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Uncontrollable GI Bleed
Mamoun A. Rahman
Case 1
RT.
57 yrs-old lady
BGhx:
-Rectal cancer
-Pre-operative adjuvant chemotherapy: 5FU based
-low anterior resection
Medications:
- Losec 20 mg Od
Presentation
C/O:
Lower abdominal pain for 3-4 days
Admitted
Next morning: PR bleeding, bright red
Weak and anxious
O/E:
- Pale
- Pulse: 98
- BP: 106/64
- Abdomen: stoma; soft, non tender.
- DRE: clotted blood, nil active bleeding
Lab results
Hb: 10.1
PCV: 0.30
WBC: 6.8
Urea: 4.7
Cr: 95
Na: 137
K: 4.3
ALP: 141
GGT: 151
Bil: 3
Few hours later
Had another episode of PR bleed
Hb: 8.3
PCV: 0.24
Received 2 unit of RCC
Patient “stabilized”
PR bleeding continuing
- pulse: 109
CT angiography
On arrival in X-Ray
Anxious
Tachypnoeic
Cold and clammy
Pulse: 125
BP: 70/50
Unstable
Resuscitation by surgical team
O2
Trendelenburg position
3 IV lines
Received Hartmann’s solution and Gelofusin
Tranfusion with 2 units O –ve blood
ICU informed
Urgent angiography
Angiography & embolization
Bleeding in the pelvis
Ruptured aneurysm
branch of internal iliac
artery
Anterior branch of IIA
embolized
Post embolization
Transferred to ICU
Pulse: 144
BP: 140/65
Chest: course crepitations
Received Frusemide 40 mg
Remained stable, melaena only
Case 2
TY
52 yrs-old lady
Background history:
- Recurrent cholangitis
- ERCP and stent
C/O
- Epigastric pain
- Fever
- Pale stool
- Dark urine
Hb
11.6
Ur
13.1
HCT
36.1
Cr
138
WBC
4.7
Na
135
Neut
3.78
K
4.4
Cl
110
Bil
113.9
ALT
131
O/E
- Jaundiced
- Temp: 41
- Tender RUQ
PT
11.6
INR
1.1
Lab results
Amylase
10
ALP
270
CRP
352
GGT
278
- Cholestatic picture
USS
Cotracted, thick-walled GB, multiple stones
CBD: 14 mm, stones
ERCP performed
Sphincterotomy and CBD
clearance
Bleeding from sphincter site
Adrenalin injected
Continued to ooze
Post ERCP
Haematemesis
Melaena
Dizzy
Pulse: 90
BP: 139/67
Hb:9.7
INR: 1.2
CT Angiogram:
- ?Arterial haemorrhage at
ampulla
Embolization
Bleeding from branches
of GDA and Superior
pancreaticodudenal
artery
Embolization performed
with coil and gel foam
SMA angiogram:
normal
Day 1 Post Embolization
Seen by team as a consult
Vitals stable
Hb: 6.6
INR: 1.37
Transfused 4 units of RCCs
and 1 unit FFP
IV fluids and Abx continued
Repeat ERCP:
- No further bleeding. Stent
inserted
Post repeat ERCP
Remained asymptomatic
No further GI bleeding
Discharged with planned ERCP and
Cholecystectomy in 6 weeks’ time
Superselective embolization of
lower GI hemorrhage
Etiologies of Lower GI bleeding
Most common in the elderly
Variety of causes :
- Diverticular disease (10% to 20% risk)
- Neoplasia ( Ca colon causes 5% of
major bleeding)
Boley et al, Am J Surg 1979
- Angiodysplasia (right colon, <10% risk)
Evaluation
Recurrent minor bleeding: colonoscopy
Severe but intermittent, stable patient: Tc99M RBC scanning
Hemodynamically unstable patient:
angiography
Helical CT: 80% accurate in some series
Ernst et al, Eur Radiol 2003
History
Rosch and Bookstein,
early 1970s
Ischemic complications
was13% to 33%
Throughout the 1980s it
was a taboo
Dissatisfaction with
vasoconstriction
methods led renew
interest in embolization
in 1990s
Coaxial Microcatheters
Range in size from 2.5
to 3 F
5-French catheter may
be used to select a firstorder vessel
microcatheter can be
advanced through this
catheter more distally
Superselective Catheterization
Distal arteries, close
to bleeding points
Embolic material is
deployed
It limits the segment
of bowel at risk for
ischemia
Choice of embolic
Gel foam
Polyvinyl alcohol
particles
Microcoils
some combination
Published experience
Guy et al, 1992, reported 10 superselective
embolization procedures in nine patients. All
procedures were successful
Gordon et al, 1997: 17 cases of
microcatheter embolization using microcoils,
gel foam, and polyvinyl alcohol particles.
Success rate was 76%. No bowel ischaemia
Published experience
>100 successful embolization have been
reported 1997 – 2002
Clinical success ranged from 44% to 91%
Ischemic complications ranged from 0% to
6%
Funaki et al, AJR, 2001
Bandi et al, J Vasc Interv Radiol, 2001
Published experience
Tan et al, 2008. 265 patients underwent
angiography for GI bleeding.
32 ( 12%) had superselective embolization
for lower GI hemorrhage
In 31 patients (97%) technical success was
achieved
7 had re-bleed
1 had bowel ischaemia
Limitations of embolization
Colonic bleeding is multifactorial
- Diverticular bleed vs. Angiodysplasia
Patients who are not actively bleeding
Difficult vascular anatomy or severe
atherosclerotic disease
“Symptomatic treatment”
Summary
Minimally invasive techniques have replaced
surgical resection as the initial therapies of
choice
Superselective embolization and endoscopic
treatment appear complementary
Thank you