INTRODUCTION
Although lower gastrointestinal bleeding (LGIB) is usually a self-limiting condition, severe or persistent hemorrhage occasionally requires active intervention to localize and control the bleeding point. Current investigations and nonoperative interventions (radiological and endoscopic) are successful in the majority of cases in localizing and treating the cause of the bleeding. However, on occasion the site of bleeding remains obscure and surgical exploration becomes necessary. Surgical options usually distil down to a choice between “best guess” segmental colectomy or subtotal colectomy, balancing the potential risk of rebleeding with the less extensive resection (up to 33%) against the higher morbidity and mortality (up to 57%) associated with more extensive resection or reoperation if bleeding recurs [1, 2].
We present a unique approach to the localization of obscure LGIB, which enabled targeted segmental colonic resection.
TECHNIQUE
A 51-year-old male patient with primary hyperaldosteronism and a previous cerebrovascular accident (with no neurological deficit), presented with four days of painless hematochezia, with a fall in hemoglobin from 150 to 57 g/L. He responded well to resuscitation with intravenous fluids and blood transfusions, but continued to have episodes of hypotension and hematochezia. Over the ensuing 5 days, investigations (including three computed tomography [CT] angiography studies, a technetium-99m labeled red blood cell nuclear scan, gastroscopy, and colonoscopy) failed to localize the site of the bleeding. Colonoscopy demonstrated left colonic diverticular disease and blood plus clots throughout the colon, with fresh blood in the ileum. However, the patient was reluctant to undergo surgery, and nonoperative treatment was continued until a total of 14 U of packed red blood cells had been transfused. A capsule endoscopy suggested a distal ileal source of bleeding, but no abnormality was seen on the CT studies. Given the transfusion-dependent persistent LGIB, the patient consented to an exploratory laparotomy, intraoperative enteroscopy (IOE), and repeat colonoscopy.
On laparotomy, blood was apparent in the whole colon, but not the terminal ileum, with the only abnormality on inspection and palpation of the small and large intestine being uncomplicated left colonic diverticulosis. Transoral small bowel endoscopy to 100 cm of the terminal ileum was performed using an adult colonoscope, with the aid of the operating surgeon. No mucosal abnormality was seen. On-table colonoscopy was then performed up to visualize the remaining small bowel, and once again, no mucosal abnormality was seen in the colon or small bowel. Old blood in the colon, particularly on the right side, obscured views, but no active bleeding point was seen. It was felt that the small bowel had been adequately cleared as the site of the bleeding, as views of the small bowel mucosa were excellent throughout. It was now apparent that there was an unlocalized bleeding point somewhere in the colon, with the only definite pathology being diverticular disease in the left colon. Given that there was no active bleeding, the opportunity had arisen to temporize and not proceed directly with “best guess” hemicolectomy or subtotal colectomy, with their associated high rebleeding, reoperation, and morbidity rates. A temporary end colostomy was fashioned from the proximal transverse colon, where it would normally be transected during a right hemicolectomy and the laparotomy incision closed. The distal stapled transverse colonic stump was left in the peritoneal cavity, with the idea that if further bleeding occurred, it would present from either the stoma or the anus, localizing the source to either the left or right colon.
On postoperative day 6, the patient had a large volume (800 mL) bleed and he returned to theatre. A repeat endoscopy from the stoma failed to identify the source within the colon; however, given the localization, a standard right hemicolectomy with primary anastomosis was performed. Examination of the resected specimen (Fig. 1) revealed a 2-mm Dieulafoy lesion within the ascending colon and an overlying adherent clot. This was confirmed by a subsequent histological examination, which demonstrated ulcerated overlying mucosa and ectatic vessels in the underlying submucosa.
The patient was eventually discharged home after a 25-day admission, having returned to theatre to have a fascial wound dehiscence primarily repaired. At a 6-month follow-up, there were no more ongoing wound problems and no further LGIB episodes.
Ethics statement
This study was approved by the Human Research and Ethics Committee of The Northern Hospital (No. CR08). All procedures performed were in accordance with the ethical standards of the institutional and the 1964 Declaration of Helsinki and its later amendments. Informed consent was obtained from all individual participants included in the study.
