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REVIEW
The management of lower gastrointestinal bleeding Y. Marion a,d,∗, G. Lebreton a,d, V. Le Pennec b,d, E. Hourna b,d, S. Viennot c,d, A. Alves b,d a
Service de chirurgie digestive, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France b Service de radiologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France c Service de gastro-entérologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France d Université de Caen, faculté de médecine, 14000 Caen, France
KEYWORDS Lower gastrointestinal bleeding; Angiography; Endoscopy; Video capsule endoscopy; Enteroscopy; Surgery
∗
Summary Lower gastrointestinal (LGI) bleeding is generally less severe than upper gastrointestinal (UGI) bleeding with spontaneous cessation of bleeding in 80% of cases and a mortality of 2—4%. However, unlike UGI bleeding, there is no consensual agreement about management. Once the patient has been stabilized, the main objective and greatest difficulty is to identify the location of bleeding in order to provide specific appropriate treatment. While upper endoscopy and colonoscopy remain the essential first-line examinations, the development and availability of angiography have made this an important imaging modality for cases of active bleeding; they allow diagnostic localization of bleeding and guide subsequent therapy, whether therapeutic embolization, interventional colonoscopy or, if other techniques fail or are unavailable, surgery directed at the precise site of bleeding. Furthermore, newly developed endoscopic techniques, particularly video capsule enteroscopy, now allow minimally invasive exploration of the small intestine; if this is positive, it will guide subsequent assisted enteroscopy or surgery. Other small bowel imaging techniques include enteroclysis by CT or magnetic resonance imaging. At the present time, exploratory surgery is no longer a first-line approach. In view of the lesser gravity of LGI bleeding, it is most reasonable to simply stabilize the patient initially for subsequent transfer to a specialized center, if minimally invasive techniques are not available at the local hospital. In all cases, the complexity and diversity of LGI bleeding require a multidisciplinary collaboration involving the gastroenterologist, radiologist, intensivist and surgeon to optimize diagnosis and treatment of the patient. © 2014 Elsevier Masson SAS. All rights reserved.
Corresponding author. Service de chirurgie digestive, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France. E-mail address: [email protected] (Y. Marion).
http://dx.doi.org/10.1016/j.jviscsurg.2014.03.008 1878-7886/© 2014 Elsevier Masson SAS. All rights reserved.
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Introduction
Etiologies
Lower gastrointestinal (LGI) bleeding is defined as bleeding whose origin is located downstream of the duodeno-jejunal junction at the ligament of Treitz, thus including the small intestine, colon, rectum or anus. Clinical manifestations are melena or hematochezia. We speak of obscure LGI bleeding when one or more episodes of bleeding occur for which no site of origin is identified by standard endoscopy, and of occult gastrointestinal bleeding when no gross blood is observed by the patient or clinician yet there is evidence of bleeding manifested by iron-deficiency anemia with no identified extra-intestinal source of blood loss. In recent years, diagnostic and treatment modalities have developed considerably for use by gastroenterologists, radiologists and surgeons. However, the main problem of LGI bleeding remains the identification of the source rather than the treatment of bleeding.
In specifying the frequent and problematic causes, the prevalence of various etiologies is purely illustrative given the great variability of results in the literature [1,6—8]. Moreover, despite all diagnostic testing, the source of bleeding cannot be identified in approximately 10% of patients [9].
General Epidemiology LGI bleeding represents 20% to 25% of all gastrointestinal bleedings [1]. Epidemiological studies are rare. North American studies have estimated the annual incidence in adults at 21—27 per 100,000 population [2,3]. LGI bleeding occurs more frequently in men than in women (24.2% vs. 17.2%, P < 0.001) and more often in the elderly than in young subjects (∼200-fold increase in the 9th decade compared to the 3rd decade of life) [3]. This increased incidence is explained by the increasing prevalence of diverticulosis and angiodysplasia with age [2]. The mortality of LGI bleeding is estimated at 2—4% in various series [2,4]. A prospective epidemiological study carried out in France in 2007 by the National Association of General Hospital Gastroenterologists identified 1333 patients with LGI bleeding. The mean age was 72 ± 16 years; ASA (American Society of Anesthesiologists) score was 2.5 ± 0.9 and 50% of patients had an ASA of 3. Use of a predisposing medication was found in nearly 75% of patients (34% antiplatelet agents, 22% antivitamin K agents, 11% non-steroid anti-inflammatory drugs [NSAID], 7% heparin) [5].
Severity criteria The gravity of LGI bleeding is generally less severe than that of UGI bleeding; hemorrhage ceases spontaneously in 80% of cases [6]. Currently, there is no consensus definition of the severity of LGI bleeding. Severity is assessed according to its hemodynamic consequences, laboratory findings and underlying patient condition [2,6]: • systolic blood pressure 100/min; • hemoglobin 0.5 mL/min) [21]; this identifies the source of bleeding with certainty. Like CTA, the diagnostic efficacy of arteriography is high if it is performed during a period of active bleeding; its sensitivity for detection of the bleeding site ranges from 40 to 86% in literature reports [44] with a specificity of 100% [2]. Factors favoring successful detection of a bleeding site by arteriography include: hemodynamic instability, a 50% drop in hemoglobin, and transfusion of >5 units of packed RBCs in 24 hours; however, arteriography is not without complications; the incidence is estimated at 9.3% (arterial puncture site complications, contrast-related renal failure, etc.) [45]. If the arteriography is negative, some authors have proposed the injection of heparin, vasodilators and thrombolytic agents in situ to increase the diagnostic yield of angiography. In a retrospective study of 36 patients with
5 recurrent LGI bleeding (after diagnostic failure of angiography in 24 cases), this procedure allowed detection of the bleeding site in eleven patients (31%) with no reported complications [46]. These results seem surprising in terms of morbidity and make these provocative techniques to increase the sensitivity of arteriography controversial. Arteriography also provides a route for therapeutic embolization. Improvements in catheterization materiel (miniaturization) and embolic agents (mechanical agents such as coils, microparticles, and gelatin foam) allow a very safe distal embolization. Intestinal ischemic complications occur but are usually minimal and often self-limiting [42]. In a literature review that included 144 patients, the rate of asymptomatic ischemia was 9% [9]. The hemostatic success rate of arterial embolization varies between 44 and 91% [2] recurrent bleeding in 14% [44]; in such cases, the patient can undergo a second embolization procedure. In addition, venous bleeding (bleeding gastrointestinal varices complicating portal hypertension) can also benefit from interventional radiology including the performance of transhepatic portosystemic shunt (TIPS) combined with selective venous embolization [47]. Recommendations: arteriography is indicated for therapeutic purposes in LGI bleeding, after localization of an active bleeding site by CTA and failure or inability to treat the lesion endoscopically. Provocative injection of heparin or other agents is controversial and requires further study.
