S2103 Endoscopic Management of Massive Lower GI Bleeding in the Setting of Refractory Pan-Ulcerative Colitis and New Decompensated Alcoholic Cirrhosis

Abstract

INTRODUCTION: Ulcerative colitis (UC) is an inflammatory disorder that affects the colonic mucosa. Treatment is based on disease severity. Surgical colectomy is considered for refractory disease. We present a case of massive, acute lower GI bleed from refractory ulcerative pancolitis (UP) in the setting of newly-diagnosed, decompensated alcoholic cirrhosis. CASE DESCRIPTION/METHODS: 32-year-old male with UP presented with a 5-day history of hematochezia, right upper quadrant pain, and jaundice. He previously failed treatment of prednisone, mesalamine, azathioprine, adalimumab, vedolizumab, infliximab, and ustekinumab. Lab work was significant for AST 361U/L, ALT 103U/L, alkaline phosphatase 211U/L, direct bilirubin 11.9 mg/dl, hemoglobin 7.4 gm/dl, and WBC count 15 × 109/L. New diagnosis of cirrhosis was suspected on computed tomography (CT) and confirmed, with acute alcoholic hepatitis, on liver biopsy. Hematochezia continued; however, prednisone was held due to infection concerns. He acutely decompensated 6 days later requiring vasopressors for multiorgan failure and shock. He developed severe hematochezia 5 days after decompensation from active sigmoid arterial (SA) bleed seen on CT angiography (Figure 1), unresponsive to transfusion and SA embolization. Emergent colectomy was considered; however, post-operative mortality risk was deemed too high due to decompensated cirrhosis (DC). Emergent flexible sigmoidoscopy (Figure 2) showed diffusely friable mucosa with actively bleeding pseudopolyps. Partial hemostasis was achieved with epinephrine and clip placement to culprit pseudopolyps. Patient clinically improved, vasopressors were weaned off and orthotopic liver transplant (OLT) evaluation was initiated. One-week after acute bleed, he underwent OLT. Total colectomy with end-ileostomy was performed 5 days after OLT. He was discharged to acute rehabilitation facility and has good liver graft function at 2-month follow up. DISCUSSION: DC and related coagulopathy caused significant UC-related pseudopolyp bleeding. With history of failed medical therapy and predilection for hemorrhage, colectomy is preferred management. However, with DC, post-operative mortality risk approached 90%. Endoscopic intervention is unlikely to alter management in severe UC bleed and poses perforation risk from insufflation. However, endoscopic management led to temporary hemostasis, which helped patient globally recover and undergo OLT. Colectomy for refractory UC was then safely performed.Figure 1.: Area of irregularity with increased density located at the rectosigmoid junction and within the rectum which demonstrates active arterial and possible venous bleeding.Figure 2.: Severe colitis throughout the sigmoid colon characterized by linear ulcerations, and friable mucosa with multiple pseudopolyps, some of which were oozing. Three pseudpolyps with active arterial oozing were treated with epinephrine and endoclips, with good effect.