European Journal of Trauma and Emergency Surgery

, Volume 37, Issue 4, pp 365–372

Surgical management of lower gastrointestinal bleeding

Authors

    • Division of General Surgery, Department of Surgery and Section for Surgical ResearchMedical University of Graz
Review Article

DOI: 10.1007/s00068-011-0122-5

Cite this article as:
Pfeifer, J. Eur J Trauma Emerg Surg (2011) 37: 365. doi:10.1007/s00068-011-0122-5
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Abstract

Purpose

Lower gastrointestinal bleeding (LGIB) is any form of bleeding distal to the Ligament of Treitz. In most cases, acute LGIB is self-limited and resolves spontaneously with conservative management.

Methods

Only a minority of approximately 10% is admitted to hospital with signs of massive bleeding and shock requiring resuscitation, urgent evaluation and treatment.

Results

Over the past decade, there has been a progressive decrease in upper GI events and a significant increase in lower GI events. Overall, mortality has also decreased, but in-hospital fatality due to upper or lower GI complications have remained constant. The problem is that LGIB can arise from a number of sources and may be a significant cause of hospitalisation and mortality in elderly patients.

Conclusions

After initial resuscitation, the diagnosis and treatment of LGIB remains a challenge for acute care surgeons, whereby the identification of the source of bleeding is of utmost importance.

Keywords

Lower GI bleedingColonoscopyAngiographySurgery

Introduction

By definition, lower gastrointestinal bleeding (LGIB) is any form of bleeding distal to the Ligament of Treitz. It may present with a positive occult blood test, intermittent spotting or massive intestinal haemorrhage. However, unlike upper GI bleeding, most patients present electively. Furthermore, in most cases, acute LGIB is self-limited and resolves spontaneously with conservative management. Only a minority of approximately 10% is admitted to hospital with signs of massive bleeding and shock requiring resuscitation, urgent evaluation and treatment. The average age of patients presenting with acute LGIB is 71 years [1]. Over the past decade, there has been a progressive change in the overall picture of GI events leading to hospitalisation, with a clear decrease in upper GI events and a significant increase in lower GI events. Overall, mortality has also decreased, but in-hospital fatality due to upper or lower GI complications has remained constant [2]. The problem is that LGIB can arise from a number of sources and may be a significant cause of hospitalisation and mortality in elderly patients [3]. After initial resuscitation of the patient, the diagnosis and treatment of lower gastrointestinal bleeding remains a challenge for acute care surgeons. Identifying the source of bleeding can be difficult, since many patients bleed intermittently or bleeding may stop spontaneously. It is, therefore, important for the surgeon on call to be familiar with the different diagnostic and therapeutic modalities, and their advantages and disadvantages, in order to guide the management of the acutely bleeding patient.

Besides the clinical classification, this paper summarises the possible diagnostic methods and their accuracy, and the surgical treatment forms available for acute LGIB.

Clinical classification

Classifications are usually made by aetiology; however, from a practical point of view, it is better to classify bleeding according to clinical presentation and severity. We, therefore, distinguish low-volume from high-volume haematochezia, melaena and occult GI bleeding.

Low-volume haematochezia

Lesions in the distal colon or anorectal conditions are the most common causes of low-volume haematochezia. Bright-red blood coming from the distal rectum or anal canal is typical. The bleeding source might be internal haemorrhoids, anal fissures, solitary rectal ulcers or proctitis (especially after radiotherapy). Other causes are low-lying polyps or tumours, diversion colitis or (rarely) anal endometriosis [4]. All lesions are typically easy to detect with a rigid ano-/rectoscope or a flexible sigmoidoscope, and do not present as a life-threatening issue.

High-volume haematochezia

The severity of bleeding is best determined by the grade of hypovolaemia. While in mild forms there might be no significant hypovolaemia (but possibly anaemia), moderate-grade hypovolaemia responds to volume replacement and the patient is stable afterwards. In contrast, severe or high-volume haematochezia demands urgent resuscitation and therapy. Frequent colonic causes are diverticular bleeding, angiodysplasia, colonic varices and colitis of any origin. However, when red rectal bleeding is extensive, a possible upper GI source must also be excluded.

Melaena

Melaena is usually the result of a chemical reaction between gastric acid and blood. The most common causes are bleeding from oesophageal varices, Mallory–Weiss tears, peptic ulcers or a Dieulafoy lesion. In some cases, melaena can occur as distal as in the right colon due to other denaturating reactions produced by enzymes and bacteria [4], so that small-bowel lesions such as jejunal diverticulosis, Meckel’s diverticulum and enteritis can also present with melaena.