Bleeding scan: scintigraphy with radio-labeled red blood cells This method is sensitive provided that the bleeding rate is at least 0.1 mL/min. It is more sensitive but less specific than colonoscopy or angiography [2]. Like the other techniques, it identifies active bleeding but has the advantage of being able to locate a bleeding site as long as 24 hours after injection [44]. Its disadvantage is that the location of bleeding to an area of overlapping bowel loops can fail to distinguish a long sigmoid colon loop from the right colon [6]. The diagnostic yield of scintigraphy is highly variable in the literature ranging from 41 to 94% [44] with an equally variable rate of correct localization of 24—91% in various series [2]. Localization is most accurate when bleeding is identified in early images. Indeed, if the scan is positive at two hours, the location accuracy is 95-100%; this falls to 57—67% if bleeding is identified on images beyond two hours [6]. In some centers, particularly in the English-speaking world, scintigraphy is performed as an initial test before arteriography. It helps determine which patients will profit from arteriography and allows the radiologist to focus on the region of scintigraphy-detected bleeding with selective angiography. In fact, initial scintigraphy increases the diagnostic yield of arteriography by a factor of 2.4 and probably avoids performance of a non-contributory angiography if the scintigraphy is negative [2]. Scintigraphy with technetium labeled (99mTc) RBC’s retains its indication for young patients in whom Meckel’s diverticulum may be responsible for LGI bleeding [36]. Recommendations: while still widely used in Anglo-Saxon countries, scintigraphy is not available in many centers, particularly for emergency use, and it requires more acquisition time than CTA, leading to a preference for the latter. If scintigraphy is available, it remains indicated in the young patient for detection of Meckel’s diverticulum.
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CT enterography and MRI enterography [48] CT enterography requires placement of a naso-jejunal tube under fluoroscopic control; the tip should be positioned beyond the duodeno-jejunal junction at the ligament of Treitz. Enteroclysis is then performed injecting a continuous flow of oral contrast agent (Barium diluted with mannitol, PEG, or water); CT images are obtained with concomitant injection of intravenous contrast. MRI enterography also uses an oral contrast agent directly ingested by mouth along with intravenous injection of gadolinium contrast. The purpose of these two studies is to obtain an optimal and sustained distension of the small intestine in order to analyze its wall effectively throughout the duration of image acquisition. MRI enterography has the advantage of avoiding radiation exposure. These are the two best radiological tests for diagnosis of small intestinal transmural and extramural pathologies the small bowel follow-through examination has become obsolete [48]. These tests are commonly used in Crohn’s disease to detect and assess areas of inflammatory activity and to evaluate strictures and fistulae [49]. They are also very effective for assessment of transmural and extramural pathologies particularly small tumors [36]. For LGI bleeding, recent studies CT enterography, have shown it to be effective in detecting causes of obscure LGI bleeding [36]. However, Heo et al. have performed VCE after negative CT enterography and have successfully identified a lesion in 57% of patients. Agrawal et al. proposed the inverse approach, i.e., performing CT enterography when VCE was negative; in such cases, CT enterography revealed no lesions [50]. Indeed, the main limitation of these tests is their poor ability to explore the superficial mucosa, unlike current endoscopic techniques (VCE or DBE). Angiodysplasia or ulcerations are difficult to detect, yet they remain the main causes of small intestinal bleeding in the elderly. However, when luminal occlusion or risk factors for stricture (Crohn’s disease, long-term NSAID use) are present, CT and MRI enterography are preferable to VCE in order to avoid bowel obstruction during the passage of the capsule. Recommendations: CT or MRI enterography is indicated for cases of obscure LGI bleeding, as long as there is reason to suspect bowel obstruction or stricture.
Therapeutic surgical exploration In most large centers, surgical consultation occurs secondarily after initial management by the gastroenterologist and/or intensivist, when it becomes evident that his opinion or skills are required. Surgical consultation is requested if: • bleeding is localized and surgery is necessary because of the inability or failure of an endoscopic or radiological treatment; • bleeding is not localized, to discuss what surgical explorations are possible; • in emergency when faced with severe acute hemorrhage.
Localized bleeding If preoperative investigations by the gastroenterologist and/or radiologist have identified the bleeding site or if endoscopic therapy and/or radiologically-guided therapy is not feasible or has failed, a radical surgical procedure may be necessary. The specific surgical procedure depends on the
site and the etiology of bleeding. The list of operations is as varied as are the various causes of bleeding, including: • for diverticular hemorrhage, segmental colonic resection is the rule [11,25]: right hemicolectomy if bleeding is identified on the right, left colectomy if the bleeding site is localized on the left, but there is no role for subtotal colectomy in this situation; • for angiodysplasia, segmental resection of the offending digestive segment is performed [12], and similarly, in the case of Meckel’s diverticulum where resection/anastomosis is performed [17]; • for adenocarcinoma of the small intestine, wide oncologic resection with distal and proximal margins of at least 5 cm is recommended combined with en bloc mesenteric resection for loco-regional lymph node dissection [51]. Recommendations: the main indications for surgery for LGI bleeding are: localized bleeding with failure or inability to achieve hemostasis via endoscopic or radiologic intervention, or the need for curative resection (tumor of the small intestine or colon).
Unlocalized bleeding The role of surgery in the control of LGI bleeding from an unknown site raises many questions.
The role of exploratory laparotomy With the development of diagnostic and therapeutic techniques by the gastroenterologist and the radiologist, there is currently little or no role for exploratory laparotomy. If all investigations are non-diagnostic, one should temporize, stabilizing the patient hemodynamically by effective medical treatment, correcting coagulation disorders, reviewing all the diagnostic tests and repeating them if necessary. A first colonoscopy may be negative due to performance under poor conditions such as poor bowel preparation or due to spontaneous cessation of bleeding. Medical observation in the hospital is appropriate and is often useful, permitting prompt repeat colonoscopy and/or CT angiography; as stated above, these tests are more sensitive if they are performed during active hemorrhage. Recommendations: exploratory laparotomy should not be performed for LGI bleeding.
