sara kim, pgy 5 downstate medical center _sk.pdfetiology bleeding distal to ligament of treitz acute...

Management of Lower GI bleed Sara Kim, PGY 5 Downstate Medical Center

www.downstatesurgery.org

Case Presentation 81 M who presented with syncope and multiple

large bloody bowel movements.

PMHx: HTN, DM, asthma

PSHx: non-contributory

Vitals: afebrile, BP 122/83, P110

Labs:

PT 12.5, PTT 28.9

10.6

32 271 9.48


Case Presentation HD 2 2U pRBC transfused

HD 3 C-scope performed: pan diverticulosis with old

blood seen, no active hemorrhage; 3mm polyp in sigmoid colon (tubular adenoma)


Case Presentation HD 5 Had another syncopal episode Transfused 2U pRBC for Hg/hct of 6.1/18.1 Tagged RBC scan: neg

HD 7 Tagged RBC scan repeated: extravasation noted in

hepatic flexure (after 1 hr 40 min into imaging) Underwent a mesenteric angiogram: no active

bleeding, hypervascularity in right colon suggestive of angiodysplasia

Transfused 4 U pRBC


PresenterPresentation NotesUnderwent nagio 1 hr after bleeding scan resulted.

Imaging Nuclear scan and angio

images

tram track sign -- where the feeding artery and draining vein fill simultaneously


PresenterPresentation NotesImage from angiographic evaluation of acute GI hemorrhage

Tagged RBC scintigraphy


Case Presentation HD 9 Underwent exploratory laparotomy, right

hemicolectomy, ileocolic anastamosis Transfused 2U pRBC intra-op

HD 12-15/POD 3-6 Febrile, developed ileus, fever workup negative CT A/P: large fluid collection around the anastamosis

suggestive of leak with abscess formation

HD 16 IR guided drainage of abscess – 90cc of purulent fluid

evacuated Broad spectrum antibiotics started


Case Presentation HD 16-20

Improved abdominal pain, bowel function returned Intermittent fevers Continued leukocytosis

HD 27-28 IR drain removed Repeat CT A/P showed persistence of intra-abdominal abscesses

HD 29 Underwent exploratory laparotomy, drainage of multiple abscesses Creation of loop ileostomy

HD 30-34 Ileostomy functioning, tolerating diet Normalization of leukocytosis and afebrile Awaiting rehab placement


Questions??


Management of lower GI bleeds Resuscitation

Localization

non-surgical management

Surgical management

Summary


Etiology Bleeding distal to ligament of Treitz Acute Chronic obscure

20-30/100,000 patients/year

Spontaneous resolution in 75-85%

Age specific causes of lower GI bleed

Age group Causes Adolescents/Young Adults Meckels

IBD Polyps

Adults up to 60 y/o Diverticular disease Cancer IBD

Age >60 y/o AV malformations Diverticular disease (41%) Cancer (9%) Colitis (14%)


PresenterPresentation NotesTriple A repair – aortoenteric fistula

Diverticular bleed 3-5% of patients with diverticulosis present with

bleeding

Bleeding localized to Right colon -- 50%

70-80% of bleeding resolves spontaneously

38% rebleed

after second occurrence, 50% of these pts rebleed


AVM Pathogenesis: Lifetime of peristaltic contraction of muscular wall

chronic venous congestion capillary dilation ectatic vessels

90% resolve spontaneously

25% rebleed

Can be ass. With CREST syndrome and portal HTN

Most commonly in right colon

For recurrent bleeding, can give estrogens to reduce transfusion requirements


Other causes Upper GI bleed with rapid

transit

11-15% of UGI bleeds have a neg NGT lavage

Small bowel tumors

Anorectal source Hemorrhoids Solitary rectal ulcer

Iatrogenic

Colitis Diversion colitis

Radiation colitis Infectious colitis Ischemic colitis

NSAIDS

Post polypectomy bleeding

Stercoral ulcers

Aortoenteric fistula (previous AAA repair)


