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Uncontrollable GI Bleed
Mamoun A. Rahman
Case 1
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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
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Lab results
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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
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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
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Anxious
Tachypnoeic
Cold and clammy
Pulse: 125
BP: 70/50
Unstable
Resuscitation by surgical team
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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
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Bleeding in the pelvis
Ruptured aneurysm
branch of internal iliac
artery
Anterior branch of IIA
embolized
Post embolization
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Transferred to ICU
Pulse: 144
BP: 140/65
Chest: course crepitations
Received Frusemide 40 mg
Remained stable, melaena only
Case 2
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TY
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52 yrs-old lady
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Background history:
- Recurrent cholangitis
- ERCP and stent
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C/O
- Epigastric pain
- Fever
- Pale stool
- Dark urine
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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
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Cotracted, thick-walled GB, multiple stones
CBD: 14 mm, stones
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ERCP performed
Sphincterotomy and CBD
clearance
Bleeding from sphincter site
Adrenalin injected
Continued to ooze
Post ERCP
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Haematemesis
Melaena
Dizzy
Pulse: 90
BP: 139/67
Hb:9.7
INR: 1.2
CT Angiogram:
- ?Arterial haemorrhage at
ampulla
Embolization
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Bleeding from branches
of GDA and Superior
pancreaticodudenal
artery
Embolization performed
with coil and gel foam
SMA angiogram:
normal
Day 1 Post Embolization
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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
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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
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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
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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
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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
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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
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Distal arteries, close
to bleeding points
Embolic material is
deployed
It limits the segment
of bowel at risk for
ischemia
Choice of embolic
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Gel foam
Polyvinyl alcohol
particles
Microcoils
some combination
Published experience
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Guy et al, 1992, reported 10 superselective
embolization procedures in nine patients. All
procedures were successful
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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
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>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
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Tan et al, 2008. 265 patients underwent
angiography for GI bleeding.
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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
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Limitations of embolization
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Colonic bleeding is multifactorial
- Diverticular bleed vs. Angiodysplasia
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Patients who are not actively bleeding
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Difficult vascular anatomy or severe
atherosclerotic disease
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“Symptomatic treatment”
Summary
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Minimally invasive techniques have replaced
surgical resection as the initial therapies of
choice
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Superselective embolization and endoscopic
treatment appear complementary
Thank you