Technique and indications for intra-operative enteroscopy (IOE) IOE is most commonly performed during laparotomy although its use in conjunction with laparoscopy has been reported [16]. IOE is performed by introduction of the endoscope orally or trans-anally or by introduction of the scope through an enterotomy under surgical guidance, or by some combination of these techniques. Natural orifice enteroscopy is less invasive but requires more time, and it results in small intestinal and colonic distention that may interfere with abdominal closure; IOE via enterotomy is frequently incomplete [8]. Once the bleeding site is identified, treatment tailored to specific findings is performed. Literature reports have only small numbers and therefore show a great variability in results. IOE achieves complete visualization in 57—100%, with a diagnostic yield of 79% and therapeutic yield of 76% [16]. Previous identification of a lesion by VCE improves the contribution of IOE; when VCE was positive, 87% of lesions were identified versus 0% if VCE was negative [16]. These results show the important role of
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The management of lower gastrointestinal bleeding IOE when a lesion has been identified before the procedure. Morbidity is 17%, predominantly post-procedure ileus; IOE has a significant mortality of 5%, mainly due to multi-organ failure with sepsis after recurrent bleeding [16]. IOE has long been considered the gold standard for cases of obscure LGI bleeding because it was the only examination that allowed complete endoscopy of the small intestine. With the development of minimally invasive endoscopic techniques (VCE and AE) and radiologic ‘‘virtual endoscopy’’, the small intestine can now be fully explored without surgery and IOE is no longer indicated for purely diagnostic purposes. However, it remains useful and appropriate for intraoperative identification of small intestinal bleeding sites that are not accessible to standard endoscopic or radiology-guided treatment or if they cannot be localized intra-operatively without IOE because of the absence of an externally visible lesion or if preoperative tattooing was not performed. Recommendations: IOE for purely diagnostic purposes has been supplanted by VCE and AE. IOE is useful for intra-operative identification during a surgical procedure if specific preoperative marking has not been performed.
Severe acute hemorrhage Indications and results of emergency surgery It must be re-emphasized that 80% of LGI bleeding episodes stop spontaneously [6]. In addition, the population of patients who develop LGI bleeding are generally at increased risk for surgical intervention (advanced age, high ASA score, associated use of anticoagulant or antiplatelet medications). The mortality rate associated with emergency surgery is nearly 10% [2]. However, in a series of 215 patients operated under these conditions, Gayer et al. showed that mortality was lower if bleeding had been localized preoperatively thereby allowing elective surgery specifically adapted to the etiology; here, the mortality was 3.3% versus 9.4% for bleeding that could not be localized preoperatively [7]. These results underline the importance of preoperative investigations to locate the site of bleeding. Most cases of LGI bleeding, even when severe or recurrent, do not require surgery and can be controlled with medical treatment or by endoscopic or radiology-guided therapy. However, in exceptional cases, emergency surgery may be necessary. According to the review by Farell et al., emergency surgery is indicated in the following four situations [2]: • hemodynamic instability that persists despite optimal resuscitation; • persistent hemorrhage (requiring more than 6 units of RBC transfusion) and inability to define the bleeding site despite colonoscopy, push enteroscopy and CTA; • active bleeding from a segmental intestinal lesion that is amenable to surgical hemostasis; • the patient who is in good general condition and who can undergo surgery without unacceptable morbidity and with reasonable life expectancy. In this report, emergency surgery was performed in 18 to 25% of patients with LGI bleeding that required transfusion. (Grade B) [2]. Recommendation: preoperative localization of the bleeding site is essential. Emergency exploratory laparotomy and salvage surgery have a high mortality and is rarely contributory.
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If emergency salvage surgery without preoperative localization is performed, what should the actual procedure consist of? Fortunately, this situation is exceptional; only an empirical treatment approach can be proposed: • with the patient positioned for either an abdominal or perineal approach, the first step is a proctology exam to eliminate a low rectal or anal cause (4—10% of LGI bleeding). An anoscope and Parks retractors are necessary for adequate visualization; • midline laparotomy. There are no data in the literature to assess the role of laparoscopy in this context. A careful inspection and palpation of the entire GI tract downstream from the Treitz ligament should be performed. The absence of blood in the small intestine confirms a colorectal source, but its presence does not eliminate the possibility of backflow of blood through an incompetent ileocecal valve; • upper endoscopy and colonoscopy should be repeated intra-operatively: to increase the sensitivity of colonoscopy, the surgeon can perform intra-operative colonic lavage [9,21] and assist the endoscopist by guiding the endoscope past tortuous curves. It should be remembered that the cecum is visualized in only 55—70% of emergency colonoscopies [21]; • if the source of bleeding is identified, appropriate surgery is performed; • finally, if despite all explorations, the bleeding cannot be localized surgical management should be similar to that for diverticular bleeding [25]. If the small intestine is cleared and if colonic diverticula are present, data from the literature show that, in the absence of a precise localization of the site of bleeding, ‘‘blind’’ subtotal colectomy is the best treatment for bleeding of colonic origin. However, this approach carries a high mortality between 10% and 33% with a re-bleeding rate between 0 and 8%. But these results are much better than for segmental colectomy, which has a mortality rate between 20 and 57% and a rate of recurrent bleeding between 30 and 63% [25,52—54]. If there is blood in the small intestine but the remainder of the examination is normal, two different situations may be responsible: • in an elderly patient with colonic diverticula, blood may have refluxed backward from the colon. In view of the epidemiology, a diverticular origin of bleeding is probable and a subtotal colectomy is justified; • the patient is young and/or there are no diverticula, no specific resection can be recommended. Recommendations: prior to embarking upon salvage surgery, diagnostic tests should be repeated in the operating room. If no specific bleeding site is identified but bleeding of diverticular origin is probable, a subtotal colectomy should be performed rather than a ‘‘blind’’ segmental colectomy.
Management of LGI bleeding in practice Practical management of LGI bleeding depends on the severity of the hemorrhage and the availability of diagnostic and therapeutic methods at the admitting facility. Endoscopic and radiological techniques have improved to the point that the site of bleeding can be localized in the majority of cases. In addition, episodes of LGI bleeding are less serious than
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UGI bleeding with an 80% rate of spontaneous cessation of bleeding and a lower mortality of 2—4% [2] versus 6—13% [55]. It is therefore appropriate to stabilize the patient hemodynamically for transfer to a larger center if expertise in non-invasive diagnostic and therapeutic interventions is not available locally. Similarly, if the bleeding has stopped spontaneously and all investigations are non-contributory, supportive medical management can be continued with repetition of examinations if bleeding recurs. While there is no clear consensus for management as there is for UGI bleeding, the following course of management can be proposed based on an overview of all the diagnostic and therapeutic modalities and in accordance with the recommendations of the SFED (French Society of Digestive Endoscopy), AGA and ASGE [1,10,24].