Resuscitation ABC

+/- ICU evaluation

Type and screen, transfusion, reversal of coagulopathies

NGT lavage 11-15% are falsely negative Unstable pt: consider EGD

Anoscopy/rigid sigmoidoscopy


localization Diagnostic colonoscopy

Tagged red blood cell scan

CT angiogram

Selective mesenteric angiogram


Diagnostic colonoscopy Success in localizing bleeding 42-76% diagnostic yield

Pros Can be diagnostic as well as therapeutic

Cons Unprepped bowel making more difficult visualization Inability to evaluate small bowel Risks of perforation


Therapeutic colonoscopy Methods used for hemostasis Cautery Argon beam coagulator Laser coagulation Epi injection Endoscopic clips


Predictors of utilization of early colonoscopy vs. radiography for severe lower intestinal bleeding Strate LL1, Syngal S. Gastrointest Endosc. 2005 Jan;61(1):46-52.

Retrospective review of pts with severe bleeding (>2U pRBC) AND underwent colonoscopy and radiography within 24 hrs

N=118 pts met criteria for severe bleeding 33 pts underwent initial early scope Factors related to early c-scope Post-polypectomy bleeds Weekday admission Late evening admission

20 pts underwent initial radiologic procedure 17 pts had a bleeding scan 3 pts underwent angiogram Factors related to early radiography Tachycardia Syncope Bleeding during 1st 4 hrs of admission


http://www.ncbi.nlm.nih.gov/pubmed/?term=Strate LL[Author]&cauthor=true&cauthor_uid=15672055http://www.ncbi.nlm.nih.gov/pubmed/?term=Syngal S[Author]&cauthor=true&cauthor_uid=15672055

Predictors of utilization of early colonoscopy vs. radiography for severe lower intestinal bleeding Strate LL1, Syngal S. Gastrointest Endosc. 2005 Jan;61(1):46-52.

Colonscopy vs early rads, c-scope had: Shorter hospital stay Increased diagnostic yield Fewer red blood cell transfusion

NO difference in: Rates of therapeutic intervention Rates of surgery Mortality rate


http://www.ncbi.nlm.nih.gov/pubmed/?term=Strate LL[Author]&cauthor=true&cauthor_uid=15672055http://www.ncbi.nlm.nih.gov/pubmed/?term=Syngal S[Author]&cauthor=true&cauthor_uid=15672055

For acute lower GI bleeding: If hemodynamically stable: Urgent colonscopy Rapid bowel prep with isotonic colonic lavage or

GO-Lytely with 4-6 L until pink in color If hemodynamically unstable: angiography


PresenterPresentation NotesRecommendations by the gastroenterologists

Bleeding scan Procedure Ex-vivo or in vivo labeling of pt’s RBC Injection back into pt Serial scans Can re-scan up to 12-24 hrs for detection of intermittent

bleeding (for 99mTc Pertechnetate)

Detection as low as 0.05-0.1cc/min

Diagnostic yield: 41-94%

Should be immediately followed with angio/embolization or c-scope, possibly surgery

Pros: most sensitive test for bleeding

Cons: poor anatomic localization


5 yr retrospective study, N=224

115 scans were positive (51.3%) 96/115 (42.9%) localized the bleeding site

Bleeding location was determined in 48/50 pts requiring surgery pre-operatively 36/37 pts (97%) with positive bleeding scan

accurately determined location


PresenterPresentation NotesStudy done at cornell describing bleeding scan as more accurate

For active bleeding, Sensitivity: 79-97% Specificity: 70-100%

Positive tagged RBC scan – shown to be 5x more likely to require surgery

Techniques used to improve diagnostic accuracy Continuous dynamic imaging Min sampling of 1 frame/min Accurate localization depends on 1st site of bleeding further imaging revealing antegrade and retrograde flow

