Lower gastrointestinal bleeding

BACKGROUND: Lower gastrointestinal bleeding can be a confusing clinical conundrum, the satisfactory evaluation and management of which requires a disciplined and orderly approach. Diagnosis and management has evolved with the development of new technology such as selective mesenteric angiography and colonoscopy. PURPOSE: This study was undertaken to review the available data in the literature and to determine the current optimum method of evaluation and management of lower gastrointestinal hemorrhage most likely to result in a successful outcome. METHODS: Data available on the topic of lower gastrointestinal bleeding in the English literature were obtained via MEDLINE search and were reviewed and analyzed. RESULTS: The colonic origin of lower gastrointestinal hemorrhage in order of decreasing incidence is diverticulosis, inflammatory bowel disease, including ischemic and infectious colitis, colonic neoplasia, benign anorectal disease, and arteriovenous malformations. Approximately 10 to 15 percent of all cases of rectal bleeding are attributable to a cause that is proximal to the ligament of Treitz. Small intestinal sources such as arteriovenous malformations, diverticula, and neoplasia account for between 3 and 5 percent of all cases. Colonoscopy successfully identified an origin in severe hematochezia in 74 to 82 percent of cases. Mesenteric angiography has a sensitivity of 42 to 86 percent. The best method of management depends on whether hemorrhage persists, the severity of continued hemorrhage, the cumulative transfusion requirement, and the specific origin of bleeding. CONCLUSION: Lower gastrointestinal hemorrhage is a complex clinical problem that requires disciplined and sophisticated evaluation for successful management. Diverticulosis is the most common cause. Colonoscopy is the diagnostic procedure of choice both for its accuracy in localization and its therapeutic capability. Selective mesenteric angiography should be reserved for those patients in whom colonoscopy is not practical. Precise identification of the bleeding source is crucial for a successful outcome. Specific directed therapy, such as segmental colonic resection for bleeding diverticulosis, is associated with the highest success rate and the lowest morbidity. A complete review of lower gastrointestinal bleeding is contained herein.     

Diffuse microscopic angiodysplasia—A previously unreported variant of angiodysplasia

PURPOSE: The entity of diffuse microscopic angiodysplasia is described, and a patient with severe gastrointestinal hemorrhage because of this submucosal source of bleeding is reported. METHOD: Case records of a patient with severe gastrointestinal hemorrhage were reviewed, and histologic findings were compared with colonoscopic and operative findings. The patient received 51 units of packed red blood cells over 3.5 months and remained undiagnosed, despite an exhaustive evaluation, until autopsy. RESULTS: Ectatic veins, venules, and capillaries were present within the submucosa in virtually every section of the small and large intestine examined (79 of 86 sections). Histologic evidence of bleeding from these submucosal vessels was identified in three sites (colon, jejunum, and ileum). The absence of endoscopically visible lesions was explained by findings that vessels did not traverse the muscularis mucosa and that mucosal depth was normal. This case of diffuse microscopic angiodysplasia, therefore, represents a unique variant, because the vascular findings were so diffuse and the mucosa remained histologically and endoscopically uninvolved, despite severe bleeding. CONCLUSION: Gastrointestinal bleeding from angiodysplasia is generally assumed to arise from endoscopically recognizable vascular ectasia within the mucosa. Thus, this case helps provide an explanation for some cases in which occult or massive bleeding is assumed to be secondary to angiodysplasia,even when endoscopic verification is not possible. Recognition of this disease process may require segmental resection or deep biopsy of endoscopically normal intestine.     

Control of hemorrhage from a mucous fistula with Foley catheter tamponade

Massive hemorrhage from the colon is always a problem. When that bleeding occurs in a defunctionalized colonic mucous fistula, the surgeon can approach the bleeding site from both ends simultaneously. Two methods of controlling hemorrhage from a mucous fistula with the assistance of Foley catheter tamponade are presented.     

Massive lower gastrointestinal hemorrhage caused by pseudocyst of the pancreas ruptured into the colon

We report two cases of massive lower gastrointestinal (LGI) bleeding occurring in young adult men, as the first manifestation of pseudocyst of the pancreas. Despite the rarity of such a complication, pancreatic pseudocyst should be kept in mind as a possible source of massive LGI bleeding requiring immediate surgical treatment.     