Acute lower gastrointestinal bleeding As for any other source of bleeding, initial medical management is of fundamental importance, including stabilization of the patient’s hemodynamic condition, transfusion if necessary, and correction of coagulation disorders to enable the performance of necessary diagnostic explorations under safe conditions (Fig. 1). Detailed history and physical examination including a rectal exam should be performed. All patients with LGI bleeding should undergo initial upper endoscopy and urgent colonoscopy after bowel preparation. If there is active ongoing bleeding, angiography also seems indicated as an initial investigation. Currently, CTA has many advantages: it is available in most centers, can be performed quickly with a satisfactory diagnostic yield when there is active bleeding, and helps to guide a therapeutic colonoscopy or embolization. At this stage, the site of bleeding has been localized in most cases. If diagnostic studies are negative, continued efforts should be made to locate the bleeding site rather than
resorting to ‘‘blind’’ exploratory surgery, which has a high mortality and is likely to be non-contributory. VCE has gradually emerged as a second-line modality for visualizing the small intestine, even in the emergency setting [34]. Upper endoscopy and colonoscopy should be repeated. In young patients, the diagnosis of Meckel’s diverticulum must be considered as well as inflammatory bowel disease or a neoplasm. A CT or MRI enterography and/or bleeding scan using Tc99 m scintigraphy should be discussed on a case-by-case basis. Once the bleeding site has been identified, treatment is based on interventional endoscopy or radiological embolization depending on the respective technical difficulties and availability of these modalities at the treating facility. If all else fails, elective surgery is performed. Emergency salvage surgery without localization of the bleeding site has become exceptionally rare and should be avoided as much as possible. If, unfortunately, it proves to be necessary, the surgery is then empirical depending on operative findings. Based on the hypothesis that the most common cause of LGI bleeding is diverticulosis, performance of a subtotal colectomy may be appropriate.
Chronic lower and/or upper GI bleeding without hemodynamic instability Initial assessment is performed with upper endoscopy and colonoscopy (Fig. 2). CTA is not indicated because of its low yield when bleeding is not active and its lower sensitivity compared to endoscopy for this indication. If the tests are non-contributory, management should be the same as for occult LGI bleeding. VCE is the investigation of choice if endoscopic assessment fails to localize a bleeding site. If there is concern about intestinal stricture or obstruction, then VCE is contraindicated and a ‘‘virtual enteroscopy’’ by either CT or MRI
Figure 1. Management of acute lower GI bleeding. LGI = lower gastrointestinal; EGDScopy = esophago-gastro-duodenal endoscopy; AE = assisted enteroscopy; VCE = video capsule endoscopy; eCT = CT enterography; eMRI = MRI enterography; Bleeding scan = 99mTc technetium radio-labeled RBC scan.
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Figure 2. Management of chronic LGI bleeding with no hemodynamic instability. LGI bleeding = lower gastrointestinal bleeding; Upper endoscopy = esophago-gastro-duodenoscopy; AE = assisted enteroscopy; VCE = Video capsule enteroscopy; eCT = CT enteroscopy; eMRI = MRI enteroscopy; Bleeding scan = Tc99 m radio-labelled RBC scan; IOE = intra-operative enteroscopy.
enterography is performed. In young patients, a bleeding scan using 99mTc scintigraphy should be considered. If all investigations are negative, upper endoscopy and colonoscopy should be repeated. If the source of bleeding still cannot be localized, treatment should consist of supportive medical management with repetition of all studies as appropriate. Once a bleeding site has been identified, hemostatic treatment by interventional colonoscopy or AE is performed. If non-invasive approaches are not feasible or unsuccessful, surgery focused on the identified site is then performed with preoperative marking of the site during colonoscopy or AE using clips or tattooing. If a small bowel bleeding source is identified that cannot be marked preoperatively, enteroscopy is performed intra-operatively.
Conclusions There is no consensus regarding management of LGI bleeding, but the primary goal in all cases is identification of the bleeding site. In recent years, the development of endoscopic and radiological techniques has allowed minimally invasive exploration, which may allow subsequent or simultaneous hemostatic therapy via colonoscopy or assisted enteroscopy. If the bleeding is actively ongoing, embolization will stop bleeding in most cases. In addition, surgery still plays a role for bleeding from an identified site, or, more rarely, in case of failure or inability to perform other treatments. In any event, the diversity and complexity of the management of LGI bleeding require multidisciplinary consultation for the most severe cases involving gastroenterologists, radiologists, surgeons, and intensivists.
ESSENTIAL POINTS The essential points are: • lower gastrointestinal bleeding requires multidisciplinary care involving intensivist, radiologist, gastroenterologist and surgeon; • the main objective is to localize the source of bleeding; • upper gastrointestinal endoscopy should always be performed since bleeding from the esophagus, stomach, or duodenum can present as hematochezia when there is abundant UGI bleeding; • CT angiography (CTA) has gradually established its role in the diagnosis of acute LGI hemorrhage in patients with ongoing active bleeding due to its timeliness and high diagnostic yield; this modality has become increasingly available in most centers; • intra-operative enteroscopy, formerly regarded as the gold standard for occult LGI bleeding, has been superseded by newer diagnostic techniques and minimally invasive treatment techniques for small intestinal bleeding: video capsule endoscopy, enteral CT, enteral-magnetic resonance imaging (MRI) and assisted enteroscopy; • once the site of bleeding is located, most cases of LGI bleeding can be treated by endoscopy or interventional radiology. If such modalities fail or are unavailable, elective surgical treatment is recommended;
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Y. Marion et al. • indications for urgent life-saving surgery has become exceptional and should be avoided as much as possible; • the spontaneous cessation and the lesser gravity of most cases of LGI bleeding (as opposed to UGI bleeding) justifies patient transfer to a specialized center after initial hemodynamic stabilization if the site of bleeding cannot be localized and advanced diagnostic techniques are not available at the firstline hospital.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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The management of lower gastrointestinal bleeding [39] Ernst O, Bulois P, Saint-Drenant S, et al., Helical CT. in acute lower gastrointestinal bleeding. Eur Radiol 2003;13: 114—7. [40] Rajan R, Dhar P, Praseedom RK, Sudhindran S, Moorthy S. Role of contrast CT in acute lower gastrointestinal bleeding. Dig Surg 2004;21:293—6. [41] Junquera F, Quiroga S, Saperas E, et al. Accuracy of helical computed tomographic agiography for the diagnosis of colonic angiodysplasia. Gastroenterology 2000;119:293—9. [42] Marti M, Artigas JM, Garzon G. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology 2012;262:109—16. [43] Geffroy Y, Rodallec MH, Boulay-Coletta I, Jullès MC, RidereauZins C, Zins M. Multidetector CT angiography in acute gastrointestinal bleeding: why, when, and how. Radiographics 2011;31(3):E35—46. [44] Kamaoui I, Milot L, Pilleul F. Acute lower gastrointestinal bleeding: role of imaging. J Radiol 2010;91(3 Pt. 1): 261—9 [Review]. [45] Egglin TK, O’Moore PV, Feinstein AR, et al. Complications of peripheral arteriography: a new system to identify patients at increased risk. J Vasc Surg 1995;22:787—94. [46] Kim CY, Suhocki PV, Miller Jr MJ. Provocative mesenteric angiography for lower gastrointestinal hemorrhage: results from a single institution study. J Vasc Iinterv Radiol 2010;21(4):477—83.
