COLONIC BLEEDING a presentation on general surgery.pptx

Colonic bleeding (Shackelford)

1. COLONIC BLEEDING AND ISCHEMIA ALVIN T. LORENZANA, MD GENERAL SURGERY RESIDENT REGION II TRAUMA AND MEDICAL CENTER

2. COLONIC BLEEDING LOWER GI BLEEDING – DISTAL TO THE LIGAMENT OF TREITZ SMALL BOWEL BLEEDING COLONIC BLEEDING– ASSOCIATED WITH INCREASED HEALTH CARE USE – COST TO SOCIETY IN-HOSPITAL MORTALITY RATE – 2-4% ADVANCED AGE (>70 YEARS) INTESTINAL ISCHEMIA COMNRBID ILLNESS

3. COLONIC BLEEDING PREDICTORS OF SEVERE BLEEDING TACHYCARDIA (>100 BPM) HYPOTENSION (SBP < 115 MMHG) SYNCOPE NONTENDER ABDOMINAL EXAMINATION RECTAL BLEEDING IN THE FIRST 4 HOURS OF EVALUATION ASPIRIN USE MORE THAN 2 COMORBID CONDITIONS

4. COLONIC BLEEDING ETIOLOGIES DIVERTICULOSIS NEOPLASIA VASCULAR ECTASIA OTHERS INFLAMMATORY BOWEL DISEASE INFECTIOUS COLITIS POSTPOLYPECTOMY ISCHEMIC COLITIS

5. COLONIC BLEEDING ANORECTAL Hemorrhoids Neoplasm Pressure necrosis (indwelling rectal tubes) Radiation proctitis

6. PROFILE MORE LIKELY TO BE MALE ALCOHOL USE TOBACCO ASPIRIN USE NONSTEROIDAL ANTINFLAMMATORY AGENTS

7. CARCINOMA – MOST COMMON CAUSE OF LOWER INTESTINAL BLEEDING DIVERTICULOSIS – MOST COMMON CAUSE OF ACUTE SYMPTOMATIC LOWER GI BLEEDING

8. DIVERTICULOSIS 30% IN OLDER THAN 50 YEARS 60% IN OLDE THAN 80 YEARS PAINLESS HEMATOCHEZIA 70-80% WILL HAVE SPONTANEOUS RESOLUTION 20% OBTAIN A DEFINITIVE DIAGNOSIS OF A DIVERTICULAR BLEED BASED ON COLONOSCOPIC FINDINGS AOF ACTIVE BLEEDING OR A VISIBLE VESSEL OR CLOT. MOSTLY ARE DIAGNOSED PRESUMPTIVELY – DUE TO PRESENCE OF DIVERTICULA DURING COLONOSCOPY

9. NEOPLASIA MAJORITY OF PATIENTS WITH COLORECTAL NEOPLASIA – OCCULT BLOOD LOSS AND ARE MORE LIKELY TO PRESENT WITH IRON DEFICIENCY ANEMIA LOWER GI BLEEDING + WEIGHT LOSS + CHANGE IN BOWEL HABITS = SUSPICION FOR NEOPLASIA DRE is imperative Most common cause of bleeding: Ulceration of the tumor surface

10. VASCULAR ECTASIA AKA angiodysplasia, arteriovenous malformation, angioectasia Frequent cause of recurrent Lower GI bleeding Age related degeneration of previously normal colonic blood vessels CECUM AND ascending colon Typically are less than 5mm in diameter and are multiple Characteristic findings: small red flat lesion with ectatic vessels radiating from the central lesion Factors for bleeding: a. number of lesions b. presence of coagulopathy or bleeding disorder

11. DIAGNOSIS OF LOWER GI BLEEDING Varies with: Age Presence or absence of active bleeding Severity of hemodynamic compromise All patients patients with lower GI bleeding require a physical examination, including DRE

12. LABORATORY Performed to: Evaluate level of anemia Rule out coagulopathy

13. DEFINITION OF TERMS OCCULT BLEED: Absence of gross bleeding Heme positive stools MELENA: Passage of dark, black, or tarry stools SCANT INTERMITTENT HEMATOCHEZIA: Intermittent passage of usually bright red blood per rectum SEVERE HEMATOCHEZIA: Large-volume bright red blood per rectum

14. BLEEDING SEVERITY AND MANAGEMENT American Society of Gastrointestinal Endoscopy (ASGE)

15. ENDOSCOPIC TREATMENT of ACUTE HEMORRHAGE Depends on: THE ENDOSCOPIST THE LOCATION OF THE LESION THE SIZE OF THE LESION MOST COMMONLY USED METHOD Epinephrine injection Heater probe coagulation Endoscopic clip placement