Occult GI bleeding

In about 5% of all cases, no specific cause of the bleeding site can be identified [5, 6]. The bleeding is slow and of low volume, and might be detectable only with chemical or immunological methods [710].

Specific aetiologies of LGIB

Diverticular disease

Diverticular disease is common in the Western population. It is estimated that, by the age of 85 years, 65% of the population will have diverticula. Some estimate that 30–40% of patients with diverticulosis will present with bleeding in their life span [3] and 5% of patients will have severe haemorrhage [11]. Although diverticula are more common in the left colon, right-sided diverticula account for approximately 50% of bleeding diverticulosis. Bleeding will stop spontaneously in 80% of cases, and 25% will re-bleed at some point [12]. Notably, diverticular disease, the most common cause of LGIB in Western populations, is uncommon in China [13].

Vascular malformations of the colon

Angiodysplasia and other vascular ectasias are commonly found in the right colon but can occur anywhere in the colon or small bowel, especially in elderly patients. A degenerative cause is most likely [4]. The lesions can be single or multiple, with a diameter of as much as 5 mm. Angiodysplasia as a source of massive bleeding requiring surgery is seen in just 3.6% of patients [14]. Other vascular malformations are telangiectasias (often as part of a hereditary syndrome) or hamartomas. The latter can already manifest during childhood as intermittent rectal bleeding [15]. Patients with portal hypertension may develop portosystemic shunts in several areas, including the colon and rectum. Although uncommon, LGIB due to colonic or rectal varices has been described [16]. Sometimes, connective tissue disorders such as Ehlers–Danlos syndrome can also present with intermittent gastrointestinal bleeding due to concomitant arterio-venous malformations [17].

Post-polypectomy bleeding

Significant bleeding after polypectomy has been described in 0.2–6% of patients [18]. Delayed haemorrhage is an infrequent but serious complication of colonoscopic polypectomy. Large size (>2 cm) is the only polyp-related factor that has been unequivocally proven to increase the risk of delayed bleeding. Polyp location in the right colon seems, however, to be an independent and substantial risk factor for delayed post-polypectomy haemorrhage [19].

Colitis and ulcers

Colitis of any aetiology may result in rectal bleeding. While ischaemic colitis usually produces acute low-volume haematochezia that resolves spontaneously, radiation colitis typically causes chronic low-volume haematochezia. In inflammatory bowel disease, Crohn’s disease has a slightly higher incidence of massive LGIB than ulcerative colitis [20]. Ulcers in the lower gastrointestinal tract of any cause may produce voluminous bleeding [21]. The main sites for ulcers due to nonsteroidal anti-inflammatory drugs (NSAIDs) are the terminal ileum and cecum [22].

Neoplasia

It is interesting that colorectal cancer characteristically produces chronic low-volume bleeding with concomitant anaemia. Massive bleeding is rarely encountered.

Endometriosis

Typically, endometriosis produces low-volume bleeding synchronous with the menstrual cycle, but the main symptom is often pain and obstruction.

Aorto-enteric fistula

This condition is a rare complication after the surgical placement of a prosthetic graft for an aortic aneurysm; due to the often massive bleeding and sepsis, the mortality rate is as high as 43% [23].

Diagnosis

History and clinical examination

The initial evaluation should include a focused clinical history, including presentation, frequency and severity of bleeding, regular intake of medication, especially NSAIDs and anti-clotting medication, and previous polypectomy, surgery or radiation therapy. Clinical examination is important to confirm the severity of bleeding and to judge whether a life-threatening situation is present.

Colonoscopy

If the patient appears to be haemodynamically stable, colonoscopy is the preferred diagnostic tool. Emergency endoscopy should be avoided and an urgent colonoscopy (within 24 h after admission) after cleansing of the large bowel is preferred. In a recent review of 1,112 patients, all patients underwent colonoscopy, 33.2% within 24 h of admission [24]. An acute purgative cleansing of the colon is possible in 80.8% of patients [3]. The great advantage is that endoscopy may be diagnostic and therapeutic at the same time. If the bleeding spot is localised, clips, an injection or a coagulation treatment may be applied.

Angiography

In the emergency situation, angiography is the most important examination. Angiography plays, on the one hand, a key role in the localisation of the bleeding site, and, on the other, modern embolisation techniques make it a viable therapeutic option [25]. A haemorrhagic rate of at least 1–2 ml/min is, however, necessary in order to localise the bleeding spot through contrast blush [26]. In a recent review, mesenteric angiography for lower gastrointestinal bleeding effectively identifies the site of bleeding in 48% of patients and allows embolisation in 45%. Embolisation achieves clinical success in 76% of patients but repeat embolisation was associated with a higher rate of complications [27].