11 [47] Chikamori F, Kuniyoshi N, Kagiyama S. Role of percutaneous transhepatic obliteration for specials types of varices with portal hypertension. Abdom Imaging 2007;32(1):92—5. [48] Kermarrec E, Barbary C, Corby S, Béot S, Laurent V, Regent D. CT enteroclysis: a pictorial essay. J Radiol 2007;88(2):235—50. [49] Jensen MD, Kjeldsen J, Rafaelsen SR, Nathan T. Diagnostic accuracies of MR enterography and CT enterography in symptomatic Crohn’s disease. Scand J Gastroenterol 2011;46(12):1449—57. [50] Soyer P. Obscure gastrointestinal bleeding: difficulties in comparing CT enterography and video capsule endoscopy. Eur Radiol 2012;22(6):1167—71. [51] Agarwal S, McCarron EC, Gibbs JF, Nava HR, Wilding GE, Rajput A. Surgical management and outcome in primary adenocarcinoma of the small bowel. Ann Surg Oncol 2007;14:2263—9. [52] Beck DE, Margolin DA, Whitlow CB, Hammond KL. Evaluation and management of gastrointestinal bleeding. Ochsner J 2007;7(3):107—13. [53] Wilkins T, Baird C, Pearson AN, Schade RR. Diverticular bleeding. Am Fam Physician 2009;80(9):977—83 [Review]. [54] O’Grady HL, Hartley JE. Radiographic work-up and treatment of lower gastrointestinal bleeding. Clin Colon Rectal Surg 2008;21(3):188—92. [55] Holster IL, Kuipers EJ. Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives. World J Gastroenterol 2012;18(11):1202—7.
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Available online at
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REVIEW
The management of lower gastrointestinal bleeding Y. Marion a,d,∗, G. Lebreton a,d, V. Le Pennec b,d, E. Hourna b,d, S. Viennot c,d, A. Alves b,d a
Service de chirurgie digestive, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France b Service de radiologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France c Service de gastro-entérologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France d Université de Caen, faculté de médecine, 14000 Caen, France
KEYWORDS Lower gastrointestinal bleeding; Angiography; Endoscopy; Video capsule endoscopy; Enteroscopy; Surgery
∗
Summary Lower gastrointestinal (LGI) bleeding is generally less severe than upper gastrointestinal (UGI) bleeding with spontaneous cessation of bleeding in 80% of cases and a mortality of 2—4%. However, unlike UGI bleeding, there is no consensual agreement about management. Once the patient has been stabilized, the main objective and greatest difficulty is to identify the location of bleeding in order to provide specific appropriate treatment. While upper endoscopy and colonoscopy remain the essential first-line examinations, the development and availability of angiography have made this an important imaging modality for cases of active bleeding; they allow diagnostic localization of bleeding and guide subsequent therapy, whether therapeutic embolization, interventional colonoscopy or, if other techniques fail or are unavailable, surgery directed at the precise site of bleeding. Furthermore, newly developed endoscopic techniques, particularly video capsule enteroscopy, now allow minimally invasive exploration of the small intestine; if this is positive, it will guide subsequent assisted enteroscopy or surgery. Other small bowel imaging techniques include enteroclysis by CT or magnetic resonance imaging. At the present time, exploratory surgery is no longer a first-line approach. In view of the lesser gravity of LGI bleeding, it is most reasonable to simply stabilize the patient initially for subsequent transfer to a specialized center, if minimally invasive techniques are not available at the local hospital. In all cases, the complexity and diversity of LGI bleeding require a multidisciplinary collaboration involving the gastroenterologist, radiologist, intensivist and surgeon to optimize diagnosis and treatment of the patient. © 2014 Elsevier Masson SAS. All rights reserved.
Corresponding author. Service de chirurgie digestive, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France. E-mail address: [email protected] (Y. Marion).
http://dx.doi.org/10.1016/j.jviscsurg.2014.03.008 1878-7886/© 2014 Elsevier Masson SAS. All rights reserved.
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Introduction
Etiologies
Lower gastrointestinal (LGI) bleeding is defined as bleeding whose origin is located downstream of the duodeno-jejunal junction at the ligament of Treitz, thus including the small intestine, colon, rectum or anus. Clinical manifestations are melena or hematochezia. We speak of obscure LGI bleeding when one or more episodes of bleeding occur for which no site of origin is identified by standard endoscopy, and of occult gastrointestinal bleeding when no gross blood is observed by the patient or clinician yet there is evidence of bleeding manifested by iron-deficiency anemia with no identified extra-intestinal source of blood loss. In recent years, diagnostic and treatment modalities have developed considerably for use by gastroenterologists, radiologists and surgeons. However, the main problem of LGI bleeding remains the identification of the source rather than the treatment of bleeding.
In specifying the frequent and problematic causes, the prevalence of various etiologies is purely illustrative given the great variability of results in the literature [1,6—8]. Moreover, despite all diagnostic testing, the source of bleeding cannot be identified in approximately 10% of patients [9].
General Epidemiology LGI bleeding represents 20% to 25% of all gastrointestinal bleedings [1]. Epidemiological studies are rare. North American studies have estimated the annual incidence in adults at 21—27 per 100,000 population [2,3]. LGI bleeding occurs more frequently in men than in women (24.2% vs. 17.2%, P < 0.001) and more often in the elderly than in young subjects (∼200-fold increase in the 9th decade compared to the 3rd decade of life) [3]. This increased incidence is explained by the increasing prevalence of diverticulosis and angiodysplasia with age [2]. The mortality of LGI bleeding is estimated at 2—4% in various series [2,4]. A prospective epidemiological study carried out in France in 2007 by the National Association of General Hospital Gastroenterologists identified 1333 patients with LGI bleeding. The mean age was 72 ± 16 years; ASA (American Society of Anesthesiologists) score was 2.5 ± 0.9 and 50% of patients had an ASA of 3. Use of a predisposing medication was found in nearly 75% of patients (34% antiplatelet agents, 22% antivitamin K agents, 11% non-steroid anti-inflammatory drugs [NSAID], 7% heparin) [5].
