eMedicine Specialties > General Surgery > Colorectal

Lower Gastrointestinal Bleeding, Surgical Treatment: Treatment

Author: Burt Cagir, MD, FACS, Assistant Professor of Surgery, State University of New York, Upstate Medical Center; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic
Coauthor(s): Elizabeth Cirincione, MD, Director of Colon and Rectal Surgery, Department of Surgery, Nassau University Medical Center
Contributor Information and Disclosures

Updated: Oct 29, 2009

Treatment

Medical Therapy

Vasoconstrictive agents

Initially, vasoconstrictive agents, such as vasopressin (Pitressin), can be used. An experimental study of treatment of lower GI bleeding by selective arterial infusion of vasoconstrictors, such as epinephrine with propranolol and vasopressin, was reported. Although epinephrine and propranolol drastically reduced mesenteric blood flow, they also caused a rebound increase in blood flow and recurrent bleeding. Vasopressin is a pituitary hormone that causes severe vasoconstriction in the splanchnic bed. Vasoconstriction reduces the blood flow and facilitates hemostatic plug formation in the bleeding vessel. The results are less than satisfactory in patients with severe atherosclerosis and coagulopathy.

Following positive angiogram findings, the angiographic catheter is left in place and vasopressin infusion is started at a rate of 0.2 unit/min. A repeat angiogram is obtained every half hour, and the rate of infusion is increased up to 0.4 unit/min if bleeding continues. Vasopressin doses above 0.4 unit/min are not recommended because of the high rate of potential complications. If hemorrhage remains controlled, the dose of vasopressin is reduced to half every 6-12 hours. The angiographic catheter, following an additional 6-12 hours of saline infusion, is removed. If vasopressin infusion fails to control the hemorrhage, patients should undergo a segmental resection.

The initial experience with vasopressin infusion was reported in 1973-1974. Twenty-four patients were included in this study. In 22 of the patients, bleeding was controlled. Of these, 12 received no further therapy and were discharged. Three patients (25%) developed recurrent bleeding within 2-12 months of discharge. Selective vasopressin infusion was used as the sole treatment and arrested the bleeding in 36-100% of the cases. Because the rebleeding rates fluctuated between 27-71%, vasopressin infusion was used in the acute event to stabilize patients prior to surgery.

During vasopressin infusion, monitor patients for recurrent hemorrhage, myocardial ischemia, arrhythmias, hypertension, and volume overload with hyponatremia. Nitroglycerine paste or drip can be used to overcome cardiac complications. Selective mesenteric infusion induces bowel wall contraction and spasms, which should not be confused with bowel wall ischemia. Do not administer vasopressin into systemic circulation intravenously because this causes coronary vasoconstriction, diminished cardiac output, and tachyphylaxis.

Superselective embolization

Superselective embolization of the mesenteric vessels is an alternative technique for treating massive lower GI bleeding. Rösch and colleagues first described this technique in 1972. Autologous clot, Gelfoam, polyvinyl alcohol, microcoils, ethanolamine, and oxidized cellulose can be used as embolic agents.2,13 Embolization involves superselective catheterization of the bleeding vessel to minimize necrosis, the most feared complication of ischemic colitis.

Rosenkrantz et al reported 3 cases of colonic infarction.14 One patient died following segmental colectomy, and the other patients revealed full-thickness bowel wall injury in the resected specimen. Intestinal ischemia and infarction have also been reported. To prevent this complication, perform embolization beyond the marginal artery as close as possible to the bleeding point in the terminal mural arteries. A total of 139 cases have been collected from the medical literature since 1972.

Overall bleeding was controlled in 115 patients (83%), with a rebleeding rate of 11% (15 patients). Complications were observed in 20%, and bowel injury and perforation were observed in 12% (16 patients). The overall mortality rate was 11% (15 patients); thus, careful patient selection is necessary for this procedure. Use embolization in high-risk patients whose conditions are refractory to conservative management. If terminal mural branches of the bleeding vessel cannot be catheterized, abort the procedure and immediately perform surgery.

Kuo et al evaluated the safety and effectiveness of superselective microcoil embolization for the treatment of lower GI bleeding in 2003.15 Twenty-two patients with angiographic evidence of lower GI bleeding underwent superselective microcoil embolization during a 10-year period. Complete clinical success was achieved in 86% of patients with a rebleeding rate of 14%. Minor and major ischemic complication rates were reported as 4.5% and 0%, respectively.

