Surg 1993 Oct 59(10) 676-8

45
Endoscopes

• Push enteroscopy
• Push enteroscopy involves the use of a special
  enteroscope of increased length
• Can be advanced as much as 100 cm past the
  ligament of Treitz
• Sonde enteroscopy
• A long scope is passed either through the nose or
  the mouth and is advanced by peristalsis into the
  small intestine
• Sonde enteroscopy is a lengthy and uncomfortable
• Double balloon endoscopy
• Push-and-pull enteroscopy
• Involves the use of a balloon at the end of a
  special enteroscope camera and an overtube, which
  is also fitted with a balloon
• Can also be passed in retrograde fashion, through
  the colon and into the ileum to visualize the end
  of the small bowel
• Yamamoto H, Sugano K. A new method of
  enteroscopythe double-balloon method. Can J
  Gastroenterol. 2003 Apr17(4)273-4

46
Surgery

• Preoperative
• Acute lower GI hemorrhage is a common clinical
  entity and is associated with significant
  morbidity and mortality
• Mortality rates are increased with age (gt60 y),
  multiorgan system disease, transfusion
  requirements (gt5 units/24hr), need for operation,
  and recent stress (eg, surgery, trauma, sepsis)
• Three major aspects are involved in managing
  lower GI hemorrhage
• The initial priority is to treat the shock
• Second, localization of the source of bleeding
• Third task, formulating an interventional plan
• Angiogram angiographic embolization or
  vasopressin infusion
• Segmental bowel resection is performed following
  correction of the patient's physiologic
  parameters, if patient is hemodynamically stable
• anemia, coagulation factors, etc
• Intraoperative
• If the patient is hemodynamically unstable,
  perform an emergency operation
• Perform intraoperative EGD, surgeon-guided
  enteroscopy, and colonoscopy in order to locate
  the precise bleeding point
• It may sometimes be better to perform subtotal
  colectomy with distal ileal inspection
• If the bleeding point cannot be diagnosed through
  intraoperative pan-intestinal endoscopy and if
  evidence points to a colonic bleeding, perform a
  subtotal colectomy with ileorectal anastomosis
• Postoperative
• Hypotension and shock are the eventual
  consequences of significant blood loss

47
Surgery

• An emergency operation is required in
  approximately 10 of patients with lower GI
  bleeding
• Hemodynamically unstable patient, perform an
  emergency operation before any diagnostic study
• When the bleeding point is localized, perform a
  limited segmental resection of the bowel
• 483 cumulative cases of limited segmental
  resection derived from 23 publications since
  1974
• rebleeding rate was 7 (0-21)
• mortality rate was 10 (0-15)
• morbidity rate of 0-33
• limited segmental resection is preferred because
  it can be performed with low morbidity,
  mortality, and rebleeding rates
• Subtotal colectomy is a rational option
• rebleeding rate 3
• morbidity rate 32
• mortality rate 19
• Blind segmental resection should not be performed
• high rebleeding rate of up to 75
• a morbidity rate up to 83
• mortality rate up to 60

48
Latest Diagnostic Procedure
49
Capsule Endoscopy (CE)

• Capsule Endoscopy
• The new procedure was approved by the U.S. Food
  and Drug Administration (FDA) in 2001
• Approximately the size of a large vitamin, the
  capsule includes a miniature color video camera,
  a light, a battery and transmitter
• Weighs 3.7 g and measures 11 mm 26 mm
• Image features include a 140 field of view, 18
  magnification, 1 to 30 mm depth of view, and a
  minimum size of detection of about 0.1 mm
• The camera takes two pictures every second for
  eight hours
• Transmits images to a data recorder about the
  size of a portable CD player that patients wear
  around the waist
• Information it contains is downloaded onto a
  computer for examination
• Estimated cost of Hardware/Software 19,500
• Capsule cost Pack of 1 for 500
• Capsule endoscopy not a substitute for regular
  endoscopy

50
Capsule Endoscopy (CE)

• Clinical Application of Wireless Capsule
  Endoscopy
• Chinese Journal of Digestive Diseases
• Volume 4 Issue 2 Page 89 - July 2003
• Zhi Zheng GE, Yun Biao HU, Yun Jie GAO Shu Dong
  XIAO
• Shanghai Second Medical University Renji
  Hospital, Shanghai Institute of Digestive
  Disease, Shanghai, China
• From May through September 2002
• 15 patients with suspected small bowel diseases
• Persistent gastrointestinal bleeding and negative
  findings on upper endoscopy, colonoscopy, small
  bowel radiography, and bleeding-scan
  scintig-raphy or mesenteric angiography.
• Small bowel findings in 11 of the 15 patients
  (73) Four of the patients had two lesions
• The images displayed were considered to be good
• The capsule remained in the stomach for an
  average of 82 min (range 6-311 min)
• Mean transit time in the small bowel was 248 min
  (range 104-396 min)
• Mean time of recording was 7 h 29 min (from 5 h
  to 8 h 30 min)
• Mean time to reach the cecum was 336 min
  (180-470 min)
• Average number of the images transmitted by the
  capsule was 57,919
• Average time it took to review the images
  transmitted was 82 min (range 30-120 min)
• Average time of elimination of the capsule was
  33 h (range 24-48 h)
• All 15 patients reported that the capsule was
  easy to swallow, painless, and preferable to
  conventional endoscopy. No complications were
  observed