Transcript template

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 # 2
Aorto-bi-iliac graft
aorto-renal artery graft
for aortoiliac disease
History of Present Illness
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•
•
•
•
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?
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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 Sig
15 – 60 cm
loss of vascular pattern
intense erythema, purple
discoloration
Plan?
Hospital Course
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•
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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…..
Now What?
• 12 Hours later - Massive bleed!!
– Blood from rectum…
– Blood from Colostomy…
– Blood per NGT…
Operative Findings
• 2 liters of blood in abdomen
• Dehiscence of proximal aortic
anastomosis
• Fistula to 3rd portion of duodenum
• Dehiscence of rectal stump
• Repair of graft and rectal stump
Aorto-Enteric Fistula
• Incidence less than 1%
• 4th 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”)
Hematemasis
Back or Abd pain
Melena
Shock
Pulsatile mass
Syncope
94
78
48
46
33
17
10
Diagnostic Tools in Patients with
enteric Fistula
Aorto-
Detection Rate (%)
CT
Angiography
EGD
Technetium scan
Enteroclysis
Colonoscopy
Ultrasound
Barium enema
61
26
25
14
13
10
0
0
Prognosis - Aorto-Enteric Fistula
• Early Mortality
21%
• Late Mortality
24%
• 5-Year Survival
61%
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?
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•
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Intestinal duplication
Juvenile polyp
FAP
Meckel’s diverticulum
IBD
Work Up?
• EGD
Negative
• Colonoscopy
Negative
• Other Tests
?
Meckel’s
Scan
Negative
Tagged
RBC Scan
Negative
What Now??
Second
Meckel’s
Scan
Positive!
Treatment ?
• Operation Laparoscopic 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
Ectopic tissue
Gastric
Pancreatic
Carcinoid
Duodenal
Lipoma
Leiomyosarcoma
Diverticulitis
Enterolith
No Abnormality
Patients
No.
%
59
9
4
3
2
1
45
11
46
33
5
2
2
1
0.6
25
6
25
*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
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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
• 1990 - Gastric ulcer
• Coronary Artery Disease – MI x 2
Differential Diagnosis
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•
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Diverticular bleed
Angiodysplasia
Carcinoma
UGI Source
– recurrence of gastric ulcer?
Work Up?
• EGD
NGT related erosions only
• Colonoscopy
Blood 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
Negative
• Provocative Angiogram:
– Access through common femoral artery
– IMA, the SMA
Now What?
– Heparin - 5000U
– tPA - 10 to 50mg in 5mg increments
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 mortality2
1Welch
et al. Adv Surg 1973;7:95
2Hoedema et al. Dis Colon Rectum 2005;48:2010
Mesenteric Angiography
*Vernava et al. Dis Colon Rectum 1997;40:846-858.
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
Rate (%)
Mortality
(%)
Write
Browder
Nath
Welch
Boley
20
17
16
42
27
0
0
0
10
15
0
0
0
2
4
*Vernava et al. Dis Colon Rectum 1997;40:846-858.
Blind Segmental Colectomy
Author
N
Re-bleed
Rate (%)
Mortality
(%)
McGuire
Casarella
Eaton
Drapanas
5
4
24
23
40
50
75
35
20
50
50
30
*Vernava et al. Dis Colon Rectum 1997;40:846-858.
Subtotal Colectomy
Author
N
Re-bleed
Rate (%)
Mortality
(%)
Eaton
Drapanas
Welch
Britt
Abcarian
4
35
10
10
10
0
0
0
0
60
0
11
10
20
40
Vernava et al. Dis Colon Rectum 1997;40:846-858
Pitfalls of Blind Subtotal Colectomy*
Procedure
Re-bleed
TAC, IRA
TAC, IRA
TAC, IRA
TAC, IRA
TAC, IRA(2)
Yes
Yes
Yes
Yes (died)
Yes (both died)
Final Diagnosis
Bleeding Hemorrhoids
Solitary Rectal Ulcer
LB & SB Ectasias
Osler-Weber-Rendu
Unknown
*Abcarian et al. Dis Colon Rectum 1982;25:441-445
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
Symptoms
Possible Diagnosis
Abd. pain & bleeding
Ischemic 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
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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