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