Delayed imaging continuous dynamic imaging


PresenterPresentation Notes2011

Glucagon administration (0.25-2mg IV) -- provoking Slows transit time (b receptor mediated) Increases in BP and cardiac contractility and

vasodilation Can potentiate effects of oral anticoagulation

Subtraction scintigraphy Looking at the changes in the images during the

time interval Decreases false neg (from overlying vascular

structures) Decreases false pos (from background tagged

RBC concentrate)


CT angiography Can detect 0.5 cc/min (in swine model)

If active bleeding is present, 90% sensitivity

If intermittent bleeding, 45-47% sensitive

Pros: widely available, minimally invasive

Cons: contrast induced nephropathy, contrast allergy, nontherapeutic

Procedure: CT without and with IV contrast, no PO contrast


CT angiography Positive: extravasation of

contrast into bowel lumen Area of high attenuation on arterial phase which increases on venous phase

A,B: arterial phase

C,D: venous phase


PresenterPresentation NotesPicture from: diagnosis of GI bleeding: a practical guide for clinicians

Detection of Active Gastrointestinal Hemorrhage with CT Angiography: A 4½-year Retrospective Review Daniel W. Kennedy, MD, Christopher J. Laing, MD, Lee H. Tseng, MD, David I. Rosenblum, DO, Stephen W. Tamarkin, MD. Journal of Vasc and Interv Rad. Volume 21, Issue 6, June 2010, Pages 848–855

86 pts CT

26% + for active bleed

86% confirmed

74% neg for bleed

92% did NOT require

intervention

• No cases that had a neg CT had a positive angio within 24 hrs • Authors support use of CT prior to angio for pts with bleeding of Unknown origin


http://www.sciencedirect.com.newproxy.downstate.edu/science/journal/10510443/21/6http://www.sciencedirect.com.newproxy.downstate.edu/science/journal/10510443/21/6

Selective mesenteric angiogram Diagnostic yield: 40-86%

+/- provocative testing Heparin Thrombolytics Vasodilators Improves diagnostic yield to 29-100%

Pros: diagnostic and therapeutic

Cons: intermittent bleeding, vascular calcifications, small vessel or venous bleeding

Complications: hematoma, bowel ischemia, arterial dissection or spasm

Indications: hemodynamically unstable, recurrent GI bleeding, contraindication for endoscopy, neg upper and lower endoscopy

Detects 1-1.5cc/min in practice



PresenterPresentation NotesReview article discussing angioembolization

Selective Mesenteric Embolization Therapeutic angio Vasopressin infusion Cessation of bleeding in 50-90% of pts Rebleeds in 35-50% of pts

Embolization Cessation of bleeding in 80-100% 14-29% recurrence

Methods used for hemostasis: Gelfoam Microcoils Liquid embolic agents Polyvinyl alcohol


Localization and Definitive Control of Lower GI Bleeding with Angiography and embolization Am Surg April 2013 Yi WS, Garg G, Sara JA

159 angiograms performed

Localization • successful in 23.7%

50% had definitive control of bleeding

1 pt had post-embolization ischemia requiring laparotomy


PresenterPresentation Notes8 year retrospective reviewExclusion criteria – upper GI bleed

Noninvasive evaluation of active lower gastrointestinal bleeding: comparison between contrast-enhanced MDCT and 99mTc-labeled RBC scintigraphy. Zink SI1, Ohki SK, Stein B, Zambuto DA, Rosenberg RJ, Choi JJ, Tubbs DS. AJR Am J Roentgenol. 2008 Oct;191(4):1107-14. doi: 10.2214/AJR.07.3642.

