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ENDOSCOPIC MANAGEMENT OF LOWER GASTROINTESTINAL BLEEDING
DEEPAK AMARAPURKAR*, NIKHIL PATEL**
*Consultant Gastroenterologist, Hepatologist and Gastrointestinal Endoscopist; **Sr. Research Assistant, Bombay Hospital and medical Research Centre, Mumbai.
Blood loss from the gastrointestinal (GI) track emanating from the location distal to the ligament of Trietz is referred as lower GI bleeding. Lower GI bleed is classified into 1) acute lower GI bleed 2) intermittent melaena and haematochezia and 3) obscure GI bleed. Acute lower GI bleed (LGIB) is practically defined as bleeding of less than 3 days duration that results in haemodynamic compromise, anaemia or the need for blood transfusion. Intermittent haematochezia is defined as chronic LGIB lasting for more than 3 days and obscure GI bleed encompasses positive faecal occult blood testing and or iron deficiency anaemia with no obvious evidence of GI blood loss and bleeding of unknown origin that persists or recurs despite negative upper GI endoscopy or colonoscopy.[1]
Initial evaluation of acute LGIB includes detail history, physical examination, initial laboratory studies and resuscitative measures. History includes 1) nature and duration of bleeding, stool colour and frequency 2) associated symptoms: abdominal pain, recent change in bowel habits, fever urgency/tenesmus, weight loss 3) past history : previous bleeding episodes, trauma, history of past abdominal surgeries, peptic ulcer disease, inflammatory bowel disease, radiation therapy abdomen and pelvis, and prior history of cardiopulmonary, renal and liver diseases 4) current and recent medications including NSAIDs, aspirin and anticoagulants and allergies. Physical examination must include recording of viral signs, postural change in the blood pressure, cardio pulmonary abdominal and digital rectal examination. Initial laboratory examination includes complete blood count, serum electrolytes, blood urea nitrogen, creatinine, coagulation studies, blood grouping and cross matching and electrocardiogram if the patient is above the age of 50 years or has coronary risk factors. Resuscitative measures and an appropriate level of patient monitoring must be established before diagnostic testing or specific therapeutic intervention. Intensive monitoring and care is appropriate for the patient with instability of vital signs not responding to initial resuscitative measure. Initial admission to an intensive care unit is also appropriate for the patient at risk for complications from comorbid illness.[1,2]
Acute lower GI bleeding may present with massive haematochezia or moderate bleeding. Sometimes the upper GI bleeding becomes massive enough to present as haematochezia. Important causes of acute lower GI bleed are 1) bleeding haemorrhoid 2) inflammatory bowel disease 3) malignancy 4) non steroidal anti-inflammatory drugs 5) angiomatous malformation 6) bleeding polyp 7) diverticulosis 8) enteric fever and rarely, tuberculosis of the colon and massive worm infestation can present as acute LGIB, especially in tropical countries like India. In about 5-10% cases of haematochezia, an upper GI source may be found even if there will not be a positive nasogastric aspirate.[3-5]
DETERMINING THE SOURCE OF LGIB
Lesions frequently encountered in evaluation of haematochezia reported in the western literature are diverticular disease 17-40%, colonic vascular ectasia 2-30%, colitis (ischaemia, infectious, in flammatory bowel disease, radiation proctopathy 9-21%, colonic neoplasia/post polypectomy bleeding 11-14%, anoerctal causes including haemorrhoids, rectal varices 4-10%, upper gastrointestinal sites including duodenal/gastric ulcer, varices 0-11%, small bowel sites, including Crohn's ileitis, vascular ecstasia, Meckel's diverticula, tumours 2-9.%[6,7] (Table 1). In 80% of the patients with diverticular haemorrhage will stop spontaneously. In a previously reported study, 60% patients requiring more than 4 units of transfusion in 24 hours of diverticular bleed required surgery.[8] Though surgery was mainstay of severe diverticular bleeding the pivotal role of colonoscopy in acute LGIB due to diverticular disease is established by Jensen et al.[9] Reported incidences of colonic vascular ecstasia varies widely in different clinical series. Acute bleeding appears to be more frequently due to lesions in proximal colon.[10] Ischaemic colitis often presents with abdominal pain and self limiting haematochezia colitis is segmental and most often affecting the splenic flexure.[11] Bloody diarrhoea is most frequent symptom of infectious colitis and inflammatory bowel diseases of the colon.[3,4] Post polypectomy bleeding is frequently self limited but rarely may occur upto two weeks after polypectomy.[12] Anoscopy and proctoscopy should be part of initial evaluation of the patients with LGIB.