The authors also reviewed the data from 122 cases of lower GI superselective microcoil embolization in the literature. The meta-analysis was performed in 144 patients. This combined analysis revealed a minor ischemic complication rate of 9% and a major ischemic complication rate of 0%. It was concluded that superselective microcoil embolization is a safe and effective treatment of acute lower GI hemorrhage.

Colonoscopy

Colonoscopy has become the first choice of diagnostic modality following rapid purge with volume cathartics, such as GoLYTELY. Jensen and Machicado have evaluated the role of urgent colonoscopy after purge prospectively in 80 consecutive patients with severe hematochezia.16 Urgent colonoscopies were performed in the intensive care unit. Seventy-four percent of patients had colonic lesions, 11% had upper GI lesions, and 9% had presumed small bowel lesions; in 6%, no bleeding site was identified. Although Jensen and Machicado recommended that EGD be performed prior to colonoscopy, upper and lower endoscopies can be performed simultaneously.

In another study, colonoscopy yielded a diagnosis in 90% of the patients, which provided opportunity for therapy at the same time. The patients who underwent colonoscopic evaluation had a significantly shorter hospital stay. Perform the urgent colonoscopy in the operating room or endoscopy suite on hemodynamically stable patients. If patients become unstable or colonoscopy reveals an active fulminant inflammation, abort the procedure.

Endoscopic coagulation

The treatment options for angiodysplasias are numerous, including segmental bowel resection and selective mesenteric embolization. Endoscopic coagulation of angiodysplasias is becoming a treatment of choice using either heated probe or lasers, such as Nd:YAG and argon. Argon laser treatment is recommended for mucosal or superficial lesions because the energy penetrates only 1 mm. Nd:YAG lasers are more useful for deeper lesions because they penetrate 3-4 mm.

Hunter et al evaluated 222 GI endoscopic laser procedures in 122 patients. Hemorrhage was arrested in 84% of the patients with GI bleeding. No perforations were reported in this series. One death occurred and was attributed to laser therapy in a patient with duodenal ulcer and gastroduodenal artery bleeding.

Forty patients with GI arteriovenous malformations underwent 72 photocoagulation sessions with mostly argon laser. Of those 40 patients, 15 had significant hemorrhage from colonic arteriovenous malformations. No deaths occurred in ablation of GI arteriovenous malformations in 15 patients with colonic lesion.

One of the advantages of upper or lower endoscopic evaluation is that it provides access to therapy in patients with GI bleeding. Endoscopic control of bleeding can be achieved using thermal modalities or sclerosing agents. Absolute alcohol, morrhuate sodium, and sodium tetradecyl sulfate can be used for sclerotherapy of upper and lower GI lesions.

Endoscopic thermal modalities (eg, laser photocoagulation, electrocoagulation, heater probe) can also be used to arrest hemorrhage. Endoscopic control of hemorrhage is suitable for GI polyps and cancers, arteriovenous malformations, mucosal lesions, postpolypectomy hemorrhage, endometriosis, and colonic and rectal varices.

The medical literature has also been reviewed for endoscopic treatment of significant lower GI bleeding. A total of 286 patients were identified in 8 publications. Hemorrhage was successfully arrested in 70% of patients, with a rebleeding rate of 15%. Endoscopic therapy for lower GI bleeding is a minimally invasive and viable option in carefully selected patients.17

Surgical Therapy

An emergency operation is required in approximately 10% of patients with lower GI bleeding. When the bleeding point is localized, perform a limited segmental resection of the small or large bowel. The crude outcome analysis was applied to 483 cumulative cases of limited segmental resection derived from 23 publications since 1974. The rebleeding rate was 7% (0-21%), and the mortality rate was 10% (0-15%). A morbidity rate of 0-33% was reported in only a very few publications; thus, limited segmental resection is preferred because it can be performed with low morbidity, mortality, and rebleeding rates.

If the patient is hemodynamically unstable because ongoing hemorrhage, perform an emergency operation before any diagnostic study.

In these cases, make every attempt to diagnose the bleeding point intraoperatively. Intraoperative EGD, surgeon-guided enteroscopy, and colonoscopy may be helpful in diagnosing undiagnosed massive GI bleeding. Depending on the availability of local resources and the patient's condition, it may sometimes be better to perform subtotal colectomy with distal ileal inspection than to try to achieve these other tests, particularly if the surgeon is not privileged or comfortable with endoscopy.

If the bleeding point cannot be diagnosed following a thorough intraoperative endoscopy and examination and if evidence points to colonic bleeding, perform a subtotal colectomy with ileorectal anastomosis. Subtotal colectomy is a rational option because it is associated with a very low rebleeding rate (3%) and with acceptable average morbidity (32%) and mortality (19%) rates.

