Acute Lower Gastrointestinal Bleeding

Jonathan P. Terdiman, M.D. University of California, San

Francisco

Lower GI Bleeding

•  Epidemiology, Etiology and Outcomes •  Presentation and Diagnosis •  Therapy •  Management strategy by clinical scenario •  Putting it all together

Epidemiology and outcome

•  Annual incidence is 20-30/100, 000 –  1/4 to 1/3 of all acute bleeds requiring hospital stay

•  Disease of the elderly –  200 fold increase from the 3rd to 9th decades of life

•  Comorbid medical conditions are common •  NSAID use is common

–  > 50%

Strate L; B&W 1996-99

Strate L; B&W 2001-2003

Schmulewitz N; Duke, 1993-2000

Retrospective Prospective Retrospective

Number 275 252 415

Mean age 70 66 67

Cause

Diverticulosis 41% 30% 41%

Rectal ulcers: stercoral, solitary ulcer

8% 9% 6%

Postpolypectomy 6% 7% 2%

AVM 1% 3% 3%

Hemorrhoids 11% 11% 13%

Ischemic colitis 11% 10% 8%

Other colitis (IBD, infectious, radiation)

12% 15% 7%

Neoplasm 3 % 6% 7%

No source found 7% 9% 11%

Epidemiology and outcome

•  Outcome depends on etiology and comorbidities – > 80% of bleeding will stop spontaneously and

not recur –  5-10% will have persistent or severe bleed – Mortality is < 5%

Outcomes Author/ year

N Continued or rebleeding

Died Surg Tx

pRBCs (SD)

LOS (Days)

Strate 2005

275 4.0% 2.6% 2.5 (4.5)

Strate 2003

252 7% 2.4% 3.6% 2.0 (3.0)

4.3

Schmule- witz 2003

565 11% 3% 5% 3.1 (3.9)

6.7

Das 2003

332 19% 5% 2.2 4.4

Diverticular Bleeding

Intractable bleed in hospital = 7%

In hospital mortality = 2% Longstreth Am J Gastro 1997;92:419

Presentation •  Vital signs

–  20-30% with shock or orthostasis •  Form of bleeding

– Hematochezia versus melena •  Abdominal pain

– Present versus absent, location •  Directed history and Exam

– Comorbid conditions •  Labs

Risks for Ongoing Bleeding

•  Strate et al. Arch Int Med, 2003 – HR > 100 OR, 3.67 – Sys BP < 115 OR, 3.45 – Syncope OR, 2.82 – Painless OR, 2.43 – Overt bleed (4 hr) OR, 2.32 – ASA use OR, 2.07 –  2 active comorbid OR, 1.93

Risks for Severe Bleed

•  Severe bleeding (ongoing bleed and/or > 2 units transfusion) occurs in: –  79-84% with > 3 risk factors 17% of total –  43% with 1-3 risk factors 78% of total –  6-9% with 0 risk factors 5% of total

Strate et al. Am J Gastro, 2005

Outcomes Based on Risk •  Low Risk = 0 factors

–  Surgery = 0% –  Death = 0% –  LOS = 2.8 days

•  Moderate Risk = 1-3 risk factors –  Surgery = 1.5% –  Death = 2.9% –  LOS = 3.1 days

•  High Risk = > 3 risk factors –  Surgery = 7.7% –  Death = 9.6% –  LOS = 4.6 days

Risk of Death���Strate, Clin Gastro Hepatol, 2008

•  Nationwide audit in US •  Mortality = 3.9% •  Risk factors

– Age > 70 OR = 4.9 –  Int ischemia OR = 3.5 – >/= 2 comorbid OR = 3.0 – Nosocomial bleed OR = 2.4 – Coagulopathy OR = 2.3 – Hypovolemia OR = 2.2 – Transfusion OR = 1.6 – Men OR = 1.5

Hospitalization •  Abnormal vital signs •  Ongoing rectal bleeding •  Active/multiple comorbid conditions •  Suspicion of upper tract bleed •  Previous aortic surgery •  Severe anemia (HgB < 8) •  Fever, leukocytosis •  Abdominal pain/tenderness

Triage/LOS •  Clinical criteria

– High, Moderate, Low – HIGH Risk: shock or > 3-4 units blood/day

•  Endoscopic or Angiographic Criteria? – High Risk

•  Active arterial bleed , ulcer with vessel, from TIC •  Cancer

– Lower Risk •  Polyp/polypectomy, ectasia, colitis, anorectal

Triage and Optimal Length of Stay

•  Data are scarce compared with upper GI bleed

•  Expert opinion – High risk

•  ICU for 24 hours, hospital for 72 hours – Moderate Risk

•  Hospital for 24-48 hours, early refeeding – Low Risk

•  Feed and early discharge

Critical Initial Diagnostic Steps •  Upper versus lower tract bleed

– Color of bleed – NG aspirate – History – Labs – EGD

•  Anorectal versus other lower source of bleed – History – Bedside anoscopy

Nasogastric Aspirate

•  > 90% of those with red, pink or black aspirates have upper GI source

•  > 60% of those with negative (bilious) aspirate have lower source, < 1% with upper source

•  Equivocal aspirate? –  10% or more of upper tract bleeds (DU)

Rapid purge colonoscopy

Observe: no bleed, colonoscopy w/in 1-2 days

Angiography

Nuclear bleeding scan; If neg, colonoscopy

If positive, angio

Sigmoidoscopy

?

