HEMORRAGIA DIGESTIVA BAJA

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HEMORRAGIA DIGESTIVA BAJA

• Lisandro Pereyra
• Servicio de Gastroenterología y Endoscopía
• Hospital Alemán

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Objetivos

• Lo teórico
• Definición
• Causas
• Abordaje
• Tratamiento

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Una breve historia...
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Corría el año 2001

• Residente de primer año
• Primera guardia solo
• Llamado desde la guardia externa...
• Un ingreso
• Paciente con hemorragía digestiva baja
  descompensado

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????
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Preguntas a responder...

• En que etiología tengo que pensar?
• Cuando es grave una HDB?
• En que pacientes debo pedir una VCC? Urgente?
• Hacemos la VCC con o sin preparación ?
• Cuando de realizar una angiografía?
• Cuando un centellograma?

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Definición

• Es originada por lesiones ubicadas por debajo del
  ángulo de Treitz

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Epidemiología

• Es menos frecuente que la HDA
• Es mas frecuente en gt 65 años
• El 80 de los casos cesa espontáneamente
• En un 25 de los casos se observa recidiva

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Manifestaciones clínicas

• Proctorragia, enterorragia
• Hematoquezia
• Melena

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Etiología

• Colon (85)
• Intestino delgado (5)
• HDA (10)

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Preguntas a responder...

• En que etiología tengo que pensar?

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Etiologías mas frecuentes

• Hemorroides
• Enfermedad diverticular es la causa mas
  frecuente en edad avanzada. En gral autolimitada
  y recidivante. Mas frecuente es la localización
  de divertículos sangrantes en colon derecho,
  aunque los divertículos son mas frecuentes en
  colon izquierdo.
• Angiodisplasia constituye la 2º causa en
  pacientes mayores. Se caracterizan por ser
  múltiples, gt en colon derecho. Suelen generar
  sangrado recurrente y autolimitado.

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Colitis isquémica
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Abordaje....

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Importante interrogar

• Antecedentes personales y familiares de patología
  del aparato digestivo
• Realización de colonoscopía previa (polipectomía)
• Episodios previos de sangrado
• Cambios en el ritmo evacuatorio, perdida de peso,
  anemia (neoplasia)
• Diarrea inflamatoria, tenesmo rectal, dolor
  abdominal tipo cólico (enfermedad inflamatoria
  intestinal)
• Sangre roja rutilante que aparece en el agua del
  inodoro o en el papel higiénico (hemorroides)

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Examen fisico

• Primero SIGNOS VITALES TA, FC, FR y Tº.
  Ortostatismo, ritmo diurético, sensorio
• Piel palidez, cianosis
• Abdomen dolor a la palpación, masa palpable,
  signos de irritación peritoneal
• Tacto rectal para objetivar sangrado y evaluar
  lesiones anorrectales

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Laboratorio

• Hemograma Hto, Hb, Plaquetas
• Coagulograma
• Urea (muy elevada)
• Creatinina normal
• Saturación de O2
• Grupo sanguíneo y factor Rh

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Importante establecer pronóstico.......
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Preguntas a responder...

• Cuando es grave una HDB?

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Factores de riesgo de mayor mortalidad

• Edad gt de 60 años
• Hemorragia digestiva masiva con descompensacion
  hemodinamica
• Enfermedades asociadas insuficiencia hepatica,
  renal, o respiratoria, IAM reciente, hepatopatia
  previa
• Antecedentes de hemorragia digestiva previa
• Recidiva precoz del sangrado

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Validation of a clinical prediction rule for
severe acute lower intestinal bleeding.Strate
LL, Saltzman JR, Ookubo R, Mutinga ML, Syngal S.

