The Use of Octreotide in Refractory Gastrointestinal Bleeding Due to Crohnʼs Disease

Abstract

A 36 year male with history of Crohn's disease complicated by anal stricture and anorectal fistula presented to the emergency department with one day of severe rectal bleeding. His Crohn's disease was diagnosed at age six and he underwent a left hemicolectomy at age 14. He had been treated with mesalamine, adalimumab, infliximab with 6-mercaptopurine in the past, and was currently being treated with vedolizumab. On presentation to the emergency room he was tachycardic. His abdomen was mildly distended with decreased bowel sounds. His labs were significant for leukocytosis (WBC 16.9) and anemia (Hemoglobin 10.8 g/dL). A CT scan showed nonspecific colitis and narrowing of the mid descending colon. He was treated with intravenous levofloxacin and metronidazole and after unremarkable stool cultures, intravenous methylprednisolone was added. He continued to have hematochezia and his hemoglobin continued to drop (7.4 g/dL, followed by 6.9 g/dL). He was transferred to the medical intensive care unit and was transfused four units of packed red blood cells. He was then started on intravenous octreotide 50 mcg/hr. After starting octreotide no further episodes of bleeding occurred. Repeat hemoglobin was 11.1 g/dL and remained stable. Colonoscopy was performed which showed skip areas of ulceration including the rectum and ileocecal valve. The intravenous octreotide was continued for a total of 72 hours. The patient was discharged home and has had no further episodes of bleeding. Octreotide is an analog of somatostatin. It is known to decrease splanchnic blood flow, and it may have a local vasoconstrictive effect. For these reasons it is a Class 1, Level A recommendation for patients with esophageal variceal bleeding (1). The effect of octreotide on other types of gastrointestinal bleeding is less clear. Andrews et al reported a patient with severe hematochezia due to CMV colitis who continued to bleed despite ganciclovir, but stopped bleeding after initiation of octreotide (2). Our case is the first reported use of octreotide to control lower gastrointestinal bleeding due to severe Crohn's colitis. Considering its safety profile, octreotide may be considered in patients with refractory lower gastrointestinal bleeding. Further randomized control trials are warranted.