DISCUSSION
LGIB is defined as hemorrhage distal to the ligament of Treitz [2]. Obscure LGIB is defined as persistent or recurrent LGIB that has not been localized with initial investigations including gastroscopy, colonoscopy, and radiological investigations [3]. There are many approaches to the management of obscure LGIB, including radiological, endoscopic, and surgical. CT angiography has a high sensitivity (85.2%) and specificity (92.1%) for diagnosing acute GI bleeds [4]. CT angiography with blush before colonoscopy also improves the detection rate (35.7% vs. 20.6%, P=0.01), resulting in increased chances of managing this condition endoscopically [5]. Angiography and embolization can be used to manage LGIB if the bleeding has been localized, particularly for patients who are unable to tolerate colonoscopy or surgical intervention. The sensitivity of angiography in LGIB is 24% to 70% [6], but bleeding of greater than 0.5 mL/min is required for localization [7], and there is a risk of rebleeding, ischemic bowel, and renal complications [6].
Early colonoscopy in the management of LGIB is defined as an intervention within 24 hours of presentation. It remains a matter of debate due to concerns regarding inadequate visualization [2, 6], but it is safe, with complications reported to be as low as 0.6%, compared to 0.3% in elective colonoscopies [6]. The benefit of colonoscopy is that it may be both diagnostic and therapeutic, enabling the treatment of actively bleeding lesions or areas with stigmata of recent hemorrhage. Endoscopic hemostatic techniques include adrenaline injection, thermal coagulation, and endoscopic clips [2, 8], and evidence suggests that a combination of two or more techniques may be associated with lower rates of rebleeding than monotherapy [9].
IOE has been largely superseded by the introduction of less invasive enteroscopy modalities, such as video capsule endoscopy, balloon-assisted/double-balloon enteroscopy, and CT enterography [10]. The overall morbidity rate of IOE in a literature review of 309 patients was 16.8% (39 patients) with the most notable complication being ileus in 46% of patients [3]. IOE can be performed via several methods, including transoral and transanal techniques such as in our case, enterotomy, or a combination of the above [3]. Pitfalls include the time-consuming nature of the procedure, tearing of the mesentery, and abdominal distension, which may make closing the abdominal wall difficult [3].
Surgical management for obscure LGIB has decreased over time due to increased capabilities and advancements in radiological and endoscopic management [6] and is largely reserved for those with refractory LGIB despite nonoperative modalities or obscure bleeding. The mortality and complication rates in patients requiring surgery for LGIB are as high as 16% and 60%, respectively [11]. Surgical options for obscure LGIB include subtotal or segmental colectomy with or without anastomosis [12]. Rebleeding rates due to missed pathology are higher in “blind” segmental colonic resections than in those after empirical subtotal colectomy, ranging from 33% to 75%, but drop to 4% to 14% in targeted segmental colectomy after localization [8]. Therefore, patients who undergo segmental colonic resection in the presence of preoperative angiographic localization are less likely to experience rebleeding [13]. Mortality is also lower in those with segmental colonic resection (7%–22%) than in those who undergo a subtotal colectomy (20%–40%). [13, 14].
The surgical management of obscure LGIB remains challenging, particularly in patients where localization has failed despite multiple modalities. One has to balance the potential risk of rebleeding in “best guess” segmental colectomy versus the morbidity and mortality of an empirical subtotal colectomy. Greco et al. [15] analyzed the National Surgery Quality Improvement Program database and found that patients had higher risk of ileus, cardiac, and renal complications, as well as mortality (P<0.05) following total colectomy for LGIB. Our novel approach for localizing obscure LGIB has not been described in the literature before. By forming a temporary end colostomy in the proximal transverse colon where it would normally be transected during a right hemicolectomy, we were able to localize the bleeding to the right colon and avoid the morbidity associated with a subtotal colectomy. Assuming that the rectum is clear of pathology from colonoscopy, per anal bleeding would indicate a left-sided resection (Fig. 2). This should be tailored to the patient’s physiological state at time of resection and their anatomy i.e. bowel length and mobility. This technique has the drawback of necessitating further operations, particularly in patients seeking to be stoma-free. Patient selection, however, is important because the patient must be responsive to resuscitation and able to undergo a second procedure.
Patients with obscure LGIB can be difficult to manage, and there are many modalities of investigation and approaches to management. The management needs to be individualized to the patient, and it must be appreciated that significant morbidity and mortality are associated with surgical management, particularly with subtotal and blind-segmental colectomy when the bleeding cannot be localized. Our novel approach with a temporary end transverse colostomy has not been described before in the literature and offers another option in the armamentarium of the general surgeon in patients with obscure LGIB suspected from the colon. This is especially applicable to patients who are hemodynamically responsive to fluid and blood products to facilitate localization of bleeding for a subsequent targeted segmental colectomy and anastomosis.