• FC gt100
• TAS lt 115mmhg
• Sincope
• Sangre por el recto en las cuatro primeras hora
  de evaluación
• AINES
• gt2 comorbilidades

Riesgo de sangrado severo Bajo riesgo ninguna
variable clínica (9) Riesgo moderado entre 1
y 3 variables (43) Alto riesgo mas de 3
variables (84)
Am J Gastroenterol. 2005 Aug100(8)1821-7.
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Abordaje medico

• Colocación de 1 o 2 vías periféricas, eventual
  colocación de vía central para medir PVC
• Reposición de líquidos (SF o coloides)
• Colocación de sonda vesical para cuantificar
  diuresis (si esta oligúrico)
• Eventual transfusión de Globulos Rojos
• Administración de O2

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Diagnóstico
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Diagnóstico y tratamiento específicos

• Anoscopia-rectosigmoidoscopia
• Colonoscopia visualiza todo el colon, permite
  obtener biopsia de lesiones sospechosas, realizar
  polipectomias, usar tecnicas de coagulación para
  controlar hemorragias
• Centellografia con GR marcados con Tc 99
  localiza el sitio de sangrado, pero no la
  etiologia, necesario salida de sangre 0,1-0,5
  ml/min
• Arteriografia selectiva celiaco-bimesenterica
  permite ver el sitio de sangrado, la posible
  etiología y realizar hemostasia transitoria con
  vasopresina o embolizacion arterial. Es necesario
  salida de sangre gt 1,5 ml/min y no requiere
  preparación intestinal.

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Preguntas a responder...

• En que pacientes debo pedir una VCC? Urgente?
• Hacemos la VCC con o sin preparación ?

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Preparar o no preparar antes de VCC?Preparar
con que?En que momento la hacemos?

• Colonoscopía

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Preparar con que ?
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Preparación para colonoscopía

• Evitar fosfatos....(pacientes hipovolémicos)
• PEG
• Enemas

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Hepatogastroenterology. 2009 Sep-Oct56(94-95)133
1-4. Management of acute lower intestinal
bleeding what bowel preparation should be
required for urgent colonoscopy? Saito K, Inamori
M, Sekino Y, Akimoto K, Suzuki K, Tomimoto A,
Fujisawa N, Kubota K, Saito S, Koyama S, Nakajima
A. Source Department of Gastroenterology, Tokyo
Metropolitan Hiroo Hospital, 2-34-10 Ebisu,
Shibuya-ku, Tokyo, 150-0013, Japan. Abstract BACKG
ROUND/AIMS The management of acute intestinal
bleeding is not standardized. The aim of this
study was to determine the most suitable method
of bowel preparation for urgent
colonoscopy. METHODOLOGY One hundred and forty
patients admitted with acute lower intestinal
bleeding (ALIB) to our Hospital (April 1998 to
March 2004) were studied. The preparation for
colonoscopy consisted, usually, of oral
administration of polyethylene glycol (PEG)-salt
solution. For elderly patients or for those
suspected of bleeding from a sigmoid colon
lesion, colonoscopy was performed following
glycerin enemas or water enemas. For patients
with a suspected rectal lesion or soon after
undergoing a polypectomy, colonoscopy was
performed without any of the above
procedures. RESULTS Ischemic colitis was the
most common cause of bleeding. The overall cecal
completion ratio was 41, compared with 74 in
the PEG group. The percentage of those in whom
colonoscopy was impossible (poor preparation) was
16 overall, compared with 5 in the PEG group.
Endoscopic hematemesis were performed
successfully for 26 patients who were mainly
postpolypectomy cases or had rectal
ulcers. CONCLUSIONS In urgent colonoscopy, the
preparation with PEG-salt solution may improve
the patient's outcome. In postpolypectomy
patients and those with rectal ulcers preparation
was not always needed.
Hepatogastroenterology. 2009 Sep-Oct56(94-95)133
1-4. Management of acute lower intestinal
bleeding what bowel preparation should be
required for urgent colonoscopy? Saito K, Inamori
M, Sekino Y, Akimoto K, Suzuki K, Tomimoto A,
Fujisawa N, Kubota K, Saito S, Koyama S, Nakajima
A. Source Department of Gastroenterology, Tokyo
Metropolitan Hiroo Hospital, 2-34-10 Ebisu,
Shibuya-ku, Tokyo, 150-0013, Japan. Abstract BACK
GROUND/AIMS The management of acute intestinal
bleeding is not standardized. The aim of this
study was to determine the most suitable method
of bowel preparation for urgent
colonoscopy. METHODOLOGY One hundred and forty
patients admitted with acute lower intestinal
bleeding (ALIB) to our Hospital (April 1998 to
March 2004) were studied. The preparation for
colonoscopy consisted, usually, of oral
administration of polyethylene glycol (PEG)-salt
solution. For elderly patients or for those
suspected of bleeding from a sigmoid colon
lesion, colonoscopy was performed following
glycerin enemas or water enemas. For patients
with a suspected rectal lesion or soon after
undergoing a polypectomy, colonoscopy was
performed without any of the above
procedures. RESULTS Ischemic colitis was the
most common cause of bleeding. The overall cecal
completion ratio was 41, compared with 74 in
the PEG group. The percentage of those in whom
colonoscopy was impossible (poor preparation) was
16 overall, compared with 5 in the PEG group.
Endoscopic hematemesis were performed
successfully for 26 patients who were mainly
postpolypectomy cases or had rectal
ulcers. CONCLUSIONS In urgent colonoscopy, the
preparation with PEG-salt solution may improve
the patient's outcome. In postpolypectomy
patients and those with rectal ulcers preparation
was not always needed.
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En que momento pedimos la VCC?Urgente o en forma
electiva?
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m J Gastroenterol. 2010 Dec105(12)2636-41 quiz
2642. Epub 2010 Jul 20. Randomized trial of
urgent vs. elective colonoscopy in patients
hospitalized with lower GI bleeding. Laine L,
Shah A. Source Division of Gastrointestinal and
Liver Diseases, Keck School of Medicine,
University of Southern California, Los Angeles,
California 90033, USA. llaine_at_usc.edu Abstract OBJ
ECTIVES We sought to determine, in patients
with serious hematochezia, the proportion who
have an upper gastrointestinal (GI) source and
whether urgent colonoscopy improves outcomes as
compared with elective colonoscopy in those
without an upper source. METHODS Patients with
hematochezia were eligible if they also had heart
rate gt100, systolic blood pressure lt100,
orthostatic change in heart rate or blood
pressure gt20, hemoglobin drop 1.5 g/dl, or
blood transfusion. Patients had upper endoscopy
within 6 h. Those without an upper source were
randomized to urgent ( 12 h) or elective (36-60
h after presentation) colonoscopy. The primary
end point was further bleeding. Patients were
followed for the duration of hospitalization. RESU
LTS Eighty-five eligible patients had urgent
upper endoscopy 13 (15) had an upper source.
The remaining 72 were randomized to urgent (N36)
or elective (N36) colonoscopy. Further bleeding
occurred in 8 (22) vs. 5 (14) of the urgent vs.
elective groups (difference8, 95 confidence
interval (CI)-9 to 26). Units of blood (1.5 vs.
0.7), hospital days (5.2 vs. 4.8), subsequent
diagnostic or therapeutic interventions for
bleeding (36 vs. 33), and hospital charges
(27,590 vs. 26,633) also were not lower in the
urgent group. A major limitation is that the
study was terminated before reaching the
prespecified sample size. CONCLUSIONS Patients
with clinically serious hematochezia should have
upper endoscopy initially to rule out an upper GI
source. Use of urgent colonoscopy in a population
hospitalized with serious lower GI bleeding
showed no evidence of improving clinical outcomes
or lowering costs as compared with routine
elective colonoscopy.
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Resultados
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Papel de la COLONOSCOPIA?

• Oportunidad de detección de estigmas ?
• colonoscopia precoz
• Rendimiento diagnóstico ? 80
• Detención espontánea de la hemorragia (85-90)

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CUÁNDO LA COLONOSCOPIA?