16. ANGIOGRAPHIC TREATMENT of ACUTE HEMORRHAGE Follows unsuccessful endoscopy or if there is rapid ongoing bleeding IN ORDER: Selective SMA Selective IMA Celiac axis studies Intraarterial injection of Vasopressin – used most of the time for active bleeding Others: selective embolization with coils, gels, or cellulose materials Success rate: 40-78% COMPLICATIONS: renal toxicity, arterial injury, ischemia (higher than in endoscopy) – explains why it is done after a colonoscopy

17. SURGICAL TREATMENT Reserved for bleeding that cannot be controlled with endoscopy or angiography. Indications: Hemodynamic instability ongoing transfusion requirements Persistent hemorrhage not responsive to other methods Preop preparation: Endoscopic tattooing or angiographic identification of the bleeding source Intraoperative endoscopy – needed if bleeding is not perioperatively localized – if still not localized, subtotal colectomy is recommended.

18. COLONIC ISCHEMIA Before: synonymous with colonic infarction or gangrene DEFINITION: Colonic ischemia – hypoperfusion of the colon Mesenteric ischemia – hypoperfusion of the small intestine ETIOLOGIES: A. Occlusive or non-occlusive arterial obstruction B. Obstruction of venous outflow

19. COLONIC CIRCULATION protected from ischemia by its abundant collateral circulation (between the celiac artery, SMA, IMA, and iliac artery) A rch of Riolan Marginal artery of Drummond N etwork of communicating submucosal vessels exists within the bowel wall

20. PATHOPHYSIOLOGY OF COLONIC ISCHEMIA Whether it is increased demand by colonic tissue superimposed on already marginal blood flow or whether the flow itself is acutely diminished – not yet determined

21. COLONIC ISCHEMIA T ends to be a disease of older adults and may therefore result from: age-related alteration in the mesenteric vasculature age-related tortuosity of the longer colonic arteries (increased resistance) MOST CASES HAVE NO IDENTIFIABLE CAUSE (thought to be the result of local nonocclusive ischemia - low-flow state in association with small vessel disease Thromboembolic disease – less often cause of ischemia

22. MEDICAL COMORBIDITIES cardiovascular disease diabetes mellitus chronic kidney disease chronic obstructive pulmonary disease Irritable bowel syndrome and constipation may also increase the risk of developing colonic ischemi postoperative complication of procedures requiring ligation or exclusion of the IMA A. A ortic surgery for the treatment of aneurysmal disease B. C olonic resection for carcinoma.

23. SYMPTOMS sudden onset of mild, crampy abdominal pain, usually localized to the lower left quadrant Less commonly the pain is severe, or conversely, in other patients the description of pain can be elicited only retrospectively An urgent desire to defecate frequently accompanies the pain and is followed, within 24 hours, by the passage of either bright red or maroon blood in the stool. Physical examination may reveal mild to severe abdominal tenderness elicited in the location of the involved segment of bowel

24. Distribution of Colonic Ischemia MOST COMMON Splenic flexure Descending colon Sigmoid colon Segmental involvement is the most common distribution (Involvement of the whole colon is rare)

25. The rectum is very rarely involved because of its abundant dual blood supply from both the splanchnic and systemic arcades. Patients noted to have right-sided–only ischemia more commonly have atrial fibrillation, coronary artery disease, and chronic kidney disease Depending on the severity and duration of the ischemic insult, fever or leukocytosis may develop. Patients with severe ischemia leading to transmural necrosis, gangrene, or perforation may develop peritonitis.

26. Natural History of Colonic Ischemia ultimate course of an ischemic insult depends on many factors: the cause (i.e., occlusive or nonocclusive) the caliber of an occluded vessel the duration and degree of ischemia the rapidity of onset of the ischemia the condition of the collateral circulation the metabolic requirements of the affected bowel the presence and virulence of the bowel flora, and the presence of associated conditions (colonic distention)

27. COLONIC ISCHEMIA S ymptoms subside within 24 to 48 hours C linical, radiographic, and endoscopic evidence of healing is seen within 2 weeks More severe, but still reversible, ischemic damage may take 1 to 6 months to resolve. The majority of patients with reversible disease develop colopathy , whereas transient colitis develops in approximately one-third. Severe reversible ischemia may result in diffuse mucosal sloughing.