55 pts underwent contrast enhanced MDCT 41 of these pts also underwent RBC scintigraphy

CT RBC scan Angio surgery

20 pts neg neg Sx not required 11 pts neg pos 2 pos 3+ 2 pts pos neg 1 neg

1 pos 1 pos

8 pts Pos Pos 4 neg angios, 1 had sx, 1+ angio

2pts pos, but sx only 1 pt pos (neg angio)


PresenterPresentation NotesGroup I -- All the patients who were neg on both did not require surgeryGroup 2 – 2 pts required surgery, one with positive angio and one with neg angio; 1 pt had + angio but did not require surgery, 1 pt did not have angio or surgery; 6 pts with neg angio and no surgery, 1 pt had bleeding localized at a small bowel anastamosis and underwent surgeryGroup 3 -- Tagged RBC scan was falsely neg in one pt that angio did detect and that pt required surgeryGroup 4 – 2 pts straight to surgery without angio, 1 pt with neg angio but had surgery, 1 pt with pos angio without surgery

http://www.ncbi.nlm.nih.gov/pubmed/?term=Zink SI[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Ohki SK[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Stein B[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Zambuto DA[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Rosenberg RJ[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Choi JJ[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Tubbs DS[Author]&cauthor=true&cauthor_uid=18806152


19 pts did NOT undergo RBC scintigraphy 5 pts underwent CT angiography (unstable) 3 had positive angios 2 had negative angios 1 had pos CT 1 had neg CT


PresenterPresentation NotesGroup I -- All the patients who were neg on both did not require surgeryGroup 2 – 2 pts required surgery, one with positive angio and one with neg angio; 1 pt had + angio but did not require surgery, 1 pt did not have angio or surgery; 6 pts with neg angio and no surgeryGroup 3 -- Tagged RBC scan was falsely neg in one pt that angio did detect and that pt required surgeryGroup 4 – 2 pts straight to surgery without angio, 1 pt with neg angio but had surgery, 1 pt with pos angio without surgery



Conclusions of the study: MDCT had a 31.7% detection rate for active bleeding About 50% required further intervention

Tagged RBC scintigraphy is BEST test for intermittent bleeding No one study is perfect with sensitivity and specificity

dependent on timing of test and nature of the bleed Advantages of MDCT for first screening test: Readily available 24 hrs/day Ancillary findings can be detected

Statistically significant disagreement between MDCT and tagged RBC scintigraphy is present


PresenterPresentation NotesGroup I -- All the patients who were neg on both did not require surgeryGroup 2 – 2 pts required surgery, one with positive angio and one with neg angio; 1 pt had + angio but did not require surgery, 1 pt did not have angio or surgery; 6 pts with neg angio and no surgeryGroup 3 -- Tagged RBC scan was falsely neg in one pt that angio did detect and that pt required surgeryGroup 4 – 2 pts straight to surgery without angio, 1 pt with neg angio but had surgery, 1 pt with pos angio without surgery


Small bowel bleeding Meckels scan (age appropriate)

Double balloon enteroscopy Diagnostic yield: 40 – 80% Can evaluate 60-80 cm of jejunum

Capsule endoscopy Diagnostic yield: 55-92% Required UGI series with small bowel follow through

to rule out a mass Failure of retrieval: 5%


Surgical management Indications for surgical intervention Transfusion requirement >4-6U of pRBC in 24 hrs Persistent bleeding (after 72 hrs) recurrent bleeding within a week Morbidity and mortality increase significantly for pts transfused

>10U pRBC

“blind” Subtotal colectomy, mortality 25-33% Associated with a high rebleeding rate up to 42% If unable to localize the site of bleeding +/- on table endoscopy

Segmental colectomy If able to localize the site of bleeding, mortality: 7% If unable to localize the site of bleeding, mortality: 57%


PresenterPresentation NotesAssociation for Academic Surgery Watch and wait: Conservative management of lower gastrointestinal bleeding William S. Yi, MD,* Reid Vegeler, MD, Kimberly Hoang, MD, Nick Rudnick, MD, and Jack A. Sava, MD Department of Surgery, Washington Hospital Center, Washington, District of Columbia journal of surgical research 177 (2012) 315e319

Surgical treatment concepts for acute lower gastrointestinal bleeding. Czymek R1, Kempf A, Roblick UJ, Bader FG, Habermann J, Kujath P, Bruch HP, Fischer F. J Gastrointest Surg. 2008 Dec;12(12):2212-20. doi: 10.1007/s11605-008-0597-5. Epub 2008 Jul 18.