• En las primeras 24 horas tras primera atención
• Tras estabilización del paciente y aproximación
  diagnóstica (contraindicación SHOCK).
• Ventajas
• Permitir la limpieza colónica
• Posibilidad de detectar estigmas o recidiva
  hemorrágica.
• Manejo más eficiente del paciente
• Tratamiento de la lesión
• Disminuir la recurrencia
• Acortar la estancia hospitalaria

Gostout CJ. NEJM 2000 342 125-7 Gostout CJ.
Am J Gastroenterol 2003 98 1996 9 García
Sánchez MV. Gastroenterol Hepatol 2001 24 327
32 Jensen DM et al. N Engl J Med 2000 342 78 -
82 Strate LL. Am J Gastroenterol 2003 98
317-22
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Tratamiento especifico

• Endoscopico electrocoagulacion, termocoagulacion
  o clips
• Arteriografia perfusion de vasopresina
  intraarterial o embolizacion arterial

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Centellograma con GR marcados Tecnecio 99

• Requiere sangrado activo
• 0,1ml- 0,5ml/min
• Pobre precisión diagnóstica

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Centellograma con Tecnecio 99

• Limited value of technetium 99m-labeled red cell
  scintigraphy in localization of lower
  gastrointestinal bleeding.
• Hunter JM, Pezim ME Am J Surg. 1990159(5)504.
• The aim of this study was to assess the accuracy
  of technetium 99m-labeled red cell scintigraphy
  in localizing the site of lower gastrointestinal
  bleeding. The outcome of 203 patients undergoing
  technetium 99m-labeled red cell scintigraphy was
  reviewed, and the scan result was compared with
  the true site of bleeding. The true site of
  bleeding was determined by other methods
  including angiography and surgical pathology.
  Fifty-two scans (26) were positive and indicated
  a specific site of bleeding. A definitive
  bleeding site was identified in 22 patients by
  other means and correlated with the technetium
  scan in only 9 cases. The nuclear scan was
  incorrect in the remaining 13 cases, implying a
  localization error of 25 (13 of 52). A subgroup
  of 19 patients with a positive scan underwent a
  surgical procedure directed by the nuclear scan.
  Eight of these 12 patients had incorrect surgical
  procedures based upon findings of more definitive
  tests, indicating a surgical error of 42 (8 of
  19). We conclude that the technetium 99m-labeled
  red cell scan's ability to accurately localize
  the site of lower gastrointestinal bleeding is
  limited. Furthermore, performing a surgical
  procedure that relies exclusively on localization
  by red cell scintigraphy will produce an
  undesirable result in at least 42 of patients.

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Angiografía

• Detecta sangrado gt1,5ml/min
• Pacientes con descompensación hemodinámica
• Sospecha de sangrado masivo
• Falla de colonoscopía

Am Surg. 2005 Jul71(7)539-44 discussion
544-5. Superselective catheterization and
embolization as first-line therapy for lower
gastrointestinal bleeding. Neuman HB, Zarzaur BL,
Meyer AA, Cairns BA, Rich PB. Emergent operative
intervention for lower gastrointestinal bleeding
(LGIB) is associated with significant morbidity
and mortality. Advances in endovascular
techniques have made superselective
catheterization and embolization (SSCE) of small
visceral arterial branches possible. We
hypothesized that SSCE for LGIB would be an
effective first-line therapy and associated with
low mortality. We identified all patients that
underwent visceral angiography at our institution
from 1997 to 2003. Records from all patients with
documented LGIB and in whom SSCE was used as
first-line therapy were reviewed. Twenty-three
patients (69 /- 11 years) were treated with SSCE
as an initial intervention for LGIB. A definitive
bleeding site was identified in 95 per cent of
cases (22/23). Eleven patients (48) developed an
early complication recurrent bleeding (n5 two
required surgery), asymptomatic ischemic colonic
mucosa (n3), acute renal insufficiency (n1
resolved), and femoral pseudo-aneurysm (n2 one
treated operatively). Long-term (mean 19 months)
follow-up was available for 17 patients. Five
patients (22) experienced recurrent LGIB, and
three patients had evidence of colonic ischemic.
One patient required endoscopic dilation of a
stricture, and three underwent surgical
resection. There was no mortality in our series.
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Tratamiento quirurgico

• Con el uso de la endoscopia terapeutica y la
  radiologia intervencionista, se ha reducido la
  necesidad de intervencion quirurgica
• Se reserva ante fracaso del tratamiento
  endoscopico (escleroterapia) o en pacientes
  graves con sangrado incoercible
• Se realiza la reseccion intestinal

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Lo práctico
Colonoscopía
Angiografía
Enteroscopía, estudio del ID (video cápsula)
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Muchas gracias