an 81 year old man

1. An 81-Year-Old Man with Massive Rectal Bleeding Prepared by: Dr. Mohammad Shaikhani.

81-year-old man was admitted to this hospitl for massive rectal bleeding.

He had abdominal fullness, nausea, rectal urgency& passed a mixture of bright-red blood and soft stool

No abdominal or rectal pain, heartburn, or dyspepsia,no vomiting or dysphagia.

CXR & Plain abd XR were normal.

Every year for the past few years, he had an episode of LGIB.

Two years earlier, COLONOSCOPY revealed diverticulosis throughout the colon, blood throughout the colon but no active bleeding, no blood or mucosal abnormalities in the terminal ileum; OGD revealed superficial erosions & altered blood in the stomach, thought to be consistent with trauma from a NGT, superficial erosions in the duodenum, without active bleeding.

H/O HT, hyperlipidemia,CHF, CAD with AMI & DES ,COPD, pulmonary fibrosis, gout,, spinal osteomyelitis, hip fracture.

He was a widower who lived alone.

He had consumed alcohol daily , smoked in the past; stopped drinking several months earlier , stopped smoking several years earlier.

No family H/O GIT cancer.

He was allergic to penicillin,erythromycin, clindamycin, vancomycin.

Medications included buprenorphinenaloxone, digoxin, modafinil, verapamil, aspirin,furosemide, escitalopram, simvastatin, folate,potassium chloride, finasteride, quinine, pantoprazole,galantamine, a multivitamin.

During the previous 5 months, he had used oxygen supplementation at home.

Moderate respiratory distress

Mildly diaphoretic.

BP 97/51 mm Hg, PR 95

Oxygen saturation 80% while he was breathing ambient air, which improved to 92% with oxygen

The jugular venous pulse was visible at 10 cm.

There were crackles in both lungs.

The abdomen was soft, with hyperactive bowel sounds; no tenderness, distention, or hepatosplenomegaly was present.

Red and maroon blood was present in the rectum.

No hemorrhoids were seen.

The feet were warm, the pulses were full, and the remainder of the examination was normal.

Serum electrolytes were normal; creatine kinase cardiac isoenzymes , troponin I were negative.

Insulin, sodium polystyrene sulfonate, ondansetron, furosemide, esomeprazole, albuterol, normal saline (1 liter), fresh-frozen plasma (2 units), packed red cells (4 units) were administered IV; BP rose as high as 110 to 117/45 to 60 mm Hg, with PR 90 to 95. A

NGT placed, gastric lavage revealed no blood in the stomach. Hematochezia continued.

Approximately 7 hours after arrival, a CV catheter was inserted, , additional red cells (3 units) were infused.

Dyspnea worsened, with respirations up to 32 per minute, the trachea was intubated.

A diagnostic procedure was performed.

This patient had a transient response but required ongoing resuscitation.

Studies to determine the location of the hemorrhage had to be selected carefully to avoid unnecessary delays in definitive care.

Selective superior mesenteric arteriography revealed active extravasation of contrast material from a proximal jejunal branch& was catheterized superselectively with a microcatheter.

Arteriography through the microcatheter revealed focal extravasation of contrast material and pooling in the jejunum.

There was a suggestion of increased vascularity at the site of contrast-material extravasation.

We suspected a small-bowel tumor or diverticulum.

We decided to embolize the bleeding vessel with the understanding that this would temporarily stop the bleeding and enable better hemodynamic stability, so that the patient could safely be taken to the operating room

The bleeding vessel was embolized with two coils and a Gelfoam pledget

His hemodynamic status improved after embolization.

The catheter was left in the jejunal branch to help the surgeon identify the bleeding segment quickly.

The patient was sent to the operating room.

Acquired ,seen throughout SI: 79% duodenum, 18%jejunum& ileum, 3% in all three segments.

By UGl series, frequency of duodenal diverticula is 6 -7%

The overall frequency of jejunoileal diverticula is 0.7%.

Autopsy: prealence as high as 4.6%,most commonly seen in men in the seventh or eighth decade of life.

35% are associated with diverticula of colon, 26% with diverticula ofduodenum, 2% with diverticula of the esophagus.

46% have complications, as compared with 13% of patients with duodenal diverticulosis.

Symptoms, including pain, malabsorption due to bacterial overgrowth, seen in 40% with small-intestine diverticulosis.

Presentations with acute symptoms are seen in 18% & include perforation, diverticulitis, hemorrhage.

GIB is characteristically acute / massive

The diagnosis is rarely made preoperatively with an acute onset.

It had a small neck-sac ratio, renders them difficult to diagnose with oral contrast , because of poor filling of the sac.