CT

In recent decades, computed tomography (CT) angiography has come to play a more dominant role in the diagnosis of obscure gastrointestinal bleeding. In a recent publication, 86 CT angiograms were obtained from 74 patients with the clinical diagnosis of acute GI haemorrhage from an unknown source. Twenty-two of the 86 CT angiograms (26%) were positive for active haemorrhage, with findings confirmed in 19 of the 22 cases (86%). Sixty-four of the 86 CT angiograms were negative, and 59 (92%) of the CT angiograms required no further intervention. Interestingly, there were no cases in which CT angiography was negative and subsequent angiography within 24 h was positive. The overall sensitivity, specificity, accuracy, and positive and negative predictive values of CT angiography in the detection of active GI haemorrhage within this study population were 79, 95, 91, 86 and 92%, respectively. The authors concluded that this study especially supports the use of CT before angiography in those patients with acute GI bleeding of an unknown source who are being considered for catheter-directed intervention [28].

Others

Scintigraphy using technetium-99m pertechnetate [(99 m)TcO(4)(−)] is the method of choice for the diagnosis of ectopic gastric mucosa in a Meckel’s diverticulum. In children, this test shows high diagnostic accuracy, with a sensitivity of 85–95% and a specificity of 90–95% [29]. It seems, however, that old-fashioned nuclear scans like (99m)Tc-labelled erythrocytes have lost their dominant position in the last decade due to newer and more accurate technologies, e.g. multidetector-row CT, enhanced magnetic resonance angiography and capsule endoscopy [30]. Although the sensitivity of the nuclear scan is significantly higher than that of angiography, localisation of the bleeding site might be a problem [31].

Management of bleeding

Resuscitation

High-volume or severe bleeding means that the patient loses more than 1,500 cc per 24 h or has signs of shock on admission. These patients have a risk of exsanguination and, sometimes even during the resuscitation phase, further diagnostic investigations (e.g. angiography) must be undertaken.

Resuscitation is done with intravenous fluids or transfusions. Clotting parameters should be measured and deficits corrected.

Endoscopy

The first step of evaluation even in severe LGIB is emergency gastroscopy (as in severe upper GI bleeding, all gastric acid might be consumed and instead of melaena, dark red blood clots might be evacuated). This evaluation is followed by lower GI endoscopy, namely, rigid ano-/rectoscopy, to exclude haemorrhoidal bleeding. If the patient is unstable, emergency angiography should be done immediately. If the patient is haemodynamically stable, colonoscopy can be attempted, but endoscopy is often not possible due to the lack of cleansing. In a recent review, the overall success rate for localising the bleeding site was 60–97% [32].

Angiography

With the superselective mesenteric angiography technique with microcatheters, vessels as small as 1 mm may be selectively embolised. This technique is highly successful and relatively safe, with 97% technical success and 3% post-embolisation ischaemia in a recent large series from Singapore [33].

Surgical treatment

The indications for surgical treatments are:
  • Patients with exsanguinating haemorrhage

  • Elderly patients (>60 years of age): if more than 4 units of blood are necessary during initial resuscitation after admission, if patient has recurrence of bleeding after initial endoscopic bleeding control and if persistent bleeding occurs requiring more than 8 units of blood within 48 h

  • Younger patients (<60 years of age): if 8 or more units of blood are required during the initial resuscitation phase and persistent bleeding requires 12 units of blood over a 48-h period [34].

If upper and lower GI endoscopy is negative, a small-bowel source should be suspected. It is of utmost importance to identify the bleeding site by endoscopy, nuclear scan, angiography or multidetector-row CT, and to select the appropriate treatment according to the nature of the lesion and the clinical course. In principle, we distinguish between two forms of surgical treatment: (a) directed segmental colectomy, if the bleeding site has been localised preoperatively, or (b) blind segmental or subtotal colectomy, if no obvious bleeding spot can be found. In rare cases, laparotomy and intraoperative endoscopy plus diaphanoscopy after on-table lavage of the various bowel segments might be an alternative (Fig. 1). The principle of diaphanoscopy is that, by the passage of light through body tissues, the examination of internal structures is possible and, thus, especially vascular malformations can be detected.
https://static-content.springer.com/image/art%3A10.1007%2Fs00068-011-0122-5/MediaObjects/68_2011_122_Fig1_HTML.jpg
Fig. 1