Severity criteria The gravity of LGI bleeding is generally less severe than that of UGI bleeding; hemorrhage ceases spontaneously in 80% of cases [6]. Currently, there is no consensus definition of the severity of LGI bleeding. Severity is assessed according to its hemodynamic consequences, laboratory findings and underlying patient condition [2,6]: • systolic blood pressure 100/min; • hemoglobin 0.5 mL/min) [21]; this identifies the source of bleeding with certainty. Like CTA, the diagnostic efficacy of arteriography is high if it is performed during a period of active bleeding; its sensitivity for detection of the bleeding site ranges from 40 to 86% in literature reports [44] with a specificity of 100% [2]. Factors favoring successful detection of a bleeding site by arteriography include: hemodynamic instability, a 50% drop in hemoglobin, and transfusion of >5 units of packed RBCs in 24 hours; however, arteriography is not without complications; the incidence is estimated at 9.3% (arterial puncture site complications, contrast-related renal failure, etc.) [45]. If the arteriography is negative, some authors have proposed the injection of heparin, vasodilators and thrombolytic agents in situ to increase the diagnostic yield of angiography. In a retrospective study of 36 patients with
5 recurrent LGI bleeding (after diagnostic failure of angiography in 24 cases), this procedure allowed detection of the bleeding site in eleven patients (31%) with no reported complications [46]. These results seem surprising in terms of morbidity and make these provocative techniques to increase the sensitivity of arteriography controversial. Arteriography also provides a route for therapeutic embolization. Improvements in catheterization materiel (miniaturization) and embolic agents (mechanical agents such as coils, microparticles, and gelatin foam) allow a very safe distal embolization. Intestinal ischemic complications occur but are usually minimal and often self-limiting [42]. In a literature review that included 144 patients, the rate of asymptomatic ischemia was 9% [9]. The hemostatic success rate of arterial embolization varies between 44 and 91% [2] recurrent bleeding in 14% [44]; in such cases, the patient can undergo a second embolization procedure. In addition, venous bleeding (bleeding gastrointestinal varices complicating portal hypertension) can also benefit from interventional radiology including the performance of transhepatic portosystemic shunt (TIPS) combined with selective venous embolization [47]. Recommendations: arteriography is indicated for therapeutic purposes in LGI bleeding, after localization of an active bleeding site by CTA and failure or inability to treat the lesion endoscopically. Provocative injection of heparin or other agents is controversial and requires further study.
Bleeding scan: scintigraphy with radio-labeled red blood cells This method is sensitive provided that the bleeding rate is at least 0.1 mL/min. It is more sensitive but less specific than colonoscopy or angiography [2]. Like the other techniques, it identifies active bleeding but has the advantage of being able to locate a bleeding site as long as 24 hours after injection [44]. Its disadvantage is that the location of bleeding to an area of overlapping bowel loops can fail to distinguish a long sigmoid colon loop from the right colon [6]. The diagnostic yield of scintigraphy is highly variable in the literature ranging from 41 to 94% [44] with an equally variable rate of correct localization of 24—91% in various series [2]. Localization is most accurate when bleeding is identified in early images. Indeed, if the scan is positive at two hours, the location accuracy is 95-100%; this falls to 57—67% if bleeding is identified on images beyond two hours [6]. In some centers, particularly in the English-speaking world, scintigraphy is performed as an initial test before arteriography. It helps determine which patients will profit from arteriography and allows the radiologist to focus on the region of scintigraphy-detected bleeding with selective angiography. In fact, initial scintigraphy increases the diagnostic yield of arteriography by a factor of 2.4 and probably avoids performance of a non-contributory angiography if the scintigraphy is negative [2]. Scintigraphy with technetium labeled (99mTc) RBC’s retains its indication for young patients in whom Meckel’s diverticulum may be responsible for LGI bleeding [36]. Recommendations: while still widely used in Anglo-Saxon countries, scintigraphy is not available in many centers, particularly for emergency use, and it requires more acquisition time than CTA, leading to a preference for the latter. If scintigraphy is available, it remains indicated in the young patient for detection of Meckel’s diverticulum.
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CT enterography and MRI enterography [48] CT enterography requires placement of a naso-jejunal tube under fluoroscopic control; the tip should be positioned beyond the duodeno-jejunal junction at the ligament of Treitz. Enteroclysis is then performed injecting a continuous flow of oral contrast agent (Barium diluted with mannitol, PEG, or water); CT images are obtained with concomitant injection of intravenous contrast. MRI enterography also uses an oral contrast agent directly ingested by mouth along with intravenous injection of gadolinium contrast. The purpose of these two studies is to obtain an optimal and sustained distension of the small intestine in order to analyze its wall effectively throughout the duration of image acquisition. MRI enterography has the advantage of avoiding radiation exposure. These are the two best radiological tests for diagnosis of small intestinal transmural and extramural pathologies the small bowel follow-through examination has become obsolete [48]. These tests are commonly used in Crohn’s disease to detect and assess areas of inflammatory activity and to evaluate strictures and fistulae [49]. They are also very effective for assessment of transmural and extramural pathologies particularly small tumors [36]. For LGI bleeding, recent studies CT enterography, have shown it to be effective in detecting causes of obscure LGI bleeding [36]. However, Heo et al. have performed VCE after negative CT enterography and have successfully identified a lesion in 57% of patients. Agrawal et al. proposed the inverse approach, i.e., performing CT enterography when VCE was negative; in such cases, CT enterography revealed no lesions [50]. Indeed, the main limitation of these tests is their poor ability to explore the superficial mucosa, unlike current endoscopic techniques (VCE or DBE). Angiodysplasia or ulcerations are difficult to detect, yet they remain the main causes of small intestinal bleeding in the elderly. However, when luminal occlusion or risk factors for stricture (Crohn’s disease, long-term NSAID use) are present, CT and MRI enterography are preferable to VCE in order to avoid bowel obstruction during the passage of the capsule. Recommendations: CT or MRI enterography is indicated for cases of obscure LGI bleeding, as long as there is reason to suspect bowel obstruction or stricture.
Therapeutic surgical exploration In most large centers, surgical consultation occurs secondarily after initial management by the gastroenterologist and/or intensivist, when it becomes evident that his opinion or skills are required. Surgical consultation is requested if: • bleeding is localized and surgery is necessary because of the inability or failure of an endoscopic or radiological treatment; • bleeding is not localized, to discuss what surgical explorations are possible; • in emergency when faced with severe acute hemorrhage.
Localized bleeding If preoperative investigations by the gastroenterologist and/or radiologist have identified the bleeding site or if endoscopic therapy and/or radiologically-guided therapy is not feasible or has failed, a radical surgical procedure may be necessary. The specific surgical procedure depends on the
site and the etiology of bleeding. The list of operations is as varied as are the various causes of bleeding, including: • for diverticular hemorrhage, segmental colonic resection is the rule [11,25]: right hemicolectomy if bleeding is identified on the right, left colectomy if the bleeding site is localized on the left, but there is no role for subtotal colectomy in this situation; • for angiodysplasia, segmental resection of the offending digestive segment is performed [12], and similarly, in the case of Meckel’s diverticulum where resection/anastomosis is performed [17]; • for adenocarcinoma of the small intestine, wide oncologic resection with distal and proximal margins of at least 5 cm is recommended combined with en bloc mesenteric resection for loco-regional lymph node dissection [51]. Recommendations: the main indications for surgery for LGI bleeding are: localized bleeding with failure or inability to achieve hemostasis via endoscopic or radiologic intervention, or the need for curative resection (tumor of the small intestine or colon).