N=6

3 pt

s

Localized in 61 pts

Endoscopy – 41 pts

Angiography – 12 pts

Tagged RBC scan – 8 pts

Retrospective review of pts requiring surgical intervention for GI bleed


http://www.ncbi.nlm.nih.gov/pubmed/?term=Czymek R[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Kempf A[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Roblick UJ[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Bader FG[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Habermann J[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Kujath P[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Bruch HP[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Bruch HP[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Fischer F[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Fischer F[Author]&cauthor=true&cauthor_uid=18636299


Indication for surgery: acute, uncontrollable and recurrent bleeding

Segmental resection is recommended if bleeding is localized

If bleeding not localized, subtotal resection is treatment of choice

For small bowel hemorrhage, regular re-evaluation required


http://www.ncbi.nlm.nih.gov/pubmed/?term=Czymek R[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Kempf A[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Roblick UJ[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Bader FG[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Habermann J[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Kujath P[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Bruch HP[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Bruch HP[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Fischer F[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Fischer F[Author]&cauthor=true&cauthor_uid=18636299

Acute Lower GI Bleeding for the Acute Care Surgeon: Current DiagnosIs And management J. lee, t. W. costantini, R. coimbra Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California-San Diego School of Medicine, San Diego, California, U.S.A. Scandinavian J Surg 98: 135-142, 2009 REVIEW


Acute Lower GI BleedIng for the Acute Care Surgeon: Current DiagnosIs And management J. lee, t. W. costantini, R. coimbra Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California-San Diego School of Medicine, San Diego, California, U.S.A. Scandinavian J Surg 98: 135-142, 2009 REVIEW


Questions??


References Diagnosis of gastrointestinal bleeding: A practical guide for clinicians Bong Sik Matthew

Kim, Bob T Li, Alexander Engel, Jaswinder S Samra, Stephen Clarke, Ian D Norton, Angela E Li. World J Gastrointest Pathophysiol 2014 November 15; 5(4): 467-478

Predictors of utilization of early colonoscopy vs. radiography for severe lower intestinal bleeding. Strate LL1, Syngal S. Gastrointest Endosc. 2005 Jan;61(1):46-52.

Accurate localization and surgical management of active lower gastrointestinal hemorrhage with technetium-labeled erythrocyte scintigraphy. Suzman MS1, Talmor M, Jennis R, Binkert B, Barie PS. Ann Surg. 1996 Jul;224(1):29-36.

Scintigraphic evaluation of acute lower gastrointestinal hemorrhage: current status and future directions. Currie GM1, Kiat H, Wheat JM. J Clin Gastroenterol. 2011 Feb;45(2):92-9.

Angiographic evaluation and management of acute gastrointestinal hemorrhage. T Gregory Walker, Gloria M Salazar and Arthur C Waltman. World J Gastroenterol. 2012 March 21; 18(11): 1191-1201.

Acute Lower GI BleedIng for the Acute Care Surgeon: Current DiagnosIs And management J. lee, t. W. costantini, R. coimbra . Scandinavian J Surg 98: 135-142, 2009 REVIEW


