LOWER GASTROINTESTINAL BLEEDING GED/05/08

Transcription

1 LOWER GASTROINTESTINAL BLEEDING GED/05/08

2 LOWER GI-BLEEDING SEARCH FOR SOURCES Epidemiological prerequisites and differential diagnosis Techniques for detection of bleeding sources Practical approach GED/05/44

3 NATURAL HISTORY OF DIVERTICULAR DISEASE Diverticulosis 25 % symptomatic 75 % asymptomatic 25 % haemorrhage 75 % diverticulitis 1/3 massive 25 % complicated 75 % uncomplicated first attack 1/3 asymptomatic 1/3 non-specific symptoms 1/3 recurrent or complicated diverticulitis GEC/05/07

4 LOWER GASTROINTESTINAL BLEEDING Incidence: 20 bleedings / / year 200-fold increase from the age of 30 until 90 24% of bleedings origin from the lower GI-tract LGBI have a less severe course as UGBI shock 19% vs. 35% blood transfusion 36% vs. 64% anemia 61% vs. 84% Mortality: 2-4% 80-85% of bleedings stop spontaneously GED/05/21

5 LOWER GASTROINTESTINAL BLEEDING ETIOLOGY Neoplasia Ischemic colitis Diverticulosis IBD Unknown Other Hemorrhoids Postpolypectomy Angiodysplasia GED/05/14

6 LOWER GASTROINTESTINAL BLEEDING WITH MASSIVE BLOOD LOSS ETIOLOGY Angiodysplasia Diverticulosis Neoplasia Unknown Other Small bowel Rectal Ischemic colitis GED/05/15

7 DIVERTICULAR BLEEDING CLINICAL FEATURES II 219 Patients with lower GI-bleeding 41.6 % from diverticula 11.0 % previous diverticular bleeding 6.6 % emergency surgery 2.2 % hospital mortality 83 Survivors with conservative treatment Relapse Year % GEC/05/08 G.F. Longstreth, 1997

8 COLONOSCOPY IN RECTAL BLEEDING FINDINGS 2449 Patients, 1223 Patients with significant findings Carcinoma 85 Polyps > 1 cm 116 IBD 230 Diverticula 871 Vessel lesions % with hemorrhoids (depending on age) 7-10 % significant proximal findings with sigmoidoscopy without pathological findings GEC/05/01 H.E. Mulcahy, AGA/ASGE 2000

9 LOWER GI BLEEDING NEW DATA Patients with known diverticulosis and severe bleeding 29 (13.5 %) definitive diverticular hemorrhage 69 (32.1 %) presumed diverticular hemorrhage 117 (54.4 %) incidental diverticulosis (D.M. Jensen, AGA 2005) Early colonoscopy and diverticular bleeding are associated with shorter hospitalization (L. Strate, AGA 2005) Angiodysplasia is the only predictor of recurrent bleeding (E. Saperas, AGA 2005) GEC/05/09

10 DIAGNOSIS OF LOWER GI BLEEDING EMERGENCY COLONOSCOPY Studies Patients Correct Incomplete Therapy Complications diagnosis examination n n n / % n / % n / % n / % / / / / 1,3 Preparation? Correct diagnosis (%) Complications (%) Prepared 62 (6 studies, 779 patients) 0 Unprepared 76 (3 studies, 461 patients) 1,3 GED/05/30

11 GED/05/25 MORTALITY OF LOWER GI BLEEDING WITH AND WITHOUT EMERGENCY COLONOSCOPY Author Mortality (%) without with Sandlow 1974 * Allan Morris 1975 * Heller Hoare Keller 1976 * Dronfield 1977 * Huber Peterson 1981 *

12 ANGIOGRAPHY BLEEDING DIVERTICULUM IN THE COECUM GED/05/19

13 DIAGNOSTIC APPROACH IN LOWER GI BLEEDING ANGIOGRAPHY Bleeding up to 0,5-1 ml/min. will be detected studies patients correct diagnosis n n n / % / 47 Complication rate 9,3 % Possibility of interventional therapy hemostasis relapse of bleeding % % Embolization 70 0 Vasopressin GED/05/27 GR Zuckerman, 1998

14 COLONOSCOPY VS ANGIOGRAPHY IN LOWER GI BLEEDING Definite diagnosis Angio + Colo + Angioma 1/5 4/5 Diverticulosis 1/4 3/4 Small intestinal lesions 0/3 2/3 Polyps / carcinoma 0/2 2/2 Rectal lesions 0/2 2/2 Endometriosis 0/1 1/1 Total 2/17 14/17 GED/05/24 Jensen, 1988

15 DIAGNOSTIC APPROACH IN LOWER GI BLEEDING SCINTIGRAPHY Bleeding up to 0,1 ml/min. will be detected 2 methods: 99m Tc colloidal sulphur 99m Tc labeled RBC studies patients positive correct scintigram diagnosis n n n / % n / % / / 78 * * % < 2 Std., % > 2 Std. if necessary provocation with heparin?? GED/05/28 GR Zuckerman, 1998

16 History/symptoms Recto/sigmoidoscopy _ Gastroscopy _ + + Therapy (endoscopic / surgical) Therapy (endoscopic) Colonoscopy _ Angiography _ Scintigraphy _ Therapy (endoscopic / surgical) Therapy (endoscopic / interventional / surgical) LOWER GASTRO- INTESTINAL BLEEDING Capsule endoscopy _ Laparotomy / intraop. endoscopy _ + + Therapy (surgical) Colectomy (?) GED/05/26

17 DIAGNOSIS IN LOWER GI-BLEEDING SUMMARY Diverticular bleeding is a frequent source of lower GI-bleeding, mostly of little severity Emergency endoscopy is most popular and probably useful Relapse rate is high elective surgery may be indicated when diagnosis is certain GED/05/45

18 To a man with a hammer a lot of things look like a nail to pounder on. Mark Twain HI/03/17