In the patient with haematochezia, an upper gastrointestinal bleeding source must be considered. A nasogastric aspirate showing copious amounts of bile and negative for blood makes an upper gastrointestinal source unlikely. Upper gastrointestinal endoscopy should be performed if the results of nasogastric aspiration shows evidence of upper gastrointestinal bleeding or is negative for blood and bile. Endoscopy (colonoscopy or sigmoidoscopy) is the test of choice for the structural evaluation of LGIB. Arteriography should be reserved for those patients with massive ongoing bleeding when endoscopy is not feasible, or with persistent/recurrent haematochezia when colonoscopy has not revealed a source. There is no role for barium enema in the evaluation of acute, severe haematochezia.[2]
Lesion Diverticular Colonic vascular ectasia Colitis (ischaemia, infectious, inflammatory bowel disease, radiation proctopathy) Colonic neoplasia/post-polypectomy bleeding Anorectal causes (including haemorrhoids, rectal varices) Upper gastrointestinal sites (including duodenal/gastric ulcer, varices) Small bowel sites, including Crohn's iteritis, vascular ectasia, Meckel's Diverticula, tumours
COLONOSCOPY IF LOWER GI BLEED
After achieving haemodynamic stability urgent colonoscopy after rapid oral purge with polyethylene glycol or fleet enemas is reported to be safe and clinically effective and is recommended as first line of investigation by American Society of Gastrointestinal Endoscopy.[1] The overall diagnostic accuracy for bleeding site detection is 90% and endoscopic haemostasis can be achieved in upto 70% patients.[13] Standard endoscopic methods for control of GI bleeding like injection therapy, thermal methods such as monopolar/bipolar coagulation heater probe combination of injection and thermal methods, laser therapy have been found to be effective in LGIB. Laser therapy though equally effective as other methods has disadvantages of high cost, lack of portability and higher rate of complications. Endoscopic injection therapy is safe, inexpensive and effective. Various agents like adrenaline, polidocanol, sodium tetradecyl sulphate, cyanoacrylate glue and thrombin are used for injection therapy. Mechanical devices such as metallic clips, rubber band ligation are also shown to be effective in control of LGIB. Detachable snares have been effectively used in management of post polypectomy GI bleeds. Argon plasma coagulation (APC) is a novel non contact, non coaptive thermal technique using the transmission of high frequency monopolar current via a probe emitting ionized electrically conductive argon plasma gas to coagulate tissue surfaces and for the haemostasis of surface bleeding. Argon plasma coagulation has been successfully used in treatment of radiation proctitis, vascular ectasia and bleeding tumours. APC equipment is low cost portable and delivers the thermal energy comparable to standard haemostatic methods but care should be taken to minimize gas distension during the use of APC as it may lead to perforation especially in the caecum.[13]
Complications of urgent colonoscopy : When bleeding is massive, conoloscopy may fail to localize a lesion. Sometimes the oral lavage used for colonic preparation in elderly patient leads to fluid overload. The excess purge at times leads to dehydration, electrolyte imbalance and hypovolaemia in patients, It may lead to colonic perforation, however the complication rates are low when colonoscopy is done by an experienced endoscopist, who performs it carefully using minimal air insufflation.
