LOWER LOWER GASTROINTESTIRAL GASTROINTESTIRAL

BLEEDINGBLEEDING

Asoc. Prof. Dr.Orhan Yalçın Asoc. Prof. Dr.Orhan Yalçın Ministry of Health, Okmeydanı Education and Ministry of Health, Okmeydanı Education and

Research Hospital, Turkey Research Hospital, Turkey

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DefinitionDefinition

Abnormal hemorrhage into lumen of Abnormal hemorrhage into lumen of the bowel from a source distal to the bowel from a source distal to ligament of Treitz.ligament of Treitz.

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30 % - 40 % diverticular disease30 % - 40 % diverticular disease ColitisColitis Colorectal neoplasiaColorectal neoplasia Benign anorectal diseaseBenign anorectal disease Coloni arteriovenous malformationColoni arteriovenous malformation Small bowel origin Small bowel origin

Despite all of the diagnostic modalities in 8 % to Despite all of the diagnostic modalities in 8 % to 12 % of patients the source of bleeding cannot be 12 % of patients the source of bleeding cannot be found. found.

In 10 % of hemotochesia cases, the source is In 10 % of hemotochesia cases, the source is from upper GI tract.from upper GI tract.

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There are three stepsThere are three steps1- Hemodynamic stabilization 1- Hemodynamic stabilization 2- Bleeding site localization2- Bleeding site localization3- Therapy3- Therapy

History History --Nature and duration of bleedingNature and duration of bleeding-Associated symptoms ( pain, weight loss )-Associated symptoms ( pain, weight loss )-Past medical events ( Injuries, surgical procedures, endoscopy, -Past medical events ( Injuries, surgical procedures, endoscopy,

IBD, etc.)IBD, etc.)-Medications ( NSAİD, anticoagulants )-Medications ( NSAİD, anticoagulants )-Physical examination / Vital signs-Physical examination / Vital signs-Laboratory: Hemogrom, PT, PTT -Laboratory: Hemogrom, PT, PTT -And resussication-And resussication

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BLEEDING SITE LOCALIZATIONBLEEDING SITE LOCALIZATION

Which modality will be used. Which modality will be used.

This depends on:This depends on:-Hemodynamic stability-Hemodynamic stability-Bleeding rate-Bleeding rate-Comorbid conditions-Comorbid conditions-Hospital expertise -Hospital expertise

MODALITIES MODALITIES -Colonoscopy-Colonoscopy-Radiolabeled red blood cell scanning-Radiolabeled red blood cell scanning-Angiography-Angiography-Multidetecter Row Helical CT-Multidetecter Row Helical CT

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COLONOSCOPY COLONOSCOPY

-- Procedure of choice as initial investigationProcedure of choice as initial investigation

-- Accuracy for localization 53 % - 97 % Accuracy for localization 53 % - 97 %

-- The distal ileum should be entubatedThe distal ileum should be entubated

-- It has both diagnostic and therapeutic effectIt has both diagnostic and therapeutic effect

-- Has ability to identify bleeding source Has ability to identify bleeding source regardless off rate and presence of regardless off rate and presence of bleeding. bleeding.

-- It is safeIt is safe

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COLONOSCOPY DISADVANTAGESCOLONOSCOPY DISADVANTAGES

-- Requires bowel preparationRequires bowel preparation

-- It is invasive procedureIt is invasive procedure

-- Prevalence of stigmata of hemorrhage is Prevalence of stigmata of hemorrhage is lowlow

-- Complication rate is low ( 0,5- 1,5 % ) but Complication rate is low ( 0,5- 1,5 % ) but major complications ( Perforation )major complications ( Perforation )

-- Can not show upper GI and small bowel Can not show upper GI and small bowel bleeding bleeding

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RAPIOLABELED RED BLOOD CELL RAPIOLABELED RED BLOOD CELL SCANNINGSCANNING

It detects at rates as slow 0,1- 0,4 ml/min bleedingIt detects at rates as slow 0,1- 0,4 ml/min bleeding- Two agents are used- Two agents are used

A- 99 m Tc-labeled sulfur colloidA- 99 m Tc-labeled sulfur colloid- Requires no preparation time- Requires no preparation time- But it’s absorbsion is rapid by liver and spleen- But it’s absorbsion is rapid by liver and spleen- This condition hinder accurate localization of - This condition hinder accurate localization of

bleedingbleedingB-B- 99 m Tc – labeled RBC s 99 m Tc – labeled RBC s-Requires some preparation time-Requires some preparation time-It is not hinder by liver and spleen-It is not hinder by liver and spleen-Much longer half time ( 24- 48 hours )-Much longer half time ( 24- 48 hours )

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RADIOLABELED RED BLOOD CELL RADIOLABELED RED BLOOD CELL SCANNING CONT.SCANNING CONT.