One Division: ���Parallel Practices

None Recurrent/ Intermittent

Continuous Severe/ Rapid

Rapid purge; non-emergent colonoscopy

Rapid-purge; Urgent colonoscopy

Angiography

Observe; prep non-emergent colonoscopy

Scintigraphy: Angiography vs.

Elective colonoscopy

Angiography

Nuclear scintigraphy •  O.1 ml/min = 1 unit rbc/2-4 hours •  Two purposes:

–  Screening prior to angiography •  Increase likelihood of positive angio

–  Localization for surgery •  Assessing “accuracy” in clinical studies

–  Variable techniques –  Variable thresholds for performing study –  Variable times to angiography or surgery –  Variable criteria for determining “accurate”

localization

Author Year

Total Scans

Positive scans Correct localization

Positive angiograms

Olds 2005

127 39% 48% 42%

Levy 2003

40* 70% 45% 0%

Ng 1997

160 54% - 43%

Suzman 1996

224 51% 78% 44%

Rantis 1995

80 48% 73% -

Voeller 1991

59 32% 69% -

Hunter 1990

203 26% 41% 44%

99mTc RBC for LGIB: Recent Studies

*

RBC Scintigraphy

•  Summary of 16 studies with 1418 patients: 78% accurate versus 22% inaccurate

•  Details matter – Active bleed at time of scan – Technetium Tc 99m-labeled in vitro – Early positive versus late positive – Upper tract source excluded

Nuclear Medicine as a Prelude to Angiography

•  Ng et al. Dis Colon Rectum 40: 1997. –  160 patients, 1989-1994 –  86 positive scans 47 underwent angiography – Look for “blush” on nuclear medicine – Grp 1 (33) blush < 2 min 20/33 positive angio – Grp 2 (14) blush > 2 min 13/14 (-) angio –  Immediate blush should go to angio; if > 2 min—

colonoscopy or observe

Angiography •  Diagnosis

–  Femoral access •  5 Fr catheters with steerable wires

–  Selective access of SMA, IMA catheterization (sometimes celiac)

•  Endoscopic identification/marking of bleeding lesion with clips facilitates

•  Endovascular therapy –  Vasopressin infusion no longer used –  Sub-3 Fr catheter placed to most peripheral arteries

•  Microcoils (1-2 mm) for colon •  Polyvinyl microspheres (350-500 um) for small

intestine

Angiography: UCSF Experience •  17 patients with angiographically detected

lower tract bleeding •  Subselective embolization possible in 14

– Tracker 2.5 Fr coaxial microcatheter – metallic coils for embolization

•  Durable hemostasis in 13/14 •  Bowel infarction or other major procedure

related morbidity in 0 Am J Surg 1997;174:24-28

Meta-analysis of Angiography for LGIB

Khanna A et al: J Gastrointest Surg 2005;9:343

•  Included: –  7 cases series; all with > 10 pts with major

LGIB tx’ed with attempted embolization •  Results:

– Median 30 d rebleeding rate: 14% (0-75) • Rebleed w/ Non-diverticular source: 45%

(OR 3.4 vs diverticular bleeding) –  75 % of rebleed w/in 3.5 days

Urgent Colonoscopy •  Colonoscopy w/in 6-24 hours of admission •  Rapid purge: Get serious!

– Polyethylene glycol-based preps –  1 Liter q 30-45 minutes – Median 6 L (range: 4-14L) – Time required: 3-4 hrs – NG tube: required in one-third – Consider: metoclopramide 10 mgIV – Goal: clear effluent (if not, give more) – Colonoscopy w/in 1 hr of clearance

•  If ongoing bleeding, colonoscopy when effluent is pink with no clots

“Urgent” (W/in 24 h) Colonoscopy in LGIB

Study (year) N Specific Dx Endoscopic Complications

Tx Green, 2005 50 48 17 2% Angtuaco, 2001 39 29 4 - Kok, 1998 190 148 10 0% Chaudhry, 1998 85 82 17 1%

TOTAL 364 307 (84%) 48 (13%)

Urgent Colonoscopy: UCLA Experience

•  Urgent colonoscopy after rapid purge •  diagnostic yield

–  80%; endoscopic –  treatment in 40% –  complications in 0%

•  Retrospective Results –  angio rate from 50 to < 5% – BE rate from 25 to 0% –  surgery rate from 20 to < 5% – LOS from 10 to 5 days and ICU stay from 3 to

1 day – Cost reduced $10, 000 per patient

Bleeding diverticula (n=3) Rx’d with Gold Probe (10-15W, 1 sec pulses X 6-18 pulses)