ARTICLE INFORMATION
-
Conflict of interest
No potential conflict of interest relevant to this article was reported.
-
Funding
None.
-
Author contributions
Conceptualization: NC; Methodology: NC, NS, RH, DB; Visualization: NC; Writing–original draft: NC; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Fig. 1.Postoperative photographs. (A) A right hemicolectomy specimen opened up postoperatively with artery forceps pointing towards the Dieulafoy lesion within the caecum, without adjacent mucosal ulceration macroscopically. (B) There was an overlying adherent clot prior to cleaning of the specimen to identify the underlying lesion.
Fig. 2.Flowchart illustrating the surgical treatment of obscure lower gastrointestinal bleeding (LGIB) and the role of a temporary stoma in the localization.
REFERENCES
- 1. Drapanas T, Pennington DG, Kappelman M, Lindsey ES. Emergency subtotal colectomy: preferred approach to management of massively bleeding diverticular disease. Ann Surg 1973;177:519–26.ArticlePubMedPMC
- 2. Farrell JJ, Friedman LS. Review article: the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther 2005;21:1281–98.ArticlePubMed
- 3. Bonnet S, Douard R, Malamut G, Cellier C, Wind P. Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding. Dig Liver Dis 2013;45:277–84.ArticlePubMed
- 4. García-Blázquez V, Vicente-Bártulos A, Olavarria-Delgado A, Plana MN, van der Winden D, Zamora J, et al. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. Eur Radiol 2013;23:1181–90.ArticlePubMedPDF
- 5. Nagata N, Niikura R, Aoki T, Moriyasu S, Sakurai T, Shimbo T, et al. Role of urgent contrast-enhanced multidetector computed tomography for acute lower gastrointestinal bleeding in patients undergoing early colonoscopy. J Gastroenterol 2015;50:1162–72.ArticlePubMedPDF
- 6. Aoki T, Hirata Y, Yamada A, Koike K. Initial management for acute lower gastrointestinal bleeding. World J Gastroenterol 2019;25:69–84.ArticlePubMedPMC
- 7. Krüger K, Heindel W, Dölken W, Landwehr P, Lackner K. Angiographic detection of gastrointestinal bleeding: an experimental comparison of conventional screen-film angiography and digital subtraction angiography. Invest Radiol 1996;31:451–7.ArticlePubMed
- 8. Raphaeli T, Menon R. Current treatment of lower gastrointestinal hemorrhage. Clin Colon Rectal Surg 2012;25:219–27.ArticlePubMedPMC
- 9. Chung IK, Kim EJ, Lee MS, Kim HS, Park SH, Lee MH, et al. Bleeding Dieulafoy’s lesions and the choice of endoscopic method: comparing the hemostatic efficacy of mechanical and injection methods. Gastrointest Endosc 2000;52:721–4.ArticlePubMed
- 10. Pasha SF, Hara AK, Leighton JA. Diagnostic evaluation and management of obscure gastrointestinal bleeding: a changing paradigm. Gastroenterol Hepatol (N Y) 2009;5:839–50.PubMedPMC
- 11. Czymek R, Kempf A, Roblick UJ, Bader FG, Habermann J, Kujath P, et al. Surgical treatment concepts for acute lower gastrointestinal bleeding. J Gastrointest Surg 2008;12:2212–20.ArticlePubMedPDF
- 12. Pfeifer J. Surgical management of lower gastrointestinal bleeding. Eur J Trauma Emerg Surg 2011;37:365–72.ArticlePubMedPDF
- 13. Parkes BM, Obeid FN, Sorensen VJ, Horst HM, Fath JJ. The management of massive lower gastrointestinal bleeding. Am Surg 1993;59:676–8.PubMed
- 14. Farner R, Lichliter W, Kuhn J, Fisher T. Total colectomy versus limited colonic resection for acute lower gastrointestinal bleeding. Am J Surg 1999;178:587–91.ArticlePubMed
- 15. Greco L, Zhang J, Ross H. Surgical options and approaches for lower gastrointestinal bleeding: when do we operate and what do we do? Clin Colon Rectal Surg 2020;33:10–5.ArticlePubMedPMC
Citations
Citations to this article as recorded by
KSCP
APFCP
SIUCP-ETS
, Tessa Daly1
PubReader
Cite this Article
XML Download
