Case Presentations (Lower Gastrointestinal Bleeding) What Would You Do? What We Did!! Eric J. Dozois, MD Division of Colon and Rectal Surgery Mayo Clinic Rochester, Minnesota

Goals of the Presentation Interesting cases of LGIB Stimulate discussion - audience Review key points of topic

CASE # 1

Chief Complaint 67 year old male Called to the intensive care unit to see a patient with bright red blood per rectum

History of Present Illness POD # 2Aorto-bi-iliac graft aorto-renal artery graft for aortoiliac disease

History of Present Illness In ICU, stable for last 24 hrs HR 90, BP 115/80, Temp 37.5 BRBPR x 2, now watery diarrhea LLQ abdominal pain Hgb = 8, WBC 18, urine output 5cc/hr

Past Medical History Cecal angiodysplasia Sigmoid diverticular disease History of colon polyps – s/p polypectomy complicated by postpolypectomy bleed

Family History 2 brothers with colon cancer 1 sister with uterine cancer 1 sister with gastric cancer

Differential Diagnosis? Colon cancer C. difficile colitis Ischemic colitis Aorto-enteric fistula Colonic/Sb Angiodysplasia Gastric or duodenal ulcer

Work Up and Plan ? Resuscitated, transfused, Abx started Stool sent for C. diff colitis Flexible sigmoidoscopy

Plan Flex Sig15 – 60 cm loss of vascular pattern intense erythema, purple discoloration

Plan?

Hospital Course Fluids, optimized hemodynamics More BRBPR, watery diarrhea Worsening LLQ pain, confused HR 130, BP 90/60, T 38.9 Repeat Flex Sig : “ much worse than yesterday !”

Plan?

Operative Management Left colon/sigmoid, patchy necrosis – Left Hemicolectomy – End Colostomy – Hartmann Pouch How would you manage the rectal stump??

Postop Course Discharged from the hospital on POD 14 2 Months later… Emergency Fem – pop Graft thrombosis, emboli 1 Month later…In ER with BRBPR…..

Hospital Course On coumadin, INR = 3, Hgb = 7 Admitted to ICU, transfused Passes 400cc amount of bright red blood per RECTUM!

Differential Diagnosis? Dis-use Proctitis Ischemic rectal stump Aorto-rectal stump fistula

Work Up? Extended “Push” EGD: – Normal Flex sigmoidoscopy: – Fresh blood & clots – Proximal stump has 3 cm ulcer – ? dehiscence of stump

CT Angiogram

Angiogram

Treatment ? Observation….. 12 Hours later - Massive bleed!! – Blood from rectum… – Blood from Colostomy… – Blood per NGT… Now What?

Operative Findings 2 liters of blood in abdomen Dehiscence of proximal aortic anastomosis Fistula to 3 rd portion of duodenum Dehiscence of rectal stump Repair of graft and rectal stump

Aorto-Enteric Fistula Incidenceless than 1% 4 th portion of duodenum “Herald bleed” - late diagnosis

Aorto-Enteric Fistula Risk Factors: – Repair for ruptured aneurysm – Infection, thrombosis, hematoma – Infection, pseudo-aneurysm, fistula

Frequency of Signs and Symptoms in Patients with Aorto-Enteric Fistula Proportion Effected (%) GI bleeding (“herald”) 94 Hematemasis 78 Back or Abd pain 48 Melena 46 Shock 33 Pulsatile mass 17 Syncope 10

Diagnostic Tools in Patients with Aorto- enteric Fistula Detection Rate (%) CT 61 Angiography 26 EGD 25 Technetium scan 14 Enteroclysis 13 Colonoscopy 10 Ultrasound 0 Barium enema 0

Prognosis - Aorto-Enteric Fistula Early Mortality21% Late Mortality24% 5-Year Survival61% Armstrong et al. J Vasc Surg 2005;42:660

Rifampin Graft, Omental Wrap

CASE # 2

Chief Complaint 9 year old male Bright red blood per rectum!

History of Present Illness 4 days of bright red blood per rectum, by day 5 stool was dark colored On first day of bleeding, 5 emesis Now – asymptomatic

Past Medical History Attention deficit disorder No bleeding risk factors Family History: – Brother had intussusception age 6mos – Mother has colon polyps age 42

Hospital Course Seen in ER – stable, Hg 7 HR 130, BP 80/60 Abd/rectal exam negative Overnight stable, Hgb = 6

Differential Diagnosis? Intestinal duplication Juvenile polyp FAP Meckel’s diverticulum IBD

Work Up? EGDNegative ColonoscopyNegative Other Tests?

Meckel’s Scan Negative

Tagged RBC Scan Negative What Now??

Second Meckel’s Scan Positive!

Treatment ? OperationLaparoscopic assisted Meckel’s diverticulectomy, appendectomy Pathology Meckel’s diverticulum with focal heterotopic gastric mucosa

Meckel’s Diverticulum (MD) Incidence of MD in general population is 1% Bleeding MD is the most common cause of acute lower GI bleeding in pediatric patients The most common presentation in a child is obstruction, and it is adults bleeding *Park et al. Ann Surg 2005;241:529

Meckel’s Diverticulum 16% - are symptomatic Presentation varies – perforation, obstruction, bleeding 29% - ectopic or abnormal tissue Park et al. Ann Surg 2005;241:529

Histologic Findings in 180 Pts* Findings Patients No.% Ectopic tissue Gastric 5933 Pancreatic 9 5 Carcinoid 4 2 Duodenal 3 2 Lipoma 2 1 Leiomyosarcoma 10.6 Diverticulitis 4525 Enterolith 11 6 No Abnormality 4625 *Park et al. Ann Surg 2005;241:529