Hemorrhage following colonoscopic polypectomy

Clinically significant hemorrhage following colonoscopic polypectomy may occur primarily as the polyp is removed or manifest itself days to weeks later secondary to clot dissolution. The rate of hemorrhage following colonoscopic polypectomy ranges widely from 0.3 to 6.1 percent, depending on whether the data are derived from studies using the number of patients or number of polypectomies. A retrospective study was performed in our institution to study 4,721 patients who underwent polypectomy between January 1987 and December 1991. Twenty (0.4 percent) of these patients required hospital admission because of 9 primary and 11 delayed hemorrhages. Fifty-four polyps were removed from these patients: 11 in the right colon, 7 in the transverse colon, 17 in the descending colon, and 19 in the sigmoid colon. Eight polyps were 2 cm or larger, 10 were pedunculated, and 44 were sessile. Six patients underwent cauterization or resnaring of the bleeding polyp site, one patient underwent subtotal colectomy, and the remainder of the patients stopped bleeding spontaneously. Factors that could be associated with the outcome of hemorrhage include patient age, size, location, number and morphology of polyps (i.e.,sessile or thick stalk), and use of anticoagulants. An experienced endoscopist with knowledge of electrosurgical and technical principles may be the most important factor for prevention of postpolypectomy bleeding     

Influence of colostomy onin vivo andin vitro permeability of the rat colon

PURPOSE: Barrier properties of an isolated colon loop and the remnant colon in continuity with the gastrointestinal tract after colostomy were studied in the rat. METHODS: The in vivo absorption after colonic loop administration of the marker fluorescein sodium was measured as the urinary recovery. The in vitro permeability was measured in Ussing diffusion chambers as the transmucosal passage of [¹⁴C]mannitol and of human serum albumin in the isolated and the nonexcluded colonic segments and was compared with the corresponding colonic regions from sham-operated rats at 1 to 14 days after operation. RESULTS: Body weight gain of the rats decreased and diarrhea appeared from day 2 after colostomy. Histologic examination showed mucosal atrophy with decreased villus height in the isolated colonic loop and an increased villus height in the nonexcluded colon segment. Absorption of fluorescein sodium in the isolated loop was increased at 8 and 14 days. Moreover, permeability in the isolated loop was increased for both mannitol and human serum albumin from four days after colostomy compared with the corresponding colonic segments after the sham operation, whereas a decrease in the passage of mannitol was noted in the nonexcluded colon. CONCLUSIONS: Experimentally performed colostomy diversion in the rat induced alterations of the barrier function in both the isolated colonic loop and the nonexcluded colon in continuity with the fecal stream.The present study was done at the Department of Animal Physiology and supported by grants from the Medical Faculty, Lund University, the Swedish Medical Research Council (grant B 96-17X11616-01A), and the Swedish Natural Science Research Council.     

Idiopathic colonic varices: an unusual cause of massive lower gastrointestinal hemorrhage

Varices of the entire colon are very rare. This rare cause of massive lower gastrointestinal hemorrhage is almost invariably associated with cirrhosis of the liver and consequent hypertension or portal venous obstruction. We report about a patient with massive lower gastrointestinal bleeding from extensive colonic varices. Despite extensive investigation and a follow-up of 3 years, the etiology of the colonic varices could not be determined. Only a few cases of apparent idiopathic (familial or non-familial) colonic varices have been described. Recognition of this abnormality is important, however, because colonic varices may be the cause of recurrent, frequently massive lower gastrointestinal hemorrhage. A misleading endoscopic diagnosis can lead to inappropriate biopsies, resulting in major bleeding.     

VASCULAR ECTASIA OF THE COLON TREATED BY ARGON PLASMA COAGULATION: REPORT OF A CASE

A 72‐year‐old woman presented with hematochezia. Colonoscopy revealed branch‐like vasodilation in the ascending colon and chronic hemorrhage from vascular ectasia of the colon was suspected. Argon plasma coagulation was performed. After treatment, epithelialization of the lesion site was noted and her anemia improved. Vascular ectasia of the colon is recognized as the etiology of lower gastrointestinal bleeding with increasing frequency. Infrared ray electronic endoscopy is useful for determining the extent of disease and argon plasma coagulation, a new hemostatic technique, is suitable for treatment of this condition.     