http://www.ncbi.nlm.nih.gov/pubmed/?term=Strate LL[Author]&cauthor=true&cauthor_uid=15672055http://www.ncbi.nlm.nih.gov/pubmed/?term=Syngal S[Author]&cauthor=true&cauthor_uid=15672055http://www.ncbi.nlm.nih.gov/pubmed/?term=Syngal S[Author]&cauthor=true&cauthor_uid=15672055http://www.ncbi.nlm.nih.gov/pubmed/?term=Suzman MS[Author]&cauthor=true&cauthor_uid=8678614http://www.ncbi.nlm.nih.gov/pubmed/?term=Talmor M[Author]&cauthor=true&cauthor_uid=8678614http://www.ncbi.nlm.nih.gov/pubmed/?term=Jennis R[Author]&cauthor=true&cauthor_uid=8678614http://www.ncbi.nlm.nih.gov/pubmed/?term=Binkert B[Author]&cauthor=true&cauthor_uid=8678614http://www.ncbi.nlm.nih.gov/pubmed/?term=Barie PS[Author]&cauthor=true&cauthor_uid=8678614http://www.ncbi.nlm.nih.gov/pubmed/?term=Currie GM[Author]&cauthor=true&cauthor_uid=20861799http://www.ncbi.nlm.nih.gov/pubmed/?term=Kiat H[Author]&cauthor=true&cauthor_uid=20861799http://www.ncbi.nlm.nih.gov/pubmed/?term=Wheat JM[Author]&cauthor=true&cauthor_uid=20861799

References Detection of Active Gastrointestinal Hemorrhage with CT Angiography: A 4½-year

Retrospective Review. Daniel W. Kennedy, MD, Christopher J. Laing, MD, Lee H. Tseng, MD, David I. Rosenblum, DO, Stephen W. Tamarkin, MD. Journal of Vasc and Interv RadVolume 21, Issue 6, June 2010, Pages 848–855

Angiographic evaluation and management of acute gastrointestinal hemorrhage. Walker TG1, Salazar GM, Waltman AC. World J Gastroenterol. 2012 Mar 21;18(11):1191-201. doi: 10.3748/wjg.v18.i11.1191.

Localization and Definitive Control of Lower GI Bleeding with Angiography and embolization. Yi WS, Garg G, Sara JA. Am Surg April 2013




http://www.sciencedirect.com.newproxy.downstate.edu/science/journal/10510443/21/6http://www.ncbi.nlm.nih.gov/pubmed/?term=Walker TG[Author]&cauthor=true&cauthor_uid=22468082http://www.ncbi.nlm.nih.gov/pubmed/?term=Walker TG[Author]&cauthor=true&cauthor_uid=22468082http://www.ncbi.nlm.nih.gov/pubmed/?term=Salazar GM[Author]&cauthor=true&cauthor_uid=22468082http://www.ncbi.nlm.nih.gov/pubmed/?term=Waltman AC[Author]&cauthor=true&cauthor_uid=22468082http://www.ncbi.nlm.nih.gov/pubmed/?term=Zink SI[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Ohki SK[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Stein B[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Zambuto DA[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Rosenberg RJ[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Choi JJ[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Tubbs DS[Author]&cauthor=true&cauthor_uid=18806152http://www.ncbi.nlm.nih.gov/pubmed/?term=Czymek R[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Kempf A[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Roblick UJ[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Bader FG[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Habermann J[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Kujath P[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Bruch HP[Author]&cauthor=true&cauthor_uid=18636299http://www.ncbi.nlm.nih.gov/pubmed/?term=Fischer F[Author]&cauthor=true&cauthor_uid=18636299

References Acute Lower GI Bleeding for the Acute Care Surgeon: Current

DiagnosIs And management. J. lee, t. W. costantini, R. coimbra. Scandinavian J Surg 98: 135-142, 2009 REVIEW

