Investigation and management of overt rectal bleeding for Medical

Views:
 
Category: Entertainment
     
 

Presentation Description

Medical gastroenterologist perspective

Comments

Presentation Transcript

Investigation and management of overt rectal bleeding (including endoscopic and radiological therapy):

Investigation and management of overt rectal bleeding (including endoscopic and radiological therapy) Venkata ( Pawan ) Lekharaju ST 6 Gastroenterology Aintree University Hospital Liverpool, UK Sep 2011

Not discussing :

Not discussing Patients with positive FOBT Obvious self limited bleeding where the likelihood of change in the vital signs or anaemia is low Chronic bleeding of obscure origin

Definitions:

Definitions Upper GI bleed Lower GI bleed Obscure GI bleed Obscure Overt GI bleed Obscure occult GI bleed

AGA – Nov 2007:

AGA – Nov 2007 Bleeding above the ampulla of Vater, within the reach of an EGD, is defined as upper GI bleeding; Small intestinal bleeding from the ampulla of Vater to the terminal ileum, best investigated by capsule endoscopy and double-balloon enteroscopy, is defined as mid GI bleeding; and Colonic bleeding is defined as lower GI bleeding, which can be evaluated by colonoscopy Raju GS et al. Gastroenterology Volume 133, Issue 5 , Pages 1694-1696, November 2007

Epidemiology:

Epidemiology 20-33% of episodes of gastrointestinal (GI) hemorrhage, Annual incidence - 20-27 cases per 100,000 population in Western countries. However, although LGIB is statistically less common than upper GI bleeding (UGIB), it has been suggested that LGIB is underreported because a higher percentage of affected patients do not seek medical attention Talley NJ, Jones M. Self-reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking. Am J Gastroenterol . Nov 1998;93(11):2179-83

Haematochezia:

Haematochezia 15% have upper GI cause 0.7%-9% have a small bowel cause Farrell jj, Friedman LS. The management of lower gastrointestinal bleeding. Aliment Pharmacol Ther 2005;21(11):1281-98 Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 1988;95(6):1569- 74

Vernava AM, Longo WE, Virgo KS. A nationwide study of the incidence and etiology of lower gastrointestinal bleeding. Surg Res Commun. 1996;18:113-20:

Vernava AM, Longo WE, Virgo KS. A nationwide study of the incidence and etiology of lower gastrointestinal bleeding. Surg Res Commun . 1996;18:113-20 Lower Gastrointestinal Bleeding in Adults Percentage of Patients Diverticular disease 60% Diverticulosis/diverticulitis of small intestine Diverticulosis/diverticulitis of colon Inflammatory bowel disease 13% Crohn disease of small bowel, colon, or both Ulcerative colitis Noninfectious gastroenteritis and colitis Benign anorectal diseases 11% Hemorrhoids Anal fissure Fistula-in-ano Neoplasia 9% Malignant neoplasia of small intestine Malignant neoplasia of colon, rectum, and anus Coagulopathy 4% Arteriovenous malformations (AVMs) 3% TOTAL 100%

Diverticulosis:

Diverticulosis Most common reason for massive LGIB in most of the single-institution publications. Most diverticular bleeding occurs without concomitant diverticulitis, and diverticulitis does not increase the risk of bleeding. Risk factors for diverticular bleeding include lack of dietary fiber, constipation, advanced age, and use of nonsteroidal antiinflammatory drugs (NSAIDs) and aspirin

Angiodysplasia:

Angiodysplasia Increased risk of rebleeding in Patients with earlier bleeding with a high bleeding rate, overanticoagulation, and multiple angiodysplastic lesions The investigators also noted that although there was a better trend for management and prevention of such recurrent bleeding with endoscopic argon plasma coagulation, this therapy was not predictive of a lower rate of hemorrhage recurrence Saperas E, Videla S, Dot J, Bayarri C, Lobo B, Abu-Suboh M, et al. Risk factors for recurrence of acute gastrointestinal bleeding from angiodysplasia. Eur J Gastroenterol Hepatol . Dec 2009;21(12):1333-9

Radiation induced colitis:

Radiation induced colitis Can occur early or late, with a median time of occurrence from 9 to 15 months. Risk factors for radiation induced LGIB include arteriosclerosis and concomitant chemotherapy 69% present with in 1 year 96% present with in 2 years Gilinsky NH, Burns DG, Barbezat GO, Levin W, Myers HS, Marks IN. The natural history of radiation-induced proctosigmoiditis: an analysis of 88 patients. q j Med 1983;52(205):40-53

Post polypectomy bleeding:

Post polypectomy bleeding Postpolypectomy bleeding occurs in approximately 0.1-3% of patients, is more often arterial, and can produce significant bleeding. Bleeding can occur at the time of polypectomy but can also manifest several hours to a few weeks after the procedure

Rectal varices:

Rectal varices Massive bleeding Banding, Sclerotherapy – helpful short term TIPSS is usually the procedure of choice to prevent recurrence

Vernava AM, Longo WE, Virgo KS. A nationwide study of the incidence and etiology of lower gastrointestinal bleeding. Surg Res Commun. 1996;18:113-20:

Vernava AM, Longo WE, Virgo KS. A nationwide study of the incidence and etiology of lower gastrointestinal bleeding. Surg Res Commun . 1996;18:113-20 Lower Gastrointestinal Bleeding in Adults Percentage of Patients Diverticular disease 60% Diverticulosis/diverticulitis of small intestine Diverticulosis/diverticulitis of colon Inflammatory bowel disease 13% Crohn disease of small bowel, colon, or both Ulcerative colitis Noninfectious gastroenteritis and colitis Benign anorectal diseases 11% Hemorrhoids Anal fissure Fistula-in-ano Neoplasia 9% Malignant neoplasia of small intestine Malignant neoplasia of colon, rectum, and anus Coagulopathy 4% Arteriovenous malformations (AVMs) 3% TOTAL 100%

Management of Lower GI Bleed:

Management of Lower GI Bleed Majority (80-85%) stop spontaneously (SIGN) Farrell jj, Friedman jS. Gastrointesinal bleeding in the elderly. Gastroenterol Clin North Am 2001;30(2):377-407

Radiology:

Radiology

Role of radiology:

Role of radiology Major breakthroughs in catheter and guidewire design as well as improvements in angiographic x-ray equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. For chronic or recurrent GI bleeding, when endoscopy is unrevealing or equivocal, barium studies, CT scanning, nuclear medicine studies, and angiography can help determine the cause of bleeding. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is extremely helpful in managing GI bleeding, particularly in high-risk patients or patients presenting as diagnostic dilemmas

PowerPoint Presentation:

A simplified algorithm of the management of acute gastrointestinal haemorrhage.

CTA:

CTA Detect flow rates as low as 0.3ml/min Nuclear scintigraphy 0.4ml/min DSA 0.5-1.0ml/min

CTA:

CTA Specificity approaching 100% However negative in 20% of patients

CTA:

CTA Non-invasive, Widely available, and can reliably guide appropriate endovascular or surgical treatment. CTA should be considered in all units irrespective of the availability of interventional radiology services. The risks of ionising radiation and intravenous contrast are greatly outweighed by the risk of morbidity and mortality associated with acute GI haemorrhage.

Question T/F:

Question T/F CT angiography (CTA): Identifies the source of acute GI haemorrhage in around 50% patients Is contraindicated in patients with cardiac pacemakers Should be performed with intravenous contrast in patients with end stage renal failure on dialysis Is the most appropriate next investigation (after normal rectal examination and proctoscopy) in a patient who presents with fresh rectal bleeding and hypotension, with a pulse rate of 80/min and blood pressure of 120/80 mm Hg following fluid resuscitation Is associated with an approximate one in 500 risk of causing a fatal radiation induced cancer in a young adult patient

Angiography:

Angiography Baum S, Nusbaum M, Blakemore WS, Finkelstein AK. The preoperative radiographic demonstration of intra-abdominal bleeding from undetermined sites by percutaneous selective celiac and superior mesenteric arteriography. Surgery . Nov 1965;58(5):797-805

Super selective angio:

Super selective angio Rosch J, Gray RK, Grollman JH Jr, et al. Selective arterial drug infusions in the treatment of acute gastrointestinal bleeding. A preliminary report. Gastroenterology . 1971;59(3):341-9. Rösch J, Dotter CT, Brown MJ. Selective arterial embolization. A new method for control of acute gastrointestinal bleeding. Radiology . Feb 1972;102(2):303-6

Angiography:

Angiography Clinical sensitivity is 60% Karanicolas PJ, Colquhoun PH, Dahlke E, Guyatt GH. Mesenteric angiography for the localization and treatment of acute lower gastrointestinal bleeding. Can J Surg . Dec 2008;51(6):437-41 Increased by using vasodilators, thrombolytics and controlled heparin

Interventional radiology:

Interventional radiology Two transcatheter methods for the treatment of GI bleeding include vasopressin infusion and embolization Superselective embolization has become more accepted in recent years Bandi R, Shetty PC, Sharma RP, et al. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol . Dec 2001;12(12):1399-405. Funaki B, Kostelic JK, Lorenz J, et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol . Oct 2001;177(4):829-36. Guy GE, Shetty PC, Sharma RP, et al. Acute lower gastrointestinal hemorrhage: treatment by superselective embolization with polyvinyl alcohol particles. AJR Am J Roentgenol . Sep 1992;159(3):521-6 Ledermann HP, Schoch E, Jost R, et al. Superselective coil embolization in acute gastrointestinal hemorrhage: personal experience in 10 patients and review of the literature. J Vasc Interv Radiol . Sep-Oct 1998;9(5):753-60

Vasopressin infusion:

Vasopressin infusion The infusion is started with the catheter in the main trunk of the mesenteric artery that is cause of bleeding. The initial rate is 0.2 U/min. A follow-up angiogram is obtained after about 30 minutes. In cases of active hemorrhage, the rate is increased to 0.4 U/min. Higher rates are not recommended because the potential complications from vasoconstriction can exceed the benefits. The infusion is tapered at 6- to 12-hour intervals and then stopped if no further bleeding ensues

Embolisation:

Embolisation Polyvinyl alcohol (PVA, Contour, Medi-tech Inc. Natick, Mass) particles and Gelfoam (Upjohn, Kalamazoo, Mich), although most of the studies have used microcoils (platinum coils), either alone or in conjunction with Gelfoam or PVA

Evangelista PT, Hallisey MJ. Transcatheter embolization for acute lower gastrointestinal hemorrhage. J Vasc Interv Radiol. May 2000;11(5):601-6 :

Evangelista PT, Hallisey MJ. Transcatheter embolization for acute lower gastrointestinal hemorrhage. J Vasc Interv Radiol . May 2000;11(5):601-6 Superselective embolization as the most effective procedure in reducing complication rates The investigators reported an 88% success rate and argued against the use of PVA as the sole embolization agent, as the small particles may reach intramural circulation and thus occlude the submucosal plexus beyond the level of collateralization, leading to significant bowel ischemia. An advantage of coils is that they are visible and, therefore, more controllable

Question T/F:

Question T/F Concerning digital subtraction angiography (DSA): It is more sensitive for GI haemorrhage than CTA It is associated with a 20% risk of significant groin haematoma It is not practicable in a patient who is under general anaesthetic The purpose of ‘digital subtraction’ is to quantify the amount of haemorrhage A positive study can reliably guide the surgeon in performing a limited colonic resection rather than subtotal colectomy.

Question T/F:

Question T/F Concerning arterial embolisation in acute GI haemorrhage: Coiling of the superior mesenteric artery is an appropriate treatment for a bleeding angiodysplasia in the ascending colon The arterial catheter is routinely left in situ for 24–48 h to facilitate repeat embolisation if haemorrhage recurs It is a more technically challenging procedure than intra-arterial vasopressin infusion In the lower GI tract, it is complicated by significant bowel infarction in around 25% of cases Hepatic artery embolisation rarely causes significant liver ischaemia providing the portal vein is patent.