VV at edge of tic

Gold probe applied Flattened VV

Savides et al. GIE 1994;40:70-72

Colonoscopy and Severe Diverticular Bleed: UCLA Experience

•  Study 1 - 73 patients (medical/surgical) •  Study 2 - 48 patients (medical/colonoscopy) •  Definite TIC bleed: 17/73 versus 10/48

– Study 2: severe hematochezia = 150 •  Outcomes

– Study 1 - 9/17 with ongoing bleed, 6/17 to OR – Study 2 - 0/10 with ongoing bleed

NEJM 2000;342:78-82

Urgent Colonoscopy?���Green, Rockey et al., Am J Gastro, 2005

•  RCT of urgent colonoscopy versus standard care with angio for ongoing bleed

•  Urgent colonoscopy in 50 – Endo Rx in 17

•  Standard care in 50 – Angio Rx in 10

Urgent Colonoscopy Standard Care Statistics Definite bleed source 42 % 21 % OR 2.6

(CI, 1.1-6.2) Presumptive bleed source

26 % 20 % OR 1.6 (CI, 1.1-6.2)

No diagnosis 4 % 24% P < 0.05 Hospital stay (days) 5.8 6.6 NS PRBCs 4.2 (0.4) 5.0 (0.5) NS Surgery 14% 12% NS Early rebleed 22 % 30 % NS Late rebleed 16% 14% NS

Results

Early Colonoscopy •  Strate et al. (Am J Gastroenterol, 2003; GIE, 2005)

–  252 patients admitted with LGIB – No benefit with respect to need for surgery,

death – Colonoscopy within 24 hours associated with

less transfusion and shorter LOS (hazards ratio, 2.02; 1.5-2.6) • < 24 hours = 2.1 days •  24-48 hours = 2.7 days • > 48 hours = 4.4 days

Urgent Surgery •  Segmental resection after localization of

bleed – Rebleeding < 15% – Mortality < 10%

•  Blind segmental resection – Rebleeding 35-75% during hospital stay – Mortality 20-50%

•  Emergency total colectomy – Rebleeding > 0-60% – Mortality > 10-40%

Surgery for LGI Hemorrhage���Directed Segmental Resection

Case #1

•  85 year old woman – multiple medical problems –  hematochezia and tachycardia –  vital signs normalize with IV fluid and NG

lavage is bilious –  initial Hct is 28% –  no further hematochezia is passed in the ED.

Question #1: What test to order?

1.  EGD and Flex Sig 2.  Colonoscopy 3.  RBC scan 4.  Angiography

Case #1

•  While being prepared for colonoscopy the patient passes more BRBPR and her BP drops. Her vital signs normalize with an increase in her transfusion rate.

Question #2

•  RBC scan is (+) for activity at the splenic flexure of the colon. Now what intervention?

1.  Colonoscopy 2.  Angiogram and embolization of site if active

bleeding seen 3.  Angiogram as prelude to surgery if bleed

localized 4.  Surgery now

Case #2

•  27 year old man –  hematochezia, normal BP and tachycardia – HR remains elevated despite IV fluids –  no further hematochezia in the ED – NG lavage is clear and initial Hct is 31%.

Question #3

•  What test (s) should be undertaken first? 1.  EGD + Flex Sig 2.  Colonoscopy 3.  RBC scan 4.  Angiography

Case #2 •  You perform and urgent EGD and flex

sigmoidoscopy. –  results are negative –  no further bleeding over the next 12 hours – Colonoscopy is negative –  after the colonoscopy more BRBPR with

tachycardia and drop in hematocrit – NG lavage is bilious again

Question #4

•  What should you do now? 1.  Repeat colonoscopy 2.  RBC scan 3.  Angiography 4.  Enteroscopy 5.  Capsule endoscopy

Case #2

•  RBC scan is positive in ileum •  Angiogram is performed and active

bleeding seen and vessel embolized •  After angiogram, CT enterography

demonstrates mass in ileum •  Elective operative resection reveals GIST

Case #3

•  64 year old man – hematochezia, tachycardia, bilious NG

lavage and Hct of 28% – two further episodes of hematochezia in

the ED

Case #3

•  While being prepared for colonoscopy an rbc scan is obtained and is negative

•  Colonoscopy – diverticula throughout the colon, L >> R – No stigmata of ongoing or recent

bleeding are seen, no therapy given

Case #3

•  While being observed in the hospital – several more discrete episodes of

hematochezia with change in VS – Rbc scans obtained again, positive in

LLQ – Angiogram, negative for active bleed – Patient has received a total of 8 units of

blood

Question #5

•  What intervention now? 1.  Left hemicolectomy? 2.  Total abdominal colectomy? 3.  Repeat Angiography? 4.  Repeat colonoscopy?

Hematochezia

Any of following? Pulse > 100/min BP < 100 mmHg BRBPR w/in 4hrs

Admit to Floor Observe If no further bleeding Elective colonoscopy; If recurrent BRBPR, Initiate rapid purge

Admit to TCU/ICU Initiate rapid purge Colonoscopy w/in 1 hr of prep

NG lavage Consider EGD in high risk groups

If massive bleeding/unable to clear, Angiography (no RBC scan) Surgery consult

No Yes