Practitioners must understand that blind segmental resection should not be performed because of a prohibitively high rebleeding rate of up to 75%, a morbidity rate up to 83%, and a mortality rate up to 60%. Once the bleeding point is identified, a limited segmental resection should be performed.

Patients who have experienced multiple episodes of lower GI bleeding without a known source or diagnosis should undergo elective mesenteric angiography, upper and lower endoscopy, Meckel scan, upper GI with small bowel series, and enteroclysis. Elective evaluation of the entire GI tract may identify uncommon lesions and undiagnosed arteriovenous malformations.

  • Rare causes of lower GI bleeding
    • Chronic radiation enteritis/proctitis
    • Ischemic colitis/mesenteric vascular insufficiency
    • Small bowel diverticulosis
    • Meckel diverticulum
    • Colonic/rectal varices
    • Portal colopathy
    • Solitary rectal ulcer syndrome
    • Diversion colitis
    • Dieulafoy lesion of colon
    • Dieulafoy lesion of small bowel
    • Vasculitides
    • Small bowel ulceration
    • Intussusception
    • Endometriosis
    • GI bleeding in runners
If the bleeding point is diagnosed by mesenteric angiography, vasopressin infusion can be temporarily used to control the hemorrhage to stabilize the patient in anticipation of semiurgent segmental bowel resection. Use selective mesenteric embolization in high-risk patients for whom the operative management is associated with prohibitive risk of morbidity and mortality. If mesenteric embolization is used, these patients must be carefully monitored for bowel ischemia and perforation. Any evidence of ongoing bowel ischemia and/or unexplained sepsis following mesenteric embolization requires exploratory laparotomy to resect the affected bowel segment. Perform subtotal colectomy with ileoproctostomy in patients with multiple episodes of nonlocalized lower GI bleeding or bilateral sources of colonic hemorrhage.

Preoperative Details

Acute lower GI hemorrhage is a common clinical entity and is associated with significant morbidity and mortality. Mortality rates associated with lower GI hemorrhage are reported to be 10-20% and are dependent on age (>60 y), multiorgan system disease, transfusion requirements (>5 units), need for operation, and recent stress (eg, surgery, trauma, sepsis).

Three major aspects are involved in managing lower GI hemorrhage. The initial priority is to treat the shock. Second, localization of the source of bleeding is required to perform the third task—formulating an interventional plan. Insert a nasogastric tube in all patients. A clear bile-stained aspirate generally excludes bleeding proximal to the Treitz ligamentum. After initial resuscitation, undertake a search for the cause of the bleeding to precisely locate the bleeding point.

Following accurate localization by angiogram, bleeding can be temporarily controlled with either angiographic embolization or vasopressin infusion. Segmental bowel resection is performed in the next 24-48 hours following correction of the patient's physiologic parameters, which include hypotension, hypothermia, acute hemorrhagic anemia, and deficient coagulation factors.

Intraoperative Details

Surgical intervention is required in only a small percentage of patients with lower GI hemorrhage. The surgical option depends on whether the bleeding source has been accurately identified preoperatively; if so, it is then possible to perform segmental intestinal resection.

If the bleeding source is unknown, an upper GI endoscopy should be performed prior to any surgical exploration. At celiotomy, identifying the bleeding point is often impossible, as blood refluxes into the proximal and distal bowel. The abdominal cavity is explored through a midline vertical incision. The assistance of a gastroenterologist is required for intraoperative endoscopic evaluation. The colonoscope is introduced, and the surgeon assists its passage. On-table colonic lavage and colonoscopy may identify the colonic source of bleeding. Surgeon-guided intraoperative small bowel enteroscopy is also performed when no colonic source of bleeding is identified. Again, the colonoscope can be used for this procedure.

Unlike colonoscopy, enteroscopy is performed during the advancement of the scope. Colonoscopic manipulation of the small bowel may cause iatrogenic mucosal tears and hematomas, which may be mistakenly identified as a source of bleeding. Another intraoperative strategy is to clamp segments of the bowel with noncrushing intestinal clamps to identify the segment that fills with blood. If the bleeding point cannot be diagnosed through intraoperative pan-intestinal endoscopy and examination and if evidence points to a colonic bleeding, perform a subtotal colectomy with end ileostomy.