Evaluation of transarterial embolization for lower gastrointestinal bleeding

INTRODUCTION: Transcatheter arterial embolization has been used as a therapeutic maneuver for lower gastrointestinal bleeding. The availability of highly selective arteriography has made this procedure safer and warrants re-evaluation. METHODS: A retrospective chart review was done of all patients undergoing arteriography for presumed lower gastrointestinal bleeding at two acute-care community hospitals. Causes of bleeding, clinical outcome, and complications caused by transcatheter arterial embolization were recorded. RESULTS: There were 26 arteriographically identified bleeding sites in the colon and small bowel. The most frequent cause of bleeding was diverticulosis (12 patients), with the diagnosis being arteriovenous malformation in two, and one unknown colonic source. Transcatheter arterial embolization was attempted for 17 separate bleeding episodes in 16 patients. Transfusion requirements were an average (± standard deviation) of 7±1.43 units per patient. Transcatheter arterial embolization was successful in stopping bleeding in 14 cases (82 percent). Two patients had surgery after transcatheter arterial embolization: one for colonic necrosis and one for persisting bleeding. There were two more unsuccessful procedures; one had a successful repeated transcatheter arterial embolization, and one stopped spontaneously. One patient rebled during the same hospitalization and was controlled with intra-arterial vasopressin. There were two deaths, both secondary to sepsis unrelated to the transcatheter arterial embolization or the gastrointestinal tract. CONCLUSIONS: Transcatheter arterial embolization is a relatively safe and successful procedure in patients with massive lower gastrointestinal hemorrhage. It is an excellent choice of therapy for patients that are poor candidates for surgery, but its role in other patients remains to be defined.Funded in part by a grant from the Blodgett-Butterworth Healthcare Foundation (formerly Ferguson-Blodgett Foundation).     

Collagenous colitis

INTRODUCTION: Collagenous colitis is a rare disease of unknown etiology that primarily affects middle-aged women. It presents with chronic watery diarrhea and thickening of the subepithelial collagen layer of the colonic mucosa in the absence of endoscopic abnormalities. PURPOSE: This study was undertaken to review the current literature on clinical course, pathology, diagnosis, and current management of collagenous colitis. RESULTS: Collagenous colitis is an inflammatory disease of the colon, clinically characterized by a waxing and waning course of watery diarrhea, an inflammatory infiltration of the colonic mucosa, and a thickening of the subepithelial collagen layer. Its pathogenesis remains unclear, but there is evidence for an inflammatory process triggered possibly by an uncommon luminal agent. Diagnosis is established by colonic biopsies; in the setting of normal colonic mucosa, the disorder is primarily managed medically with virtually no role for surgery. CONCLUSIONS: Pathogenesis of collagenous colitis remains unclear. Current data favor an inflammatory etiology, possibly involving an initiating luminal insult. Guidelines for diagnosis are being established, and medical treatment options are variably effective in the majority of cases. Very unusual refractory cases may benefit from surgical management.     

Clinical significance of diminutive polyps of the rectum and sigmoid colon

A retrospective review of 637 consecutive colonoscopies with polypectomy in 526 patients was performed to determine the association of small polyps of the rectum and sigmoid colon with more proximal colonic neoplasms. All colonic polyps were proximal to the sigmoid colon in 117 procedures. Proximal neoplasms were found in 32 percent of patients with a single polyp in the rectum or sigmoid colon. The incidence increased to 83 percent for those with three or more polyps. The occurrence of proximal colonic neoplasms was not affected by the size or histologic type of the rectosigmoid polyps. These findings would suggest that total colonic evaluation be considered in all patients with a polyp in the rectum or sigmoid colon regardless of the size or histologic type of the polyp.     

Gastroduodenal Vascular Ectasia in Patients with Liver Cirrhosis

The purpose of this study was to determine the incidence of hemorrhage due to vascular ectasia of the upper gastrointestinal tract in patients with liver cirrhosis and to assess the prevalence in cirrhotic patients without clinically overt gastrointestinal bleeding. Out of 96 cirrhotic patients with upper gastrointestinal bleeding, vascular ectasia was diagnosed in 6 patients (6.3%) as the cause of bleeding. These 6 patients had numerous spotty or confluent erythemas consisting of ectatic and tortuous capillaries throughout the antrutn and 4 patients required blood transfusion before diagnostic en-doscopy. Several sessions of endoscopic electrocoagulation resulted in eradication of almost all the abnormal vascular lesions and marked improvement of their anemia without further transfusion. The procedure was well tolerated and no resultant complications were encountered. Among 206 cirrhotic patients without clinically overt gastrointestinal bleeding 25 patients (12.1%) were diagnosed with vascular ectasia. The hemoglobin level was significantly lower in patients with vascular ectasia than those without vascular ectasia but the other features did not differ between the two groups. Vascular ectasia is an important cause of upper gastrointestinal bleeding and anemia in patients with liver cirrhosis. Endoscopic electrocoagulation may be a safe and effective treatment for controlling blood loss from gastroduodenal vascular ectasia in this subset of patients. (Dig Endosc 1999; 11: 241–245)     

