Mayo Clinic Division of Colon & Rectal Surgery Integrated Care For

1. Mayo Clinic Division of Colon & Rectal Surgery Integrated Care For Digestive Disease

2. Non-Tumoral BleedingDiverticular Disease & Angiodysplasia Eric J. Dozois, MD Division of Colon and Rectal Surgery Mayo Clinic Rochester, Minnesota

3. Lower GI BleedBackground • 1% of acute hospital admissions • Mortality ranges from 5% – 40% • 85% - will stop spontaneously • 15% - require aggressive resuscitation, multiple diagnostic modalities & intense medical and surgical management Hoedema et al. Dis Colon Rectum 2005;48:2010

4. Common Causes of Major LGIBMayo Clinic 1988 – 1996, 1018 pts* Diverticulosis 30% Post-polypectomy 7% Ischemia 6% Ulcerations 6% Malignancy 5% Angiodysplasia 4% Radiation proctopathy 2% Inflammatory bowel disease 2% *Permission from CJ Gostout, MD

5. Common Causes of Major LGIBMayo Clinic 1988 – 1996, 1018 pts* Diverticulosis 30% Angiodysplasia 4%

7. Diverticular Bleeding Non-inflammatory Pathogenesis Vasa Recta

8. Diverticular Bleeding • Most patients have minor bleeding • 30% - 50% have massive bleeding • Spontaneously resolves in 70% - 80% Browder etal. Ann Surg 1986 Nov;204(5):530-6. Gostout et al. J Clin Gastroenterol 1992;14(3):260-7.

9. Diverticular Bleeding • Re-bleeding in 20% - 30%** • 1/3 of major LGIB in elderly* *Leitman, etal. Ann Surg 1989;209:175 **Breen et al. Semin Colon Rectal Surg 1997;8:128

10. Diagnosis - Diverticular Bleeding • Diagnostic Options: • Colonoscopy** • Tagged RBC scan • Mesenteric Angiogram

11. Diagnosis by Colonoscopy Study N Specific Dx Endo Tx Chaudhry (’98) 85 82 17 Kok (’98) 190 148 10 Jensen (’00) 121 100 10 Antuaco (’01) 39 29 4 Green (’05) 50 48 17 Total 485 438 58 (88%) (12%)

12. Non-Surgical Intervention • Therapeutic Endoscopy: • Epinephrine injection – 4 quadrants • Multipolar cautery • Endoscopic hemoclip • Combination therapy – Epi & clips • Super-Selective Angiography: • Constriction - vasopressin • Embolization – gelfoam, microcoil

13. Epinephrine + Gold Probe Cautery Diverticular Bleeding

14. Triclip (Wilson-Cook) Resolution (Boston Scientific) QuickClip 2 (Olympus)

15. Endoscopic Clipping

16. Endoscopic Clipping

17. Endoscopic Hemo Clips for Acute Colonic Diverticular BleedingMayo Clinic Experience • Methods: • Study cohort identified from the prospectively collected GIBT database (1989-2005) • Clinical, endoscopic & outcome data were assessed DDW 2006 With permission by LM Wong Kee Song

18. Results – Diverticular Bleeding Patients (n = 28) Mean Age 78 (47-92) Transfusions 5 (0-17) R colon/L colon 10 / 18 No. clips used 3 (1-6) Follow-up (mos) 9 (1-59) DDW 2006 With permission by LM Wong Kee Song

19. Results - Diverticular Bleeding Immediate hemostasis 28/28 (100%) Recurrent bleeding 4/28 (14%) Long-term hemostasis 25/28 (89%) Endoscopy complications 0/28 (0%) Surgical intervention 3/28 (11%) Bleed-related mortality 0/28 (0%) DDW 2006 With permission by LM Wong Kee Song

20. Surgical Intervention • Surgical intervention will ultimately be required in 24% - 78% who bleed chronically* • In 18% - 25% urgent intervention is necessary due to persistent instability despite aggressive resuscitation** *McGuire HH. Ann Surg 1994;220:653 **Bokhari et al. Dis Colon Rectum 1997;39:191

21. Surgical Intervention • Elective (Acute or Chronic): • 2 or more episodes of transfusion dependant bleeding • Emergent (Unstable): • Stabilized first - endoscopic or angiographic technique (bridge!)

22. Surgical Management • Identified: • Directed segmental resection • Unidentified: • Intraoperative colonoscopy • Blind hemicolectomy • Blind subtotal colectomy

23. Colectomy, Re-bleed Rate & Mortality Operation Re-bleed Morbidity Mortality Dir. Seg 14% -- -- Subtotal 0% -- -- Blind Seg. 42% 83% 57% Parkes et al. Am Surg 1993;59:676

24. Angiodysplasia • AVMs, vascular ectasias, angiomas • Common source of LGIB in elderly • 15% have massive bleeding • 85% intermittent, subacute bleeding • Recurrence rate 25% • Often multi-focal, (R) colon common

25. Angiodysplasia in GI Tract Colon is most common site in GI tract • Cecum 37% • Ascending colon 17% • Transverse colon 7% • Descending colon 7% • Sigmoid colon 18% • Rectum 14% Hocter W. et al. Endoscopy 1985 Sep;17(5):182-5.

26. Angiodysplasia • In some series, it accounts for 20% - 30% of LGI bleeding, and may be the most frequent cause in patients over the age of 65. • Can present with occult blood loss or acute bleeding, causing orthostasis or hypotension Boley et al. Gastroenterology 1977;72:650-60. Browder et al. Ann Surg 1986;204(5):530-6.

27. Diagnosis - Angiodysplasia • Diagnostic Options: • Colonoscopy** • Tagged RBC scan • Mesenteric Angiogram* • Selective Angiogram

30. Pooling of Contrast in Cecum

31. Non-Surgical Intervention • Therapeutic Endoscopy: • Cautery, epinephrine, argon beam coag. • Perforation risk (*R colon) • Argon beam is preferred modality • Super-Selective Angiogram: • Treatment of choice for Sb angiectasias • Vasopressin, embolization

33. Angiodysplasia Jejunum

34. Surgical Management • Persistent transfusions or life threatening hemorrhage may be arrested with angiogram directed therapy to stabilize for surgery • Endoscopic or angiographic localization (tattoo) (bridging) can improves outcome • Multi-focal dz may require subtotal colectomy • Avoid blind segmental colectomy

35. ConclusionsDiverticular & Angiodysplastic Bleeding • Chronic vs. Acute presentation • Therapeutic endoscopy and angiography may cure or temporize disease • Surgery reserved for chronic transfusion requirements or life-threatening bleeding

36. ConclusionsDiverticular & Angiodysplastic Bleeding • Both are multi-focal disease processes & require localization for directed surgical therapy • Collaborative effort by the radiologist, endoscopist & surgeon optimizes patient care