Postoperative Details

Hypotension and shock are the eventual consequences of blood loss, but this depends on the rate of bleeding and the patient's response. Clinical development of shock may precipitate myocardial infarction, cerebrovascular accident, and renal or hepatic failure. Azotemia occurs in patients with GI blood loss.

Follow-up

Postoperative office visits every 2 weeks are essential to ensure proper wound healing. Upon discharge, a general diet abundant in fruits and vegetables is recommended. Patients are instructed to drink 6-8 glasses of fluid per day. Psyllium seed preparations should also be started.

Complications

Patients who have had surgery of the lower GI tract are prone to the development of complications. The most common early postoperative complications are intra-abdominal or anastomotic bleeding, ileus, mechanical small bowel obstruction (SBO), intra-abdominal sepsis, localized or generalized peritonitis, wound infection and/or dehiscence, Clostridium difficile colitis, pneumonia, urinary retention, urinary tract infection (UTI), deep venous thrombosis (DVT), and pulmonary embolus (PE).

Intra-abdominal sepsis following colorectal surgery is a life-threatening complication and requires aggressive resuscitation. Systemic conditions (eg, severe blood loss and shock, poor bowel preparation, irradiation, diabetes, malnutrition, hypoalbuminemia) may adversely affect anastomotic healing. Changes in anatomy and physiology of the large bowel, high bacterial content, improper operative technique, tension, and ischemia can cause anastomotic leak associated with abscess and intra-abdominal sepsis. This condition requires either laparotomy (if the sepsis is generalized) or percutaneous drainage (if the sepsis is localized).

Delayed complications usually occur more than a week after surgery. The most common delayed complications are anastomotic stricture, incisional hernia, and incontinence.

More on Lower Gastrointestinal Bleeding, Surgical Treatment

Overview: Lower Gastrointestinal Bleeding, Surgical Treatment
Workup: Lower Gastrointestinal Bleeding, Surgical Treatment
Treatment: Lower Gastrointestinal Bleeding, Surgical Treatment
Follow-up: Lower Gastrointestinal Bleeding, Surgical Treatment
Multimedia: Lower Gastrointestinal Bleeding, Surgical Treatment
References
Further Reading
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References

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Further Reading

Clinical guidelines:
ACR Appropriateness Criteria® left lower quadrant pain. American College of Radiology - Medical Specialty Society. 1996 (revised 2008). 5 pages. NGC:006988

ACR Appropriateness Criteria® treatment of acute nonvariceal gastrointestinal tract bleeding. American College of Radiology - Medical Specialty Society. 2006. 6 pages. NGC:005537

ASGE guideline: the role of endoscopy in the patient with lower-GI bleeding. American Society for Gastrointestinal Endoscopy - Medical Specialty Society. 2005 Nov. 5 pages. NGC:004584

Practice parameters for the management of hemorrhoids (revised). American Society of Colon and Rectal Surgeons - Medical Specialty Society. 1993 (revised 2005 Feb). 6 pages. NGC:004337

Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). American Society of Colon and Rectal Surgeons - Medical Specialty Society. 1996 (revised 2005 Jul). 6 pages. NGC:004432

Clinical trials:
A Study To Investigate The Safety And Efficacy Of CP- 690,550 In Patients With Moderate And Severe Ulcerative Colitis.

Mechanistic Randomized Controlled Trial (RCT) of Mesalazine in Symptomatic Diverticular Disease

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Keywords

lower gastrointestinal bleeding, gastrointestinal bleeding, rectal bleeding, colectomy, gastrointestinal endoscopy, gastrointestinal bleed, lower GI bleeding, rectal hemorrhage, lower diverticular hemorrhage, diverticular bleeding, diverticulosis, anorectal diseases, inflammatory bowel disease, IBD, angiodysplasias, small bowel diverticulosis

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Contributor Information and Disclosures

Author

Burt Cagir, MD, FACS, Assistant Professor of Surgery, State University of New York, Upstate Medical Center; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic
Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, and Society for Surgery of the Alimentary Tract
Disclosure: Nothing to disclose.

Coauthor(s)

Elizabeth Cirincione, MD, Director of Colon and Rectal Surgery, Department of Surgery, Nassau University Medical Center
Elizabeth Cirincione, MD is a member of the following medical societies: American College of Surgeons and American Society of Colon and Rectal Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Marc D Basson, MD, PhD, MBA, Professor, Chair, Department of Surgery, Michigan State University
Marc D Basson, MD, PhD, MBA is a member of the following medical societies: American College of Surgeons and American Gastroenterological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael A Grosso, MD, Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital
Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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