Case Presentations (Lower Gastrointestinal Bleeding) What Would You Do? What We Did!!

1. Case Presentations(Lower Gastrointestinal Bleeding)What Would You Do?What We Did!! Eric J. Dozois, MD Division of Colon and Rectal Surgery Mayo Clinic Rochester, Minnesota

2. Goals of the Presentation • Interesting cases of LGIB • Stimulate discussion - audience • Review key points of topic

3. CASE # 1

4. Chief Complaint 67 year old male Called to the intensive care unit to see a patient with bright red blood per rectum

5. History of Present Illness • POD # 2 Aorto-bi-iliac graft aorto-renal artery graft for aortoiliac disease

6. History of Present Illness • In ICU, stable for last 24 hrs • HR 90, BP 115/80, Temp 37.5 • BRBPR x 2, now watery diarrhea • LLQ abdominal pain • Hgb = 8, WBC 18, urine output 5cc/hr

7. Past Medical History • Cecal angiodysplasia • Sigmoid diverticular disease • History of colon polyps – s/p polypectomy complicated by postpolypectomy bleed

8. Family History • 2 brothers with colon cancer • 1 sister with uterine cancer • 1 sister with gastric cancer

9. Differential Diagnosis? • Colon cancer • C. difficile colitis • Ischemic colitis • Aorto-enteric fistula • Colonic/Sb Angiodysplasia • Gastric or duodenal ulcer

10. Work Up and Plan ? • Resuscitated, transfused, Abx started • Stool sent for C. diff colitis • Flexible sigmoidoscopy

11. Plan • Flex Sig 15 – 60 cm loss of vascular pattern intense erythema, purple discoloration

12. Plan?

13. Hospital Course • Fluids, optimized hemodynamics • More BRBPR, watery diarrhea • Worsening LLQ pain, confused • HR 130, BP 90/60, T 38.9 • Repeat Flex Sig: “much worse than yesterday!”

14. Plan?

15. Operative Management • Left colon/sigmoid, patchy necrosis • Left Hemicolectomy • End Colostomy • Hartmann Pouch How would you manage the rectal stump??

16. Postop Course • Discharged from the hospital on POD 14 • 2 Months later… Emergency Fem – pop Graft thrombosis, emboli • 1 Month later … In ER with BRBPR…..

17. Hospital Course • On coumadin, INR = 3, Hgb = 7 • Admitted to ICU, transfused • Passes 400cc amount of bright red blood per RECTUM!

18. Differential Diagnosis? • Dis-use Proctitis • Ischemic rectal stump • Aorto-rectal stump fistula

19. Work Up? • Extended “Push” EGD: • Normal • Flex sigmoidoscopy: • Fresh blood & clots • Proximal stump has 3 cm ulcer • ? dehiscence of stump

20. CT Angiogram

21. Angiogram

22. Treatment ? • Observation….. • 12 Hours later - Massive bleed!! • Blood from rectum… • Blood from Colostomy… • Blood per NGT… Now What?

23. Operative Findings • 2 liters of blood in abdomen • Dehiscence of proximal aortic anastomosis • Fistula to 3rd portion of duodenum • Dehiscence of rectal stump • Repair of graft and rectal stump

24. Aorto-Enteric Fistula • Incidence less than 1% • 4th portion of duodenum • “Herald bleed” - late diagnosis

25. Aorto-Enteric Fistula • Risk Factors: • Repair for ruptured aneurysm • Infection, thrombosis, hematoma • Infection, pseudo-aneurysm, fistula

28. Frequency of Signs and Symptoms in Patients with Aorto-Enteric Fistula Proportion Effected (%) GI bleeding (“herald”) 94 Hematemasis 78 Back or Abd pain 48 Melena 46 Shock 33 Pulsatile mass 17 Syncope 10

29. Diagnostic Tools in Patients with Aorto-enteric Fistula Detection Rate (%) CT 61 Angiography 26 EGD 25 Technetium scan 14 Enteroclysis 13 Colonoscopy 10 Ultrasound 0 Barium enema 0

30. Prognosis - Aorto-Enteric Fistula • Early Mortality 21% • Late Mortality 24% • 5-Year Survival 61% Armstrong et al. J Vasc Surg 2005;42:660

31. Rifampin Graft, Omental Wrap

32. CASE # 2

33. Chief Complaint 9 year old male Bright red blood per rectum!

34. History of Present Illness • 4 days of bright red blood per rectum, by day 5 stool was dark colored • On first day of bleeding, 5 emesis • Now – asymptomatic

35. Past Medical History • Attention deficit disorder • No bleeding risk factors • Family History: • Brother had intussusception age 6mos • Mother has colon polyps age 42

36. Hospital Course • Seen in ER – stable, Hg 7 • HR 130, BP 80/60 • Abd/rectal exam negative • Overnight stable, Hgb = 6

37. Differential Diagnosis? • Intestinal duplication • Juvenile polyp • FAP • Meckel’s diverticulum • IBD

38. Work Up? • EGD Negative • Colonoscopy Negative • Other Tests ?

39. Meckel’s Scan Negative

40. Tagged RBC Scan What Now?? Negative

41. Second Meckel’s Scan Positive!

42. Treatment ? • Operation Laparoscopic assisted Meckel’s diverticulectomy, appendectomy • Pathology Meckel’s diverticulum with focal heterotopic gastric mucosa

45. Meckel’s Diverticulum (MD) • Incidence of MD in general population is 1% • Bleeding MD is the most common cause of acute lower GI bleeding in pediatric patients • The most common presentation in a child is obstruction, and it is adults bleeding *Park et al. Ann Surg 2005;241:529

46. Meckel’s Diverticulum • 16% - are symptomatic • Presentation varies – perforation, obstruction, bleeding • 29% - ectopic or abnormal tissue Park et al. Ann Surg 2005;241:529

47. Histologic Findings in 180 Pts* Findings Patients No. % Ectopic tissue Gastric 59 33 Pancreatic 9 5 Carcinoid 4 2 Duodenal 3 2 Lipoma 2 1 Leiomyosarcoma 1 0.6 Diverticulitis 45 25 Enterolith 11 6 No Abnormality 46 25 *Park et al. Ann Surg 2005;241:529

48. Meckel’s Scan • In children, sensitivity 85%, specificity 95% • In adults, sensitivity 65%, specificity 9%. • Sensitivity decreases during acute bleeding • Intestinal duplication & nodular lymphoid hyperplasia can give false-positives

49. CASE # 3

50. Chief Complaint 88 yr old male Asked to see in the medical ICU for lower gi bleeding