- - Accurate localization rate for bleeding is Accurate localization rate for bleeding is between 42 % -85 % between 42 % -85 %

- Major complication is rare- Major complication is rare

- Has no therapeutic intervention capability- Has no therapeutic intervention capability

- It is useful especially in non life threating - It is useful especially in non life threating bleeding to confirm active bleeding and a bleeding to confirm active bleeding and a guide to mesenteric angiographyguide to mesenteric angiography

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ANGIOGRAPHYANGIOGRAPHY

- It is detects at rate as slow as 1- 1,5 ml/min- It is detects at rate as slow as 1- 1,5 ml/min

- Detection rate is between 27 %- 67 %- Detection rate is between 27 %- 67 %

- It has both diagnostic and therapeutic - It has both diagnostic and therapeutic effectseffects

- Major complication rate 2 % - 50 ( renal - Major complication rate 2 % - 50 ( renal failure, bleeding from arterial puncture, failure, bleeding from arterial puncture, embolism from dislodged thrombus )embolism from dislodged thrombus )

- Therapeutic vasopressin infusion or - Therapeutic vasopressin infusion or embolizationembolization

- It should be used if colonoscopy fails- It should be used if colonoscopy fails

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PROVOCATIVE ANGIOGRAPHYPROVOCATIVE ANGIOGRAPHY

- In some patients despite continuous In some patients despite continuous obscure bleeding, bleeding point can not be obscure bleeding, bleeding point can not be foundfound

- In this patients use of short acting - In this patients use of short acting anticoagulant agents ( including anticoagulant agents ( including vasodilators, thrombolytics )vasodilators, thrombolytics )

- When bleeding point is localized, IV - When bleeding point is localized, IV methylen blue and laparotomy.methylen blue and laparotomy.

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MULTI- DETECTOR ROW HELICAL CT.MULTI- DETECTOR ROW HELICAL CT.

- In this modality on arterial phase active - In this modality on arterial phase active bleeding is identified as a focal area of bleeding is identified as a focal area of high attentuation within the bowel lumenhigh attentuation within the bowel lumen

- Accuracy for localization 24 %- 94 % ( All - Accuracy for localization 24 %- 94 % ( All GI bleeding )GI bleeding )

-Major complication rate is 0 %- 11 %-Major complication rate is 0 %- 11 %

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THERAPY THERAPY

- Endoscopic therapy- Endoscopic therapy

- Angiographic therapy- Angiographic therapy

- Surgical therapy- Surgical therapy

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ENDOSCOPIC THERAPYENDOSCOPIC THERAPY

Electrocauterization Electrocauterization Vasoconstrictor InjectionsVasoconstrictor Injections Thermal contactsThermal contacts Sclero TherapySclero Therapy LaserLaser

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ANGIOGRAPHIC THERAPY ANGIOGRAPHIC THERAPY

A-A-- Vasopressin infusion 0,2 – 0,4 U/min - Vasopressin infusion 0,2 – 0,4 U/min - Success rate 60 %- 100 %- Success rate 60 %- 100 %- Complication rate 10 %- 20 %- Complication rate 10 %- 20 %- Re-bleeding rate 50 %- Re-bleeding rate 50 %

B-B-- Transcatheter embolization - Transcatheter embolization - Microcoil, gelatin sponge, polyvinyl alcohol - Microcoil, gelatin sponge, polyvinyl alcohol

particlesparticles- Success rate 90 %- Success rate 90 %

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SURGICAL THERAPYSURGICAL THERAPY

IndicationsIndications

- 4 units of RBC in 24 hours- 4 units of RBC in 24 hours

- Re bleeding after cessation of - Re bleeding after cessation of hemorrhage in one week hemorrhage in one week

- Ongoing bleeding after 72 hours- Ongoing bleeding after 72 hours

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If possible If possible

Bleeding site should be localized before Bleeding site should be localized before operation operation

If angiography shows but can not stop If angiography shows but can not stop bleeding, methylen blue injected shortly bleeding, methylen blue injected shortly before operationbefore operation

If preoperative is not possible on operating If preoperative is not possible on operating table every effort should be made to table every effort should be made to localize bleeding source before resectionlocalize bleeding source before resection

Blind resection should be avoided Blind resection should be avoided

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INTRAOPERATIVE ADJUNCTIVE MANEUVERSINTRAOPERATIVE ADJUNCTIVE MANEUVERS

On table colonoscopyOn table colonoscopy Per oral trans luminal enteroscopyPer oral trans luminal enteroscopy At the end subtotal colectomyAt the end subtotal colectomy

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THANK YOUTHANK YOU