Massive Colonic Bleed

John Hartley, The University of Hull, Academic Surgical Unit

Powerpoint File

Lower gastrointestinal bleeding is a common source of referral to colon and rectal surgeons.

Presentation usually falls within one of three broad categories:

1. Occult bleeding, often manifest as iron deficiency anaemia with positive faecal occult bloods.

2. Overt haemorrhage with visible blood per rectum which is typically intermittent, modest in amount, and self limiting.

3. Significant lower gut haemorrhage with the passage of large amounts of blood and haemodynamic compromise.

The former two groups of patients often present little difficulty in elective diagnosis and management. However, the latter group of patients whilst much less common, may present a significant challenge to the acute surgeon in terms of investigation and management. It is this group of patients which form the basis of this presentation.

Such patients with major lower gut bleeding are typically elderly, and often have significant co-morbidity. The commonest causes of bleeding are diverticular disease, angiodyplasia, neoplasia, and inflammatory bowel disease, with the former two being the more frequent. However, in the absence of a neoplasm or inflammatory bowel disease it may be impossible to be certain about the precise cause of bleeding, since at subsequent elective investigation in patients who stop bleeding, diverticular disease is likely to be common. Haemorrhoids can cause heavy bleeding and it is vital that adequate rectal examination is performed if such patients are to avoid being being subjected to further inappropriate investigation and even laparotomy

.

The initial management of brisk rectal bleeding should focus upon adequate resuscitation which requires appropriate intravenous access, volume resuscitation, administration of blood products as necessary, and close monitoring. With these basic supportive measures approximately 85% of patients will stop bleeding spontaneously and can thereafter undergo some form of semi-elective colonic evaluation determined by the age and general condition of the patient as well as local practice and expertise.

Those who continue to bleed or repeatedly bleed in a brisk manner present more urgent problems. Such patients in whom surgery is contemplated should have an upper GI cause for their bleeding excluded. Traditionally insertion of nasogastric tube and aspiration has been advocated for this purpose, however urgent upper GI endoscopy is more reliable. Historically emergency colectomy for bleeding has been associated with operative mortality in the region of 10 to 36%. Most series have suggested that most significant bleeding originates from the right colon – from either angiodysplasia or right sided diverticula. However blind right, or indeed left hemicolectomy, is associated with significant rates of re-bleeding and cannot be recommended. The procedure of choice in the blind situation (that is where preoperative investigation have not localised a bleeding source) should be total abdominal colectomy with either end ileostomy or ileorectal anastomosis at the surgeons discretion. Therefore time and facilities permitting some efforts at localising the source of bleeding to right or left colon are appropriate.

Modalities available include radionucleotide scanning, urgent colonoscopy, or angiography. The former technique utilises either sulphur colloid or technetium labelled red cells. Sulphur colloid scans is suitable only for active bleeding at a rate of at least 0.1ml per minute, but is highly sensitive and can be repeated where necessary, the procedure taking approximately 30 minutes to complete. Technetium labelled red cell scans are also useful in intermittent bleeding, but can take up to 24hrs to perform and is therefore of limited utility in the emergency situation. Neither technique is widely available out of hours in the United Kingdom.

Colonoscopy is generally performed in this country in the semi-elective situation in which patients who have stopped bleeding are then examined following conventional bowel preparation. However, urgent colonoscopy in the actively bleeding patient is more commonly performed in other health care systems. The procedure requires urgent bowel preparation, if necessary via a nasogastric tube, over a 1 to 2 hour period, which may present major practical difficulties. The technique appears to have genuine diagnostic utility in the emergency setting. There are also claims for therapeutic benefit with either adrenalin injection of bleeding points, or argon beam coagulation. However, since a substantial proportion of lower GI bleeds will stop spontaneously, the true efficacy of therapeutic colonoscopy in this setting remains uncertain.

Emergency angiography for lower gut bleeding requires vascular radiological expertise and is highly operator dependent. However, the technique offers not only diagnostic but also therapeutic potential and in our hands represents the procedure of choice in the emergency management of lower gut bleeding. Initial attempts at therapeutic angiography involved vasopressin infusions which have largely fallen aside because of concerns over cardiovascular complications and mesenteric ischaemia. Selective arterial embolisation for colonic bleeding was first reported over 20 years ago but was limited at that time by the incidence of colonic infarction. In recent years the development of superselective angiography means that virtual end arteries, and critically beyond the marginal artery – can be embolised with a lesser risk of colonic infarction. Importantly the ability to identify a bleeding point at angiography requires that the patient be actively bleeding at the time of the examination. In our initial experience amongst patients who were haemodynamically unstable and who were destined for emergency laparotomy should embolisation fail, contrast extravasation was identified in 17 of 38 patients (45%). Fourteen of these patients were embolised with platinum microcoils and immediate haemostasis was achieved in 12 of these, thus obviating the requirement for emergency surgery. A more recent study has shown that three of these patients subsequently ischaemic complications although all were managed conservatively, and perhaps more importantly only one patient was thereafter admitted with further bleeding. Thus in our view angiography with the aim of endovascular achievement of haemostasis should be the procedure of choice in haemodynamically unstable patients with lower gut bleeding. Furthermore, where this technique is successful it appears likely to serve as definitive long term management in a substantial proportion of patients.

Summary

Major haemorrhage from the lower gut requiring emergency intervention is unusual. The successful management of such patients requires a multidisciplinary approach. Having excluded upper gastrointestinal and anorectal sources emergency angiography is of value in achieving haemostasis and avoiding emergency surgery in this high risk situation. Those patients who come to emergency surgery should undergo abdominal colectomy rather than a segmental resection unless a bleeding source has been unequivocally identified.

References

1. Cormon ML. Vascular disease. In Corman ML, ED. Colon and rectal surgery. Philadelphia: JB Lippincott, 1993: 860-900.

2. Leitman IM, Paull AE, Shires GT. Evaluation and management of massive lower intestinal haemorrhage. Am Surg 1989; 209: 175-180.

3. Sherman LM, Shenoy SS, Cerra FB. Selective intraarterial vasopressin: Clinical efficacy and complication. Ann Surg 1979; 189: 298-302.

4. Bookstein JJ, Chlosta EM, Foley D, Walter JF. Transcatheter Haemostasis of gastrointestinal haemorrhage using modified autogenous clot. Radiology 1974; 113: 277-285.

5. Rosenkrantz H, Bookstein JJ, Rosen RJ, et al. Post embolic colonic infarction. Radiology 1982; 142: 47-51.

6. Nicholson, Ettle DF, Hartley JE, Curzon I, Lee PWR, Duthie GS, Monson JRT. Transcatheter coil embolotherpy: a safe and effective option for major colonic haemorrhage. Gut 1998;43:79-84.