Uncontrollable GI Bleed Mamoun A. Rahman

Case 1 RT. 57 yrs-old lady BGhx: -Rectal cancer -Pre-operative adjuvant chemotherapy: 5FU based -low anterior resection Medications: - Losec 20 mg Od

Presentation C/O: Lower abdominal pain for 3-4 days Admitted Next morning: PR bleeding, bright red Weak and anxious O/E: - Pale - Pulse: 98 - BP: 106/64 - Abdomen: stoma; soft, non tender. - DRE: clotted blood, nil active bleeding

Lab results Hb: 10.1 ALP: 141 PCV: 0.30 GGT: 151 WBC: 6.8 Bil: 3 Urea: 4.7 Cr: 95 Na: 137 K: 4.3

Few hours later Had another episode of PR bleed Hb: 8.3 PCV: 0.24 Received 2 unit of RCC Patient “stabilized” PR bleeding continuing - pulse: 109 CT angiography

On arrival in X-Ray Anxious Tachypnoeic Cold and clammy Pulse: 125 BP: 70/50 Unstable

Resuscitation by surgical team Trendelenburg position 3 IV lines Received Hartmann’s solution and Gelofusin Tranfusion with 2 units O –ve blood ICU informed Urgent angiography

Angiography & embolization Bleeding in the pelvis Ruptured aneurysm branch of internal iliac artery Anterior branch of IIA embolized

Post embolization Transferred to ICU Pulse: 144 BP: 140/65 Chest: course crepitations Received Frusemide 40 mg Remained stable, melaena only

Case 2 TY 52 yrs-old lady Background history: - Recurrent cholangitis - ERCP and stent

C/O - Epigastric pain O/E - Jaundiced Lab results - Fever - Pale stool - Dark urine O/E - Jaundiced - Temp: 41 - Tender RUQ Lab results - Cholestatic picture Hb 11.6 HCT 36.1 WBC 4.7 Neut 3.78 Ur 13.1 Cr 138 Na 135 K 4.4 Cl 110 PT 11.6 INR 1.1 Bil 113.9 ALT 131 ALP 270 GGT 278 Amylase 10 CRP 352

USS Cotracted, thick-walled GB, multiple stones CBD: 14 mm, stones

ERCP performed Sphincterotomy and CBD clearance Bleeding from sphincter site Adrenalin injected Continued to ooze

Post ERCP Haematemesis Melaena Dizzy Pulse: 90 BP: 139/67 Hb:9.7 INR: 1.2 CT Angiogram: - ?Arterial haemorrhage at ampulla

Embolization Bleeding from branches of GDA and Superior pancreaticodudenal artery Embolization performed with coil and gel foam SMA angiogram: normal

Day 1 Post Embolization Seen by team as a consult Vitals stable Hb: 6.6 INR: 1.37 Transfused 4 units of RCCs and 1 unit FFP IV fluids and Abx continued Repeat ERCP: - No further bleeding. Stent inserted

Post repeat ERCP Remained asymptomatic No further GI bleeding Discharged with planned ERCP and Cholecystectomy in 6 weeks’ time

Superselective embolization of lower GI hemorrhage

Etiologies of Lower GI bleeding Most common in the elderly Variety of causes : - Diverticular disease (10% to 20% risk) - Neoplasia ( Ca colon causes 5% of major bleeding) Boley et al, Am J Surg 1979 - Angiodysplasia (right colon, <10% risk)

Evaluation Recurrent minor bleeding: colonoscopy Severe but intermittent, stable patient: Tc-99M RBC scanning Hemodynamically unstable patient: angiography Helical CT: 80% accurate in some series Ernst et al, Eur Radiol 2003

History Rosch and Bookstein, early 1970s Ischemic complications was13% to 33% Throughout the 1980s it was a taboo Dissatisfaction with vasoconstriction methods led renew interest in embolization in 1990s

Coaxial Microcatheters Range in size from 2.5 to 3 F 5-French catheter may be used to select a first-order vessel microcatheter can be advanced through this catheter more distally

Superselective Catheterization Distal arteries, close to bleeding points Embolic material is deployed It limits the segment of bowel at risk for ischemia

Choice of embolic Gel foam Polyvinyl alcohol particles Microcoils some combination

Published experience Guy et al, 1992, reported 10 superselective embolization procedures in nine patients. All procedures were successful Gordon et al, 1997: 17 cases of microcatheter embolization using microcoils, gel foam, and polyvinyl alcohol particles. Success rate was 76%. No bowel ischaemia

Published experience >100 successful embolization have been reported 1997 – 2002 Clinical success ranged from 44% to 91% Ischemic complications ranged from 0% to 6% Funaki et al, AJR, 2001 Bandi et al, J Vasc Interv Radiol, 2001

Published experience Tan et al, 2008. 265 patients underwent angiography for GI bleeding. 32 ( 12%) had superselective embolization for lower GI hemorrhage In 31 patients (97%) technical success was achieved 7 had re-bleed 1 had bowel ischaemia

Limitations of embolization Colonic bleeding is multifactorial - Diverticular bleed vs. Angiodysplasia Patients who are not actively bleeding Difficult vascular anatomy or severe atherosclerotic disease “Symptomatic treatment”

Summary Minimally invasive techniques have replaced surgical resection as the initial therapies of choice Superselective embolization and endoscopic treatment appear complementary

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