Lesion not detected due to massive bleeding
surgical treatments
Bleeding stops Further investigations if bleeding recurs
capsule endoscopy
Intraoperative endoscopy +Surgery if required
Lower GI bleeding as a cause of intermittent melaena/haematochezia : Haemorrhoids and ulcerative colitis are the commonest cause of intermittent haematochezia. Once these are excluded by PR and proctoscopy, colonoscopy evaluation is undertaken. In an analysis of 51 cases of intermittent melaena or haematochezia, we found 76% have positive finding in colonoscopy (Table 2).
Total Cases Colonoscopy +ve Ulcerative Colitis Solitary rectal ulcer syndrome Rectal haemangioma Rectal varices Polyps Familial polyposis Juvenile polyposis Villous adenoma Cancers Tuberculosis colon Radiation colitis Post transplant lymphoma
Faecal occult blood positivity : Physiological blood loss from GI tract is approximately 0.5 to 1.5 ml per day.[14,15] For melaena to be produced atleast 150-200 ml of blood must be present in the stomach[16] and bleeding of 100 ml per day may have normal stool.[17] Management strategy in patients with persistent faecal occult blood positivity, consists of anoscopy, local examination and sigmoidoscopy followed by colonoscopy. If patient has a prominent upper GI symptom, then upper GI scopy should be the first line of investigation. In the absence of GI symptoms and elderly patients colonoscopy is the first line of investigation as GI malignancy is the main cause of occult blood in them.
Patients of intermittent slow bleeding may present with iron deficiency anaemia. In women iron deficiency anaemia is most common during the reproductive years, because of menstrual and pregnancy associated iron losses. Among other patients iron deficiency anaemia has been associated with occult gastrointestinal bleeding. In a study of 381 patients with iron deficiency anaemia, lesion in upper GI tract found in 41% cases, 22% had a colonic source and 5 per cent had diseases in both upper and lower GI tracts.[18-21] In a study by Rockey and Cello in 100 patients of faecal occult blood positive patients, 26 patients have positive findings in colonoscopy (Table 3).
(1998)
N = 100
(1993)
N = 100Colonoscopy +ve Cancers Polyps Diverticulosis Tuberculosis Helminthiasis Caecal ulcers Vascular ectasia
Obscure GI bleeding : In about 5% of patients with overt GI bleeding, the source of bleeding remain unidentified after readily identifiable causes of gastrointestinal bleeding have been ruled out by endoscopic procedures and these cases represent a tremendous diagnostic and therapeutic challenge. The initial evaluation should entail the consideration of lesions that are easily overlooked, such as watermelon stomach, vascular ecstasia, Dieulafoy's vascular malformation, gastric and small intestinal varices, diverticula, aortoenteric fistulas, haemobilia, haemosuccus pancreaticus, Meckels' diverticulum. In patients with apparent upper gastrointestinal haemorrhage, a reexamination of the upper GI tract leads to identification of lesions in many patients.[22-24] For patients with subacute bleeding in whom repeated endoscopies are negative, the focus of investigation should be broadened to include the small bowel, which include enteroscopy or enteroclysis. Patients with active bleeding may undergo radionuclide scanning or angiography. Intraoperative enteroscopy, either by enteroscope or standard colonoscope detect abnormalities upto 70-100% of patients.[25-26]
With upper GI symptom Upper GI endoscopy Lesion not detected Without active bleeding
Mesenteric Angiogram/
Capsule endoscopyCapsule endoscopy
Enteroclysis
Wireless capsule endoscopy is a useful tool in diagnostic work up of obscure or occult GI bleed. The capsule endoscope contains a miniature video camera, a light source, batteries and a radio transmitter. Video images are transmitted by means of radio telemetry to aerials taped to the body that allow images to be captured. The strength of the signal is used to calculate the position of the capsule in the body. Moving images from a period as long as six hours are stored on a portable recorder. Capsule endoscopy provides good views from mouth to colon and more so images small intestinal pathologies, which are difficult to pick up by other endoscopic techniques.[27-28]
Lower gastrointestinal haemorrhage is a complex clinical problem that requires appropriate approach for successful management. When properly investigated and managed the mortality and morbidities are reduced significantly. Colonoscopy is accepted as a first line diagnostic procedure due to its high diagnostic value, safety and therapeutic efficacy.
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