Unlocalized bleeding The role of surgery in the control of LGI bleeding from an unknown site raises many questions.
The role of exploratory laparotomy With the development of diagnostic and therapeutic techniques by the gastroenterologist and the radiologist, there is currently little or no role for exploratory laparotomy. If all investigations are non-diagnostic, one should temporize, stabilizing the patient hemodynamically by effective medical treatment, correcting coagulation disorders, reviewing all the diagnostic tests and repeating them if necessary. A first colonoscopy may be negative due to performance under poor conditions such as poor bowel preparation or due to spontaneous cessation of bleeding. Medical observation in the hospital is appropriate and is often useful, permitting prompt repeat colonoscopy and/or CT angiography; as stated above, these tests are more sensitive if they are performed during active hemorrhage. Recommendations: exploratory laparotomy should not be performed for LGI bleeding.
Technique and indications for intra-operative enteroscopy (IOE) IOE is most commonly performed during laparotomy although its use in conjunction with laparoscopy has been reported [16]. IOE is performed by introduction of the endoscope orally or trans-anally or by introduction of the scope through an enterotomy under surgical guidance, or by some combination of these techniques. Natural orifice enteroscopy is less invasive but requires more time, and it results in small intestinal and colonic distention that may interfere with abdominal closure; IOE via enterotomy is frequently incomplete [8]. Once the bleeding site is identified, treatment tailored to specific findings is performed. Literature reports have only small numbers and therefore show a great variability in results. IOE achieves complete visualization in 57—100%, with a diagnostic yield of 79% and therapeutic yield of 76% [16]. Previous identification of a lesion by VCE improves the contribution of IOE; when VCE was positive, 87% of lesions were identified versus 0% if VCE was negative [16]. These results show the important role of
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The management of lower gastrointestinal bleeding IOE when a lesion has been identified before the procedure. Morbidity is 17%, predominantly post-procedure ileus; IOE has a significant mortality of 5%, mainly due to multi-organ failure with sepsis after recurrent bleeding [16]. IOE has long been considered the gold standard for cases of obscure LGI bleeding because it was the only examination that allowed complete endoscopy of the small intestine. With the development of minimally invasive endoscopic techniques (VCE and AE) and radiologic ‘‘virtual endoscopy’’, the small intestine can now be fully explored without surgery and IOE is no longer indicated for purely diagnostic purposes. However, it remains useful and appropriate for intraoperative identification of small intestinal bleeding sites that are not accessible to standard endoscopic or radiology-guided treatment or if they cannot be localized intra-operatively without IOE because of the absence of an externally visible lesion or if preoperative tattooing was not performed. Recommendations: IOE for purely diagnostic purposes has been supplanted by VCE and AE. IOE is useful for intra-operative identification during a surgical procedure if specific preoperative marking has not been performed.
Severe acute hemorrhage Indications and results of emergency surgery It must be re-emphasized that 80% of LGI bleeding episodes stop spontaneously [6]. In addition, the population of patients who develop LGI bleeding are generally at increased risk for surgical intervention (advanced age, high ASA score, associated use of anticoagulant or antiplatelet medications). The mortality rate associated with emergency surgery is nearly 10% [2]. However, in a series of 215 patients operated under these conditions, Gayer et al. showed that mortality was lower if bleeding had been localized preoperatively thereby allowing elective surgery specifically adapted to the etiology; here, the mortality was 3.3% versus 9.4% for bleeding that could not be localized preoperatively [7]. These results underline the importance of preoperative investigations to locate the site of bleeding. Most cases of LGI bleeding, even when severe or recurrent, do not require surgery and can be controlled with medical treatment or by endoscopic or radiology-guided therapy. However, in exceptional cases, emergency surgery may be necessary. According to the review by Farell et al., emergency surgery is indicated in the following four situations [2]: • hemodynamic instability that persists despite optimal resuscitation; • persistent hemorrhage (requiring more than 6 units of RBC transfusion) and inability to define the bleeding site despite colonoscopy, push enteroscopy and CTA; • active bleeding from a segmental intestinal lesion that is amenable to surgical hemostasis; • the patient who is in good general condition and who can undergo surgery without unacceptable morbidity and with reasonable life expectancy. In this report, emergency surgery was performed in 18 to 25% of patients with LGI bleeding that required transfusion. (Grade B) [2]. Recommendation: preoperative localization of the bleeding site is essential. Emergency exploratory laparotomy and salvage surgery have a high mortality and is rarely contributory.
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If emergency salvage surgery without preoperative localization is performed, what should the actual procedure consist of? Fortunately, this situation is exceptional; only an empirical treatment approach can be proposed: • with the patient positioned for either an abdominal or perineal approach, the first step is a proctology exam to eliminate a low rectal or anal cause (4—10% of LGI bleeding). An anoscope and Parks retractors are necessary for adequate visualization; • midline laparotomy. There are no data in the literature to assess the role of laparoscopy in this context. A careful inspection and palpation of the entire GI tract downstream from the Treitz ligament should be performed. The absence of blood in the small intestine confirms a colorectal source, but its presence does not eliminate the possibility of backflow of blood through an incompetent ileocecal valve; • upper endoscopy and colonoscopy should be repeated intra-operatively: to increase the sensitivity of colonoscopy, the surgeon can perform intra-operative colonic lavage [9,21] and assist the endoscopist by guiding the endoscope past tortuous curves. It should be remembered that the cecum is visualized in only 55—70% of emergency colonoscopies [21]; • if the source of bleeding is identified, appropriate surgery is performed; • finally, if despite all explorations, the bleeding cannot be localized surgical management should be similar to that for diverticular bleeding [25]. If the small intestine is cleared and if colonic diverticula are present, data from the literature show that, in the absence of a precise localization of the site of bleeding, ‘‘blind’’ subtotal colectomy is the best treatment for bleeding of colonic origin. However, this approach carries a high mortality between 10% and 33% with a re-bleeding rate between 0 and 8%. But these results are much better than for segmental colectomy, which has a mortality rate between 20 and 57% and a rate of recurrent bleeding between 30 and 63% [25,52—54]. If there is blood in the small intestine but the remainder of the examination is normal, two different situations may be responsible: • in an elderly patient with colonic diverticula, blood may have refluxed backward from the colon. In view of the epidemiology, a diverticular origin of bleeding is probable and a subtotal colectomy is justified; • the patient is young and/or there are no diverticula, no specific resection can be recommended. Recommendations: prior to embarking upon salvage surgery, diagnostic tests should be repeated in the operating room. If no specific bleeding site is identified but bleeding of diverticular origin is probable, a subtotal colectomy should be performed rather than a ‘‘blind’’ segmental colectomy.