Meckel’s Scan In children, sensitivity 85%, specificity 95% In adults, sensitivity 65%, specificity 9%. Sensitivity decreases during acute bleeding Intestinal duplication & nodular lymphoid hyperplasia can give false-positives

CASE # 3

Chief Complaint 88 yr old male Asked to see in the medical ICU for lower gi bleeding

History of Present Illness Outside hospital, passed 800cc blood Hgb 8.0 Colonoscopy - clots & diverticula Transfused 4 units, Hgb remained 8.2 Transferred to Mayo, given 2 units Stable in intensive care unit

Past Medical History 10 episodes of LGIB in 20 years, ….4 in last 6 months Gastric ulcer Coronary Artery Disease – MI x 2

Differential Diagnosis Diverticular bleed Angiodysplasia Carcinoma UGI Source – recurrence of gastric ulcer?

Work Up? EGDNGT related erosions only ColonoscopyBlood throughout colon TI intubated – dark blood No active bleeding site Scattered diverticula throughout colon, dense in sigmoid

Work Up? Enteroclysis – jejunal & ileal diverticula Tagged RBC scan - Negative Provocative Angiogram : – Access through common femoral artery – IMA, the SMA – Heparin U – tPA - 10 to 50mg in 5mg increments Now What? Negative

Hospital Course Stabilized in ICU, observed Transferred to floor, resumed diet Ready for discharge on HD 7

Hospital Course Hypotensive Tachycardic Massive LGIB…. Plan?

Surgical Management Abdominal exploration Intraoperative small bowel enteroscopy Total abdominal colectomy, ileostomy

GI Bleed of Unknown Source In 95% of cases LGI bleeding can be diagnosed by a combination of endoscopy, scintigraphy, and barium studies (enteroclysis, barium enema) 1 Blind surgical resection is associated with significant re-bleed rates & high mortality 2 1 Welch et al. Adv Surg 1973;7:95 2 Hoedema et al. Dis Colon Rectum 2005;48:2010

Mesenteric Angiography *Vernava et al. Dis Colon Rectum 1997;40:

Selective Mesenteric Angiogram Therapeutic Intervention Vasopressin – 90% success, re-bleeding up to 50% – Arrhythmia, pulmonary edema, MI Super Selective Embolization – 100% success, re-bleed 7% – 40% (expertise) – Bowel infarct rare Methylene blue or India ink - localize

Provocative Angiography* Indicated when all other studies fail Uses anticoagulant (heparin), vasodilator (tolazoline), & thrombolytic agent (tPA) Major side effects are possible Success in small series = 20% - 65% *Ryan et al. J Vasc Interv Radiol 2001;12:1273

Surgical Options Directed segmental colectomy Blind segmental colectomy Blind subtotal colectomy

Directed Segmental Colectomy Author N Re-bleed Mortality Rate (%) (%) Write Browder Nath Welch Boley *Vernava et al. Dis Colon Rectum 1997;40:

Blind Segmental Colectomy Author N Re-bleed Mortality Rate (%) (%) McGuire Casarella Eaton Drapanas *Vernava et al. Dis Colon Rectum 1997;40:

Subtotal Colectomy Author N Re-bleed Mortality Rate (%) (%) Eaton Drapanas Welch Britt Abcarian Vernava et al. Dis Colon Rectum 1997;40:

Pitfalls of Blind Subtotal Colectomy* ProcedureRe-bleed Final Diagnosis TAC, IRA Yes Bleeding Hemorrhoids TAC, IRA Yes Solitary Rectal Ulcer TAC, IRA Yes LB & SB Ectasias TAC, IRAYes (died) Osler-Weber-Rendu TAC, IRA(2) Yes (both died) Unknown *Abcarian et al. Dis Colon Rectum 1982;25:

Pitfalls of Blind Subtotal Colectomy Proximal Disease: – Small bowel Source - tumors, angiodysplasia Distal Disease: – Anorectal source - SRUS, hemorrhoids, fissures, IBD Systemic Disease: – Leukemia, hemophilia, vasculitis, sarcoid

Lower GI Bleed Diagnostic Hints SymptomsPossible Diagnosis Abd. pain & bleedingIschemic bowel IBD Ruptured AAA Painless bleeding Diverticular, angiodysplasia, Benign/malignant neoplasm Proctitis

Lower GI Bleed Diagnostic Hints Symptoms Possible Diagnosis Bloody diarrhea Infectious colitis, IBD Ischemic bowel Rectal pain & bleeding Fissures Constipation & bleeding Malignancy Diverticular

Lower GI Bleed Common Etiologies Adolescence and Children: – Meckel’s diverticulum – Polyps – IBD Adults to age 60: – Neoplasm – IBD – Diverticula

Lower GI Bleed Common Causes Age > 60 yrs: – Angiodysplasia – Diverticula – Neoplasm

Lower GI Bleed Uncommon Etiologies Ischemic, Infectious (CMV) colitis Ischemic enteritis Postpolypectomy hemorrhage (0.2% - 3%) Anorectal disease (SRUS) Upper GI source (10% - 15%) Small bowel source (3% - 5%) Coagulopathy

Future Direction Capsule Endoscopy 11 x 26 mm 2 live images/sec Telemetry 6 hour battery life 2 hours to review

Future Direction Capsule Endoscopy

Indications for Surgery > 6 unit blood transfused & persistent bleeding > 10 units transfused/24hrs for stable VS Bleeding continues for 72 hrs Re-bleed within 7 days