Subsite distribution and incidence of colorectal cancer in New Zealand, 1974–1983

The purpose of this study was to examine changes in subsite distribution and incidence of colorectal cancer within different age groups. Registration of colorectal cancer by the National Cancer Registry of New Zealand approached 100 percent by 1974. The present study was based on 15,395 individuals aged 25 years and over and registered for colorectal cancer between 1974 and 1983. Subsite distribution (right colon, left colon, rectum) for different age groups (25–49, 50–69, 70+ years) was significantly skewed, with an excess of right colonic cancer in individuals aged 25–49 years and 70+ years. This right colonic excess was accompanied by a relative reduction in left colonic cancer. Age adjusted incidence rates for the periods 1974–78 and 1979–83 were compared and stratified by age group and subsite. Incidence rates increased in all subsites in individuals aged 50+ years. This was particularly evident for right sided cancer in the elderly of both sexes. There was a marked reduction in the incidence of left colonic cancer and rectal cancer in individuals under 50 years. In contrast, the incidence of right colonic cancer remained relatively stable in young individuals. Time trend studies indicate that the skewed subsite distribution of large bowel cancer in different age groups may increase with time and is probably due to varying etiological factors acting on different cohorts.The author thanks Mr. J. Fraser and the staff of the National Cancer Registry of New Zealand for their valuable assistance and Professor R. Beaglehole of the Department of Community Health, University of Auckland School of Medicine, for his helpful comments.     

Expandable metal stent application in obstructing carcinoma of the proximal colon

PURPOSE: The increased mortality of emergency vs. elective colonic surgery applies equally to the right and left colon. Recent interest has surrounded the application of expandable metal stenting in acute obstruction but has been confined to the left colon. We describe successful application of stenting in the right colon, allowing postponement of a particularly high-risk laparotomy. METHODS: A patient with acute bilateral iliofemoral thromboses simultaneously developed complete obstruction of the proximal transverse colon. After heparinization and under fluoroscopic control, a 10-cm-long, self-expanding Wallstent ^® (Schneider, Bulach, Switzerland), 22 mm in diameter, was manipulated across the obstruction. RESULTS: Immediate decompression with symptomatic relief ensued. The stent prevented obstruction during a 10-week period of anticoagulation, and repeat duplex scanning showed resolution of iliac thrombus. An elective right hemicolectomy was then performed. Postoperative course was uncomplicated, and histopathology confirmed a Dukes B carcinoma. CONCLUSIONS: This case, in which a potentially hazardous laparotomy was delayed until the operative risk improved, defines a new role for stenting in colonic obstruction and demonstrates an extension of its applicability to the right colon. Literature review found no other report of stent application in the right colon.     

Localized microscopic diverticulitis revealed by arteriography at the site of hemorrhage in diverticulosis of the colon

Summary Selective mesenteric arteriography was used preoperatively to identify the site of hemorrhage in a patient with massive rectal bleeding. A microscopic focus of diverticulitis in the sigmoid colon was found at the site of bleeding. The operation was greatly simplified by the preoperative arteriogram, and the colonic resection was more conservative than is necessary in patients with lower gastrointestinal bleeding of totally unknown etiology.     

Gastric Carcinoma 16 Years After Gastric Lymphoma Irradiation

A 61-year old white male, known to have alcoholic cirrhosis, presented with massive fresh bleeding per rectum. Various investigations failed to ascertain the cause of bleeding. Hepatoma of the liver was revealed by selective hepatic and superior mesenteric angiography. Massive lower gastrointestinal bleeding occurred again one month later and was rapidly followed by death from hepatic coma. An extensive hepatoma infiltrating the adjacent hepatic flexure of the colon was found at autopsy, the colonic infiltration explaining the lower gastrointestinal hemorrhage.     