Management of LGI bleeding in practice Practical management of LGI bleeding depends on the severity of the hemorrhage and the availability of diagnostic and therapeutic methods at the admitting facility. Endoscopic and radiological techniques have improved to the point that the site of bleeding can be localized in the majority of cases. In addition, episodes of LGI bleeding are less serious than
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UGI bleeding with an 80% rate of spontaneous cessation of bleeding and a lower mortality of 2—4% [2] versus 6—13% [55]. It is therefore appropriate to stabilize the patient hemodynamically for transfer to a larger center if expertise in non-invasive diagnostic and therapeutic interventions is not available locally. Similarly, if the bleeding has stopped spontaneously and all investigations are non-contributory, supportive medical management can be continued with repetition of examinations if bleeding recurs. While there is no clear consensus for management as there is for UGI bleeding, the following course of management can be proposed based on an overview of all the diagnostic and therapeutic modalities and in accordance with the recommendations of the SFED (French Society of Digestive Endoscopy), AGA and ASGE [1,10,24].
Acute lower gastrointestinal bleeding As for any other source of bleeding, initial medical management is of fundamental importance, including stabilization of the patient’s hemodynamic condition, transfusion if necessary, and correction of coagulation disorders to enable the performance of necessary diagnostic explorations under safe conditions (Fig. 1). Detailed history and physical examination including a rectal exam should be performed. All patients with LGI bleeding should undergo initial upper endoscopy and urgent colonoscopy after bowel preparation. If there is active ongoing bleeding, angiography also seems indicated as an initial investigation. Currently, CTA has many advantages: it is available in most centers, can be performed quickly with a satisfactory diagnostic yield when there is active bleeding, and helps to guide a therapeutic colonoscopy or embolization. At this stage, the site of bleeding has been localized in most cases. If diagnostic studies are negative, continued efforts should be made to locate the bleeding site rather than
resorting to ‘‘blind’’ exploratory surgery, which has a high mortality and is likely to be non-contributory. VCE has gradually emerged as a second-line modality for visualizing the small intestine, even in the emergency setting [34]. Upper endoscopy and colonoscopy should be repeated. In young patients, the diagnosis of Meckel’s diverticulum must be considered as well as inflammatory bowel disease or a neoplasm. A CT or MRI enterography and/or bleeding scan using Tc99 m scintigraphy should be discussed on a case-by-case basis. Once the bleeding site has been identified, treatment is based on interventional endoscopy or radiological embolization depending on the respective technical difficulties and availability of these modalities at the treating facility. If all else fails, elective surgery is performed. Emergency salvage surgery without localization of the bleeding site has become exceptionally rare and should be avoided as much as possible. If, unfortunately, it proves to be necessary, the surgery is then empirical depending on operative findings. Based on the hypothesis that the most common cause of LGI bleeding is diverticulosis, performance of a subtotal colectomy may be appropriate.
Chronic lower and/or upper GI bleeding without hemodynamic instability Initial assessment is performed with upper endoscopy and colonoscopy (Fig. 2). CTA is not indicated because of its low yield when bleeding is not active and its lower sensitivity compared to endoscopy for this indication. If the tests are non-contributory, management should be the same as for occult LGI bleeding. VCE is the investigation of choice if endoscopic assessment fails to localize a bleeding site. If there is concern about intestinal stricture or obstruction, then VCE is contraindicated and a ‘‘virtual enteroscopy’’ by either CT or MRI
Figure 1. Management of acute lower GI bleeding. LGI = lower gastrointestinal; EGDScopy = esophago-gastro-duodenal endoscopy; AE = assisted enteroscopy; VCE = video capsule endoscopy; eCT = CT enterography; eMRI = MRI enterography; Bleeding scan = 99mTc technetium radio-labeled RBC scan.
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Figure 2. Management of chronic LGI bleeding with no hemodynamic instability. LGI bleeding = lower gastrointestinal bleeding; Upper endoscopy = esophago-gastro-duodenoscopy; AE = assisted enteroscopy; VCE = Video capsule enteroscopy; eCT = CT enteroscopy; eMRI = MRI enteroscopy; Bleeding scan = Tc99 m radio-labelled RBC scan; IOE = intra-operative enteroscopy.
enterography is performed. In young patients, a bleeding scan using 99mTc scintigraphy should be considered. If all investigations are negative, upper endoscopy and colonoscopy should be repeated. If the source of bleeding still cannot be localized, treatment should consist of supportive medical management with repetition of all studies as appropriate. Once a bleeding site has been identified, hemostatic treatment by interventional colonoscopy or AE is performed. If non-invasive approaches are not feasible or unsuccessful, surgery focused on the identified site is then performed with preoperative marking of the site during colonoscopy or AE using clips or tattooing. If a small bowel bleeding source is identified that cannot be marked preoperatively, enteroscopy is performed intra-operatively.
Conclusions There is no consensus regarding management of LGI bleeding, but the primary goal in all cases is identification of the bleeding site. In recent years, the development of endoscopic and radiological techniques has allowed minimally invasive exploration, which may allow subsequent or simultaneous hemostatic therapy via colonoscopy or assisted enteroscopy. If the bleeding is actively ongoing, embolization will stop bleeding in most cases. In addition, surgery still plays a role for bleeding from an identified site, or, more rarely, in case of failure or inability to perform other treatments. In any event, the diversity and complexity of the management of LGI bleeding require multidisciplinary consultation for the most severe cases involving gastroenterologists, radiologists, surgeons, and intensivists.
ESSENTIAL POINTS The essential points are: • lower gastrointestinal bleeding requires multidisciplinary care involving intensivist, radiologist, gastroenterologist and surgeon; • the main objective is to localize the source of bleeding; • upper gastrointestinal endoscopy should always be performed since bleeding from the esophagus, stomach, or duodenum can present as hematochezia when there is abundant UGI bleeding; • CT angiography (CTA) has gradually established its role in the diagnosis of acute LGI hemorrhage in patients with ongoing active bleeding due to its timeliness and high diagnostic yield; this modality has become increasingly available in most centers; • intra-operative enteroscopy, formerly regarded as the gold standard for occult LGI bleeding, has been superseded by newer diagnostic techniques and minimally invasive treatment techniques for small intestinal bleeding: video capsule endoscopy, enteral CT, enteral-magnetic resonance imaging (MRI) and assisted enteroscopy; • once the site of bleeding is located, most cases of LGI bleeding can be treated by endoscopy or interventional radiology. If such modalities fail or are unavailable, elective surgical treatment is recommended;
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Y. Marion et al. • indications for urgent life-saving surgery has become exceptional and should be avoided as much as possible; • the spontaneous cessation and the lesser gravity of most cases of LGI bleeding (as opposed to UGI bleeding) justifies patient transfer to a specialized center after initial hemodynamic stabilization if the site of bleeding cannot be localized and advanced diagnostic techniques are not available at the firstline hospital.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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