THE CONUNDRUM OF LOWER GASTROINTESTINAL BLEEDING

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Lower gastrointestinal (GI) bleeding is considered massive and serious in nature if transfusions of 3 to 5 units of blood are required over 24 hours to maintain stability 2268; other criteria include hematocrit under 30, orthostatic changes in blood pressure, and a requirement for any quantity of transfused blood products.49 Massive hematochezia occurs principally in the elderly, with the average age of such patients around 60 years in most series 7 and a mortality of up to 21%.4, 22, 33, 36 It is indeed a conundrum for a number of reasons: First, bleeding may originate from any portion of the GI tract. Second, the bleeding is often intermittent, and the source may be difficult or impossible to identify when it is not actively bleeding. Third, this is a condition in which emergency surgery, with significant morbidity and mortality, may be required before a specific diagnosis, or even a specific site of bleeding, can be identified. Fourth, even radical surgical therapy may not prevent recurrent bleeding. Fifth, there is no universally applicable sequence of investigations or treatments.

Several pathologic entities may result in massive lower GI bleeding; however, the most common sources include diverticula, arteriovenous malformations, inflammatory bowel disease, neoplasms, and internal hemorrhoids (Table 1). Further, the clinician can often narrow the differential diagnosis to the more common causes by age group (Table 2).

Section snippets

EVALUATION OF THE ACTIVELY BLEEDING PATIENT

The specific sequence of diagnostic studies is determined primarily by the clinical status of the patient and by the rate and pattern of bleeding. In the setting of sudden onset of massive hematochezia, the history should include questions about dyspepsia, use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), as well as about abdominal and anorectal complaints, such as anal bleeding, pain, or protrusion; change in bowel habits; or similar past episodes of hematochezia. Resuscitation

Technetium-Labeled Red Blood Cell Scanning

If no immediately obvious source of bleeding is found by nasogastric aspiration and by anorectal examination, and if the bleeding is thought to be ongoing, a Tc-labeled RBC scan is a noninvasive but potentially very helpful study that can be done rapidly and often gives a general idea of the site of the bleeding. This study is useful only for localization of bleeding sites and not for making a specific diagnosis; it has no therapeutic benefit, except to direct further intervention. False

Diverticular Bleeding

The average age for people with lower GI bleeding is about 60 years, and by this age virtually everyone has developed colonic diverticula. The cause is currently thought to be increased segmental intraluminal pressure, which causes a segment of mucosa to extrude at the relatively weaker areas of the muscularis propria, which are the sites of the penetrating arterial vasa recta. These pseudodiverticula then lie immediately adjacent to the vasa recta. It is not known what initiates bleeding in

THE BLEEDING PATIENT WITHOUT SPECIFIC LOCALIZATION

It is occasionally necessary to contemplate surgical intervention without a clear idea of the specific site of bleeding. Reasons for this are generally either that the patient is believed to be hemodynamically too unstable to permit Tc-labeled RBC scanning, arteriography, or other diagnostic studies, or that these studies are not available or do not disclose the site of bleeding, or because of repeated episodes of severe bleeding on the same or subsequent hospital admissions. Exploratory

THE PATIENT WITH RECURRENT SELF-LIMITED BLEEDING

In about 5% of patients with GI bleeding, standard evaluation fails to reveal the source of the bleeding.60 In addition to repeated examination with colonoscopy and esophagoduodenoscopy, additional studies are potentially helpful in finding small bowel sources of bleeding. Small-bowel follow-through examination has the advantages that it requires minimal preparation, is relatively inexpensive, and is easily tolerated. Enteroclysis, a double-contrast technique of examination of the small bowel,

SUMMARY

Acute massive hematochezia provides one of the greatest diagnostic and therapeutic challenges to the physician. Although most patients stop bleeding spontaneously and further evaluation can be carried on with less urgency, 10% to 15% require urgent diagnostic and therapeutic procedures. Clearly, the least invasive effective solution to the bleeding problem is generally the best, although in some cases, emergency undirected surgery may be necessary. Subtotal colectomy can be done with acceptable

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