Intraoperative diaphanoscopy

It is interesting that surgery no longer plays a major role, as radiologic interventional technology has improved rapidly in the last several years. It seems that urgent surgery might be necessary in only 13.7–24% of all cases [35, 36]. The possible surgical procedures are listed in Table 1 and the current literature in Table 2. Blind segmental resection is associated with a re-bleeding rate of 47% and morbidity and mortality rates of 83 and 57%, respectively [45], and, so, should only be reserved for the very rare instance of exsanguinating colonic bleeding requiring immediate life-saving surgery [5457]. At the University Clinic of Graz, we perform approximately 4,500 abdominal visceral procedures each year, of which 12–15% are emergency operations. Due to improvement in intensive care medicine as well as diagnostic and therapeutic radiology, in the last 8 years, we did not have a single case where blind segmental or subtotal resection due to unknown lower GI bleeding was necessary. But it is obvious that the ultimate goal for every patient with severe LGIB must be to identify the bleeding site without surgical intervention.
Table 1

Possible surgical procedures for lower gastrointestinal bleeding (LGIB)

Operation

Indication

Remarks

Subtotal colectomy with ileostomy, Hartmann procedure

Emergency operation, bleeding site not localised, instable patient, poor general condition or poor anal sphincter function

Ulcerative colitis, immunosuppressed patient

Subtotal colectomy with ileorectal anastomosis

Emergency operation, bleeding site not localised, stable patient

Good general condition

Segmental resection with anastomosis

Localised bleeding site, stable patient

 

Segmental resection with stoma

Localised bleeding site, instable patient, poor general condition and/or poor sphincter function

Locally advanced stenosing tumour

Ileostomy

Recurrent bleeding probably from the small bowel; not extensive but not localised

 
Table 2

Literature review on surgery for LGIB

Author

Year

Resection

n

Re-bleed (%)

Mortality (%)

Drapanas et al. [37]

1973

LCR-blind

23

35

30

TCR

35

0

11

Welch et al. [38]

1978

LCR-directed

42

10

2

TCR

10

0

10

Eaton [39]

1981

LCR-blind

24

75

50

TCR

4

0

0

Colacchio et al. [40]

1982

LCR-directed

46

11

22

TCR

12

8

23

Britt et al. [41]

1983

LCR-directed

14

7

14

 

TCR

10

0

20

Leitman et al. [42]

1989

LCR-directed

23

4

13

TCR

7

0

40

Milewski and Schofield [43]

1989

LCR-directed

4

0

0

LCR-blind

3

40

0

Bender et al. [44]

1991

TCR (partially directed)

49

27

Setya et al. [45]

1992

TCR

12

0

33

Parkes et al. [46]

1993

LCR-directed

14

14

7

LCR-blind

7

42

57

TCR

10

0

30

McGuire [47]

1994

LCR-directed

18

1

0

TCR

7

0

60

Baker and Senagore [48]

1994

LCR-directed

42

15

TCR (partially directed)

19

6

Schilling et al. [49]

1998

LCR-directed

8

12.5

0

TCR

3

0

0

Farner et al. [50]

1999

LCR-directed

50

18

7

TCR-directed

27

4

2

García-Osogobio et al. [51]

2002

LCR-blind

39

9

19

Renzulli et al. [52]

2002

LCR-directed

5

20

10

LCR-blind

5

0

TCR-directed

1

0

3

TCR

31

0

Klar et al. [53]

2006

LCR-directed

35

21

TCR-directed

4

LSB-resection

1

LCR-directed, limited colon resection, bleeding site identified, directed surgery; LCR-blind, limited colon resection, bleeding site not identified, blind surgery; TCR, total colectomy, bleeding site not identified; TCR (partially directed), in some patients, the bleeding site was preoperatively identified; TCR-directed, bleeding site identified, but total colectomy necessary, e.g. colitis ulcerosa

– Not stated

Outcomes

Co-morbid diseases directly impact LGIB to increase morbidity and mortality in the elderly patient. After haemorrhage, the presence of serious concurrent illness is the second most important factor in predicting mortality among patients with LGIB. Co-morbid diseases that are associated with an increased incidence and severity of LGIB include cardiovascular disease, hypertension, renal disease, diabetes mellitus and malignancy [58, 59].

Conclusions

Urgent surgery to treat lower gastrointestinal bleeding (LGIB) is now very rare. Endoscopy and newer radiologic techniques have mainly replaced surgery as a first-line tool. Localisation of the bleeding point is the highest priority. Morbidity and mortality after surgery are mainly determined by co-morbidities rather than the surgical procedure itself.

Conflict of interest

The author declares that he has no conflict of interest.

Copyright information

© Springer-Verlag 2011