Uncontrollable GI Bleed
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Transcript of Uncontrollable GI Bleed
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 ALP: 141 PCV: 0.30 GGT: 151 WBC: 6.8 Bil: 3
Urea: 4.7 Cr: 95 Na: 137 K: 4.3
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 O/E - Jaundiced - Temp: 41 - Tender RUQ Lab results - Cholestatic picture
Ur 13.1
Cr 138
Na 135
K 4.4
Cl 110
Hb 11.6
HCT 36.1
WBC 4.7
Neut 3.78
Bil 113.9
ALT 131
ALP 270
GGT 278
Amylase 10
CRP 352
PT 11.6
INR 1.1
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: Tc-
99M 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 first-order 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