MD Department of Gastroenterology Cleveland Clinic Foundation Cleveland Ohio I PREAMBLE Guidelines for clinical practice are intended to suggest preferable approaches to particular medical problems as established by interpretation and collation of s ID: 10224
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PreparedforthePracticeParametersCommitteeoftheAmericanCollegeofGastroenterology. changeinbowelhabits,fever,urgency/tenesmus,weightlossrelevantpasthistory,includingpreviousbleedingepi-sodes,trauma,pastabdominalsurgeries,previouspep-ticulcerdisease,historyofinflammatoryboweldis-ease,historyofradiationtherapytotheabdomenandpelvis,andpriorhistoryofmajororgandysfunction(includingcardiopulmonary,renal,andliverdisease)current/recentmedications(includingNSAIDs,aspirin,andanticoagulants),andallergies.presenceorabsenceofchestpain/palpitations,dyspneaatrestoronexertion,lightheadedness,orposturalPhysicalexaminationshouldinclude(ataminimum):immediaterecordingofvitalsignswithposturalchanges.Adropof10mmHgoranincreaseofbeats/mininpulseisindicativeofacutebloodlossof800ml(15%oftotalcirculatorybloodvolume).Markedtachycardiaandtachypnea,associatedwithhypotensionanddepressedmentalstatusisindicativeofabloodlossof1500ml(30%circulatorybloodvolume)(1,2).cardiopulmonary,abdominalanddigitalrectalexami-Initiallaboratorystudiesshouldinclude:measurementofcompletebloodcount;itshouldberememberedthatinitialhemoglobin/hematocritvaluemaynotreflectthedegreeofbloodlossduetovolumecontraction,andmayfallsignificantlyafterhydration.serumelectrolytes,bloodureanitrogen,andcreatinine.Inuppergastrointestinalbleeding,theserumbloodureanitrogenmayrisewithoutacommensurateriseinse- .1.AlgorithmforlowerGIbleeding.AJG±August1998MANAGEMENTOFACUTELOWERGIBLEEDING1203 clinicalseries,themajorityofpatientspresentingwithhe-matocheziaare60yr.Whereastherecommendationsforstructuralevaluationbelowcanbeappliedtomostclinicalsituations,therearecircumstancesinwhichitisappropriatetoaltertheorderofteststofocusonahighlylikelycauseforbleeding.Forexample,forthepatientinthethirdorfourthdecadeoflifepresentingwithmarooncoloredstool,eval-uationforaMeckel'sdiverticulummightbeperformedveryearlyinthestructuralevaluation.Apatientwithhematoche-ziawhohadundergonecolonoscopyandremovalofasigmoidcolonpolyp3dayspreviouslymayrequirenostructuralevaluationifbleedingstopsspontaneously.Inthepatientwithhematochezia,anuppergastrointestinalbleedingsourcemustbeconsidered.Anasogastricaspirateshowingcopiousamountsofbileandnegativeforbloodmakesanuppergastrointestinalsourceunlikely.Uppergastrointestinalendoscopyshouldbeperformedifthere-sultsofnasogastricaspirationshowsevidenceofuppergastrointestinalbleeding,orisnegativeforbloodandbile.Patientswithhematocheziamostfrequentlybleedfromacolonicsource.However,whenbleedingisbrisk,anuppergastrointestinalsourceofbleedingmaypresentashema-tochezia.InaclinicalseriesbyJensenandMachicado,11%ofpatientsinitiallysuspectedofhavinglowergastrointes-tinalbleedingactuallyhadanuppergastrointestinalsource(13).Placementofanasogastrictubeshouldbeperformedinpatientswithhematochezia.Thepresenceofabloodyaspirateconfirmsthepresenceofuppergastrointestinalbleeding.Theabsenceofblooddoesnotruleoutuppergastrointestinalbleeding,asbloodfromaduodenalsourcemaynotrefluxintothestomach.Luketal.foundthatnasogastricaspirationwas98%accurateindetectionofbleedingduodenalulcers(14).Cuellaretal.performednasogastricaspirationjustbeforeendoscopyin62patientswithapparentuppergastrointestinalhemorrhage.Oneof18patients(6%)withanonbloody,yellow-greenaspiratehadaduodenalulceratendoscopy(15).IntheaforementionedseriesfromJensenandMachicado,nasogastricaspirationwasdiagnosticinthepatientswithuppergastrointestinalbleeding(13).Uppergastrointestinalendoscopyshouldbeperformediftheresultsofnasogastricaspirationshowsevidenceofuppergastrointestinalbleeding,orisnegativeforbloodandbile.Particularlyinthesettingofhematoche-zialeadingtohemodynamiccompromise,itisreasonabletoperformupperendoscopyastheinitialendoscopicevalua-tionunlessacopiousamountofnonbloodybileisrecoveredfromthenasogastrictubewhilethepatientisactivelypass-ingredbloodperrectum.Endoscopy(colonoscopyorsigmoidoscopy)isthetestofchoiceforthestructuralevaluationoflowergastrointestinalbleeding.Arteriographyshouldbereservedforthosepa-tientswithmassive,ongoingbleedingwhenendoscopyisnotfeasible,orwithpersistent/recurrenthematocheziawhencolonoscopyhasnotrevealedasource.Thereisnoroleforbariumenemaintheevaluationofacute,severehematoche-Theresultsofthelargestclinicalseriesusingcolonos-copyintheevaluationofacutelowergastrointestinalbleed-ingaresummarizedinTable2.Theoverallyieldofcolonos-copyrangedfrom69±80%(13,16±18).Thestandardmethodofevaluationintheseserieswastoperformano-scopyorretroflexedviewofthedistalrectumtoexcludeananorectalbleedingsource,thenproceedingproximallyuntilthelesionresponsibleforbleedingwasencountered.InthelargestclinicalseriesbyRossinietal.,totalcolonoscopywasnecessaryinonly133of409cases(33%);ableedinglesiondistaltothececumwasencounteredintheothercases.Themostcommonsiteofbleedingwastheleftcolon,andthemostcommonlyencounteredlesionswereulceratedcarcinomasanddiverticulardisease(16).Itmustberemem-beredthatvisualizationofanonbleedingsite(.,nonbleedinghemorrhoidsordiverticulum)doesexcludethepresenceofmoreproximalpathology.Colonoscopyisgenerallysafeinthesettingofacutelowergastrointestinalbleeding,aslongasthepatienthasbeensufficientlyresuscitatedbeforetheprocedure.Ofthe549colonoscopicexaminationssummarizedinTable2,onlyoneendoscopiccomplication(perforationofadiver-ticulum)wasreported.Intwoofthesefourclinicalseries,acolonicpurgewasadministeredbeforeendoscopicexami-nation;intheothertwoseries,colonoscopywasperformedwithoutpriorpreparation.Thecolonicpurgeusedintheseclinicalserieswaspolyethyleneglycolsolutionover2h,untiltheeffluentwasclear.Anasogastrictubecanbeusedtoadministerthissolutionifthepatientisunabletotolerateitbymouth.Therearenodatatosuggestthatacolonicpurgewillreactivateorincreasetherateofbleeding.TherearenostudiesindicatingtheexactoptimumtimingofColonoscopyintheEvaluationofLowerGIBleeding SeriesNo.ofPatientsAverageAgeColonicPurgeYield(%)MostCommonBleedingLesionRossini(16)409NRNo76UlceratedcancerJensen(13)8065Yes74VascularectasiaCaos(17)35NRYes69DiverticulardiseaseForde(18)25NRNo80Diverticulardiseasenotreported.AJG±August1998MANAGEMENTOFACUTELOWERGIBLEEDING1205 medicinescanningcomparedwithcolonoscopy,theneedtotransportthepatienttotheradiologysuite,andthepossibleinaccuratelocalizationofthesiteofbleeding,itisreason-abletorecommendcolonoscopyovernuclearmedicinescanningasthetestofchoiceforstructuralevaluationofthepatientwithacutelowergastrointestinalbleeding.Onepos-sibleroleforthistechniqueisasascreeningtestimmedi-atelybeforearteriography,aspatientswithanegativebleed-ingscanwillgenerallyhaveanegativearteriogramatthatpointintime(37).However,apotentiallimitationtothisapproachisthatinthetimerequiredtoperformthenuclearmedicinescan,thepatientmaystopactivelybleeding,elim-inatingtheopportunityforarteriographytohavedefinitivelylocalizedthebleedingsource.Norandomizedtrialscomparetheefficacyofarteriographyalonetoarteriographypre-cededbynuclearmedicinescanninginthepatientwithactivelowergastrointestinalbleeding.Patientswithpersistentorrecurrentlowergastrointestinalbleedingmayrequiresurgery.Accuratepresurgicallocal-izationofthebleedingsiteimprovespostoperativemorbid-ityandmortalityInareviewbyMcGuire,82of108episodes(76%)ofacutelowergastrointestinalbleedingduetodiverticulardiseasestoppedspontaneously.Virtuallyallpatientsrequir-4Uofbloodtransfusionina24-hperiodspontane-ouslystoppedbleeding.However,forpatientsrequiringUofbloodinthattimeperiod,thelikelihoodofsurgerywas60%.Inthosepatientsinwhomthebleedingsitewasiden-tifiedpreoperatively,only4%ofpatientssubsequentlyex-periencedrecurrentbleedingfromanothercolonicdivertic-ulum.However,insevenpatientswithoutpreoperativelocalizationundergoingcolectomyandileoproctostomy,fourdevelopedanastomoticleaks,withamortalityof29%(10).Otherserieshavenotedsignificantmorbidityandmortalitywithsubtotalªblindºcolectomyfortreatmentofmassivebleedingwherepreoperativelocalizationofthebleedingsitewasunsuccessful(38,39).Udenetal.alsofoundthatpreoperativestudieslocalizingthesiteofcolonicbleedingallowedlimitedresection,withreducedmortality(40).Useofendoscopicandradiologicstudiesinanattempttolocalizethesiteofbleedingshouldbeperformedinallcasesoflowergastrointestinalbleeding,withtheveryrareexceptionofexsanguinatingcolonicbleeding,whereimme-diatesurgery(andusuallysubtotalcolectomy)mustbeIncasesoflowergastrointestinalbleedingwherenoplausiblecolonicsourceisidentified,evaluationofthesmallbowelmaybenecessary.EvaluationforaMeckel'sdiverticulumshouldbeperformedinyoungerpatientswithacutelowergastrointestinalbleeding.EnteroscopyandsmallbowelradiographymayalsobeperformedinthepatientinwhomactivebleedinghasceasedTherearecircumstancesinwhichanuppergastrointesti-nalsourceofbleedinghasbeenruledout,andcolonoscopyrevealsnoplausiblesourceofbleedingfromthecolon.Asmallbowelbleedingsourceshouldbesought.Furtherevaluationdependsupontheclinicalsituation.Incircum-stancesofcontinuedorrecurrenthematochezia,arteriogra-phy(withorwithoutantecedentnuclearmedicinescanning)maylocalizethebleedingsite.Insomecircumstancesinwhichbleedingisongoingandtheaforementionedstudiesarenegative,laparotomyandintraoperativeendoscopymaybeindicated.Incircumstanceswherehematocheziahasceasedandvitalsignshaveclearlystabilized,otherstructuralstudiesofthesmallintestinemaybeundertaken.Endoscopicevalua-tionofthesmallintestineisfrequentlyaccomplishedwithªpushºenteroscopy,wherealongcolonoscopeordedicatedendoscope(insertiontubelength160±300cm)isadvancedperosintothesmallintestine.Pushenteroscopyconferstheadvantageofbiopsyofmasslesionsortherapyforbleeding.InaclinicalseriesbyFoutchetal.,38%ofpatientswithbleedinghadalesionidentifiedinthedistalduo-denumorproximaljejunumonpushenteroscopy.Vascularectasiasweremostcommon(41).Therearenodataontheuseofthistechniqueintheevaluationofacute,hemody-namicallysignificantlowergastrointestinalbleeding.Sondeenteroscopyinvolvespassivemigrationofasmalldiameterendoscopethroughthesmallintestine;examinationoccursastheendoscopeiswithdrawn.Asondeenteroscopemaymigratefurtherintothesmallintestine;however,thistech-niqueoffersalimitedviewoftheluminalsurfaceduetoalackoftipdeflection,andnotherapyorbiopsycanbeperformed.Again,mostclinicalexperiencewiththistech-niqueisfortheevaluationofMeckel'sdiverticulumshouldalwaysbeconsideredinyoungerpatientswithlowergastrointestinalbleeding.Thereportedsensitivityandspecificityratesfornuclearmedi-cinescanningforMeckel'sdiverticulumare85%and95%respectively(42±44).Theselesions,aswellassomeotherstructurallesionsofthesmallintestineincludingmassle-sions,ulcers,andCrohn'sdisease,maybedetectedbybariumcontraststudiesofthesmallintestine.Theliteraturesuggeststhatsmallbowelenematechniques(enteroclysis)mayhaveanincreaseddiagnosticyieldoverstandardsmallbowelfollow-throughseries(45,46). Reprintrequestsandcorrespondence:GregoryZuccaro,Jr.,M.D.,De-partmentofGastroenterologyDeskS-40,ClevelandClinicFoundation,9500EuclidAvenue,Cleveland,OH44195.1.EbertRV,SteadEA,GibsonJG.Responseofnormalsubjectstoacutebloodloss.ArchInternMed1941;68:578.2.CommitteeonTrauma,AmericanCollegeofSurgeons.Advancedtraumalifesupport.5thed.Chicago:AmericanCollegeofSurgeons,3.PumpheryCW,BeckER.Raisedbloodureaconcentrationindicatesconsiderablebloodlossinacuteuppergastrointestinalhemorrhage.BrMedJ1980;280:527.4.SnookJA,HoldstockGE,BamforthJ.Valueofasimplebiochemicalratioindistinguishingupperandlowersitesofgastrointestinalhem-orrhage.Lancet1986;2:1064.AJG±August1998MANAGEMENTOFACUTELOWERGIBLEEDING1207