28. Because the clinical course of colonic ischemia is difficult to predict, there is a need for serial examinations to evaluate for signs of clinical deterioration suggesting development of gangrene or perforation: rising temperature elevated white blood cell count worsening metabolic acidosis hemodynamic instability or peritonitis. Persistent diarrhea or bleeding beyond the first 10 to 14 days - risk for development of perforation or, less frequently, a protein-wasting enteropathy. Strictures may develop over a period of weeks to months and may be asymptomatic or produce progressive bowel obstruction

29. DIAGNOSIS CT scan combined with early colonoscopy Barium enema – “thumbprinting” or ” pseudotumors ” – subepithelial hemorrhagic nodules or bullae It is now being used to follow the course of ischemic stricture

30. DIAGNOSIS CT findings consistent with colonic ischemia include: segmental bowel wall thickening Edema Thumbprinting Perico l ic fat stranding and A scites CT findings that suggest transmural colonic infarction: Findings of colonic pneumatosis or portal venous gas CT angiography should be performed in patients with clinical suspicion for acute mesenteric ischemia

31. DIAGNOSIS EARLY COLONOSCOPY confirm the diagnosis of colonic ischemia – by direct visualization Establish the severity of the disease Has the benefit of obtaining sample via biopsy Done within 48 hours of presentation – done when CT findings are consistent with colonic ischemia Findings of dusky, cyanotic mucosa is highly suggestive of gangrene Should be done cautiously in the setting of colonic ischemia – perforation Should not be performed in the setting of peritonitis or irreversible ischemia (surgery) Mucosal infartction by biopsy – pathognomonic of ischemia

32. MANAGEMENT GENERAL PRINCIPLES Once diagnosis is established, the patient is treated expectantly with fluid resuscitation and bowel rest, unless signs and symptoms of gangrene or perforation develop Optimization of cardiac function ensures adequate systemic perfusion Medications that cause mesenteric vasoconstriction (e.g., digitalis and vasopressors) should be withdrawn if possible Urine output is monitored and maintained with parenteral isotonic fluids There is limited evidence to support the utility of administration of antibiotics; however, ACG guidelines recommend antimicrobial therapy for patients with “moderate” or “severe” disease. If the colon appears distended, either clinically or radiographically, it can be decompressed with a rectal tube, with or without gentle saline irrigation Corticosteroids are not recommended for colonic ischemia, except in cases of vasculitis

33. MANAGEMENT GENERAL PRINCIPLES CBC is repeated frequently in acute episode A though rarely needed, blood products should be administered according to the patient’s requirements Serum potassium and magnesium levels must be monitored (diarrhea and tissue necrosis) Elevated systemic levels of lactate dehydrogenase may indicate bowel ischemia but is neither sensitive nor specific for necrosis or gangrene. Patients with significant diarrhea are started on parenteral nutrition early. Narcotics should be administered judiciously Mechanical bowel preparation is contraindicated because it may cause perforation.

34. In the mildest cases of colonic ischemia, signs and symptoms of illness disappear (24 to 48 hours) C omplete clinical resolution (1 to 2 weeks) No further therapy is required in these patients Treatment includes a high-residue diet , and follow-up endoscopy is performed to confirm complete healing and exclude alternative diagnosis Management of Reversible Ischemia

35. Management of Irreversible Acute and Subacute Ischemia Acute signs of clinical deterioration during the period of observation (rising temperature, elevated white blood cell count, worsening metabolic acidosis, hemodynamic instability, or peritonitis) suggest colonic infarction and are an indication for operative intervention Patients with persistent symptoms, such as diarrhea, rectal bleeding, or recurrent sepsis, for more than 10 to 14 days may require operative intervention. Despite a normal serosal appearance, there may be extensive mucosal injury, and the extent of resection should be guided by the distribution of disease as seen on preoperative studies rather than by the appearance of the serosal surface of the colon at the time of surgery As in all resections for colonic ischemia, the specimen must be opened at the time of surgery to ensure normal mucosa at the margins . If at the time of surgery the segmental colitis is found to involve the rectum, a mucous fistula or Hartmann procedure with an end colostomy should be performed. Simultaneous proctocolectomy is rarely indicated but should be performed for gangrene of the rectum .

36. MANAGEMENT OF CHRONIC ISCHEMIA Colonic ischemia may not be accompanied by clinical symptoms during the acute insult but may still produce chronic segmental colitis Regardless, de novo occurrence of a segmental area of colitis with stricture in an older patient is most likely ischemic. How to address: Elective bowel resection i s indicated for patients with chronic segmental colonic ischemia and recurrent episodes of sepsis. The underlying etiology of these septic episodes is likely bacterial translocation from areas of unhealed segmental colitis

37. Management of Ischemic Strictures Stenosis or stricture Asymptomatic – observe (some of them will return to normal over a 12- to 24-month period with no further therapy) Symptomatic - segmental resection is required Endoscopic dilation of chronic colonic strictures as a result of ischemia is generally not recommended

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