Nuclear imaging:

Nuclear imaging Bunker SR, Lull RJ, Tanasescu DE, et al. Scintigraphy of gastrointestinal hemorrhage: superiority of 99mTc red blood cells over 99mTc sulfur colloid. AJR Am J Roentgenol . Sep 1984;143(3):543-8 Nuclear scintigraphy is generally reserved for sub-acute or chronic GI haemorrhage

Question T/F:

Question T/F Concerning nuclear scintigraphy: It is more sensitive for GI haemorrhage than CTA or DSA It is commonly available out-of-hours in UK hospitals Surgery is contraindicated for 6 h afterwards because of the radiation risk to theatre staff It typically requires 2 units of matched blood from the blood bank Serial γ camera scanning (eg, every 20 min) increases the yield of positive results, albeit with an increase in the patient's radiation exposure.

TIPSS:

TIPSS Esp in the setting of ectopic varices is an important life saving radiological intervention

Question T/F:

Question T/F The transjugular intrahepatic portosystemic stent (TIPSS) procedure Involves the creation of a shunt between the inferior vena cava and the portal vein Can be performed under local anaesthetic Is generally reserved for patients who are not considered fit for a surgical shunt procedure Is an appropriate treatment for a patient with intractable haemorrhage from stomal varices

Endoscopy:

Endoscopy

SIGN:

SIGN RCT – urgent vs standard colonoscopy = improved diagnosis, but no change in outcome Green BT, Rockey DC, Portwood G, Tarnasky PR, Guarisco S, Branch MS, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am j Gastroenterol 2005;100(11):2395-402.

Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding:

Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding Patients with clinically serious hematochezia should have upper endoscopy initially to rule out an upper GI source. Use of urgent colonoscopy in a population hospitalized with serious lower GI bleeding showed no evidence of improving clinical outcomes or lowering costs as compared with routine elective colonoscopy Laine L, Shah A. Am J Gastroenterol. 2010 Dec;105(12):2636-41; quiz 2642

SIGN:

SIGN In patients who were identified to be bleeding secondary to diverticulosis, colonoscopic haemostatic techniques were associated with: ƒ high technical success in 90-100% of cases clinical success rates of 70-100% of cases ƒ no significant complications Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000;342(2):78-82. Ohyama T, Sakurai y, Ito M, Daito K, Sezai S, Sato y. Analysis of urgent colonoscopy for lower gastrointestinal tract bleeding. Digestion 2000;61(3):189-92.

SIGN:

SIGN In patients who had bleeding following colonoscopic polypectomy or colonoscopic biopsy colonoscopic haemostatic techniques were associated with: ƒ high technical success in 99-100% of cases ƒ clinical success rates of 95-100% of cases ƒ no significant complications Rex DK, Lewis BS, Waye jD. Colonoscopy and endoscopic therapy for delayed post-polypectomy hemorrhage. Gastrointest Endosc 1992;38(2):127-9. Parra-Blanco A, Kaminaga N, Kojima T, Endo y, Uragami N, Okawa N, et al. Hemoclipping for postpolypectomy and postbiopsy colonic bleeding. Gastrointest Endosc 2000;51(1):37-41

SIGN:

SIGN In patients with massive LGIB colonoscopic haemostasis is an effective means of controlling haemorrhage from active diverticular bleeding or post-polypectomy bleeding, when appropriately skilled expertise is available

Endotherapy:

Endotherapy Depending on the lesion No randomized trials to recommend the superiority of one over other Extrapolation from Upper GI endotherapy Injection/Heater probe/Clips/APC RFA – in selected cases

Surgery:

Surgery SIGN

SIGN:

SIGN Eight cohort studies and two case control studies were identified that investigated the surgical management of lower GI haemorrhage Surgery was associated with: mortality rates of 0 - 33% of cases Rebleeding rates of 0-18% In the cohort studies the rebleeding and mortality rates for blind segmental resection were considerably higher than those for either directed segmental resection or subtotal colectomy

Surgery:

Surgery Two case control studies comparing subtotal colectomy with segmental colectomy have produced conflicting conclusions regarding the supremacy of one technique over the other In these studies, where preoperative localisation was not possible, a subtotal colectomy was a safe procedure with acceptable functional results.

SIGN Recommendation:

SIGN Recommendation Localised segmental intestinal resection or subtotal colectomy is recommended for the management of colonic haemorrhage uncontrolled by other techniques.

PowerPoint Presentation:

THANK YOU

authorStream Live Help