Schwartz’s Principles of Surgery, 9th Edition 2009

Sabiston Textbook of Surgery, 19th Edition 2012


Management of Lower GI bleedCase PresentationCase PresentationCase PresentationImagingTagged RBC scintigraphyCase PresentationCase PresentationQuestions??Management of lower GI bleedsEtiologyDiverticular bleedAVMOther causesResuscitationlocalizationDiagnostic colonoscopyTherapeutic colonoscopyPredictors of utilization of early colonoscopy vs. radiography for severe lower intestinal bleeding�Strate LL1, Syngal S.�Gastrointest Endosc. 2005 Jan;61(1):46-52.Predictors of utilization of early colonoscopy vs. radiography for severe lower intestinal bleeding�Strate LL1, Syngal S.�Gastrointest Endosc. 2005 Jan;61(1):46-52. Bleeding scanSlide Number 23Slide Number 24Slide Number 25CT angiographyCT angiographyDetection of Active Gastrointestinal Hemorrhage with CT Angiography: A 4½-year Retrospective Review �Daniel W. Kennedy, MD, Christopher J. Laing, MD, Lee H. Tseng, MD, David I. Rosenblum, DO, Stephen W. Tamarkin, MD.�Journal of Vasc and Interv Rad. Volume 21, Issue 6, June 2010, Pages 848–855Selective mesenteric angiogramSlide Number 30Selective Mesenteric EmbolizationLocalization and Definitive Control of Lower GI Bleeding with Angiography and embolization�Am Surg April 2013�Yi WS, Garg G, Sara JANoninvasive evaluation of active lower gastrointestinal bleeding: comparison between contrast-enhanced MDCT and 99mTc-labeled RBC scintigraphy.�Zink SI1, Ohki SK, Stein B, Zambuto DA, Rosenberg RJ, Choi JJ, Tubbs DS.�AJR Am J Roentgenol. 2008 Oct;191(4):1107-14. doi: 10.2214/AJR.07.3642.Noninvasive evaluation of active lower gastrointestinal bleeding: comparison between contrast-enhanced MDCT and 99mTc-labeled RBC scintigraphy.�Zink SI1, Ohki SK, Stein B, Zambuto DA, Rosenberg RJ, Choi JJ, Tubbs DS.�AJR Am J Roentgenol. 2008 Oct;191(4):1107-14. doi: 10.2214/AJR.07.3642.Noninvasive evaluation of active lower gastrointestinal bleeding: comparison between contrast-enhanced MDCT and 99mTc-labeled RBC scintigraphy.�Zink SI1, Ohki SK, Stein B, Zambuto DA, Rosenberg RJ, Choi JJ, Tubbs DS.�AJR Am J Roentgenol. 2008 Oct;191(4):1107-14. doi: 10.2214/AJR.07.3642.Small bowel bleeding Surgical managementSurgical treatment concepts for acute lower gastrointestinal bleeding.�Czymek R1, Kempf A, Roblick UJ, Bader FG, Habermann J, Kujath P, Bruch HP, Fischer F.�J Gastrointest Surg. 2008 Dec;12(12):2212-20. doi: 10.1007/s11605-008-0597-5. Epub 2008 Jul 18.�Surgical treatment concepts for acute lower gastrointestinal bleeding.�Czymek R1, Kempf A, Roblick UJ, Bader FG, Habermann J, Kujath P, Bruch HP, Fischer F.�J Gastrointest Surg. 2008 Dec;12(12):2212-20. doi: 10.1007/s11605-008-0597-5. Epub 2008 Jul 18.�Acute Lower GI Bleeding for the Acute Care Surgeon: Current DiagnosIs And management �J. lee, t. W. costantini, R. coimbra �Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California-San Diego School of Medicine, San Diego, California, U.S.A. �Scandinavian J Surg 98: 135-142, 2009 REVIEWAcute Lower GI BleedIng for the Acute Care Surgeon: Current DiagnosIs And management �J. lee, t. W. costantini, R. coimbra �Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California-San Diego School of Medicine, San Diego, California, U.S.A. �Scandinavian J Surg 98: 135-142, 2009 REVIEWQuestions??ReferencesReferencesReferences

sara kim, pgy 5 downstate medical center _sk.pdfetiology bleeding distal to ligament of treitz acute...

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