Portal hypertensive colopathy in patients with liver cirrhosis

AIM: In patients with liver cirrhosis and portal hypertension, portal hypertensive colopathy is thought to be an important cause of lower gastrointestinal hemorrhage. In this study, we evaluated the prevalence of colonic mucosal changes in patients with liver cirrhosis and its clinical significance. METHODS: We evaluated the colonoscopic findings and liver function of 47 patients with liver cirrhosis over a 6-year period. The main cause of liver cirrhosis was post-viral hepatitis (68%) related to hepatitis B (6%) or C (62%) infection. All patients underwent upper gastrointestinal endoscopy to examine the presence of esophageal varices, cardiac varices, and congestive gastropathy, as well as a full colonoscopy to observe changes in colonic mucosa. Portal hypertensive colopathy was defined endoscopically in patients with vascular ectasia, redness, and blue vein. Vascular ectasia was classified into two types: type 1, solitary vascular ectasia; and type 2, diffuse vascular ectasia. RESULTS: Overall portal hypertensive colopathy was present in 31 patients (66%), including solitary vascular ectasia in 17 patients (36%), diffuse vascular ectasia in 20 patients (42%), redness in 10 patients (21%) and blue vein in 6 patients (12%). As the Child-Pugh class increased in severity, the prevalence of portal hypertensive colopathy rose. Child-Pugh class B and C were significantly associated with portal hypertensive colopathy. Portal hypertensive gastropathy, esophageal varices, ascites and hepatocellular carcinoma were not related to occurrence of portal hypertensive colopathy. Platelet count was significantly associated with portal hypertensive colopathy, but prothrombin time, serum albumin level, total bilirubin level and serum ALT level were not related to occurrence of portal hypertensive colopathy. CONCLUSION: As the Child-Pugh class worsens and platelet count decreases, the prevalence of portal hypertensive colopathy increases in patients with liver cirrhosis. A colonoscopic examination in patients with liver cirrhosis is indicated, especially those with worsening Child-Pugh class and/or decreasing platelet count, to prevent complications such as lower gastrointestinal bleeding.     

Therapeutic experience of hyperbaric oxygenation in radiation colitis

PURPOSE: The usefulness of the hyperbaric oxygenation in a patient with radiation colitis was evaluated. METHODS: The patient had severe bleeding from the large bowel which resulted from a pelvic radiation therapy for prostatic carcinoma and was histologically diagnosed as radiation colitis. Hyperbaric oxygenation therapy consisting of 100 percent oxygen inhalation at two absolute atmospheric pressures 90 minutes daily for 30 days was performed. RESULTS: The treatment succeeded in stopping gross hemorrhage and reversed endoscopic bowel findings. CONCLUSION: The effect of the hyperbaric oxygenation therapy of radiation colitis is elucidated.     

Recurrent colonic Dieulafoy's lesion associated with bizarre vascular malformations and abnormal von Willebrand factor

Colonic Dieulafoy's lesion is an unusual source of massive lower gastrointestinal haemorrhage. It is characterized by severe bleeding from a minute submucosal arteriole that bleeds through a punctuate erosion in an otherwise normal mucosa. We describe an elderly man who presented recurrent rectal bleeding from a Dieulafoy's lesion in the sigmoid colon associated with bizarre colonic vascular malformations and an abnormal von Willebrand Factor. He was successfully treated by endoclips application. The clinicopathologic features of this unusual association are discussed and suggestions are made for diagnosis and management.     

Immunohistochemical study of the colonic muscle and innervation in idiopathic chronic constipation

PURPOSE: This study was designed to investigate neural and muscular features of the colonic wall in patients with severe idiopathic constipation. METHODS: By using quantitative immunohistochemistry, resected specimens from 14 patients with idiopathic chronic constipation and 17 nonobstructed cancer controls were studied. RESULTS: Routine histology revealed no significant histologic abnormality throughout the colon apart from four cases of melanosis coli. Ratio of the thickness of circular to longitudinal muscle was significantly lower in the left colon in constipated subjects. The myenteric plexus appeared morphologically normal in all subjects. S-100 protein, which stains neuronal supporting tissues, demonstrated an increase in the proportion of neural tissue in the myenteric plexus. There was an increased number of PGP-9.5 immunoreactive nerve fibers in the muscularis propria in constipated patients, and this was significantly higher in the ascending and descending colon. CONCLUSION: Intractably constipated patients have alterations in the neural composition of the colonic myenteric plexus and innervation of the circular muscle.Supported by a grant from Yonsei University Research Foundation, Seoul, Korea. Dr. Talbot is supported in part by the Imperial Cancer Research Fund.