Massive Lower Gastrointestinal Bleeding Research Articles

Adjunctive endoscopic clip marking enhances non-operative management of massive lower gastrointestinal bleeding.

Massive lower gastrointestinal bleeding (LGB) is common especially in elderly patients. Controversy in the approach to management stems from location of bleeding and morbidity of surgery. Colonic diverticula disease (CD) is the leading cause of painless haematochezia and haemodynamic instability. The use of a novel technique of endoscopic pre-marking (EPM) with radiopaque metal clips to localize is described. EPM guided superselective active transarterial embolization (A-TAE) when active vascular blush was seen. When no active contrast extravasation was seen, EPM also guided prophylactic superselective transarterial embolization (P-TAE). From May 2004 to December 2021, there were 36 patients with massive LGB from diverticular disease encompassing 44 separate bleeding episodes. Spontaneous haemostasis was observed in 18.2% (8/44). The overall success rate in non-operative management was 83.3% (30/36) patients. Three patients proceeded for emergency surgery. Of the 36 patients, six patients had documented EPM followed by TAE due to recurrent bleed in the same episode. A-TAE was performed in two patients. P-TAE was performed in the four patients without active contrast extravasation. Initial haemostasis was successful in five out of six patients. One patient failed embolization and proceeded to emergency surgery. Three months later, one patient encountered late rebleeding and was scheduled for elective colectomy. None of the six developed intestinal infarction from embolization. The 30-day mortality was 0%. A consistent approach to LGB and defined protocol of endoscopic haemostasis, with routine EPM and embolization, has the potential to mitigate the morbidity and mortality in this group of vulnerable patients.

MID ILEAL DUPLICATION CYST WITH ECTOPIC GASTRIC MUCOSA DETECTED BY TECHNETIUM-99M PERTECHNETATE

Gastrointestinal duplication cysts are a rare congenital malformation in the gastrointestinal tract, most commonly seen in the ilium. The present study reported a child with a mid ileal duplication cyst ofthe ectopic gastric mucosa that was diagnosed by Technetium-99m pertechnetate single-photon emission computed tomography-computed tomography (SPECT-CT) scintigraphy. Gastrointestinal duplication cysts can present with massive lower gastrointestinal bleeding in early childhood Technetium-99m pertechnetate (Meckel scan) with SPECT-CT can help reach the diagnosis and decrease morbidity and mortality.

Cytomegalovirus colitis in an immunocompromised patient presenting with massive lower gastrointestinal bleeding.

A 48-year-old man with HIV infection (CD4 count = 84 cells/μL) experienced hematemesis and hematochezia. Colonoscopy revealed massive bleeding in the colon, in which the source of the bleeding could not be identified. A total colectomy was performed. A large superficial ulcer at the rectosigmoid colon was observed. Histologically, abundant cytomegalovirus (CMV)-infected cells were noted. The pathological diagnosis was CMV colitis.

Is Urgent Diagnostic Colonoscopy still Necessary in Lower Gastrointestinal Bleeding?: A Retrospective Study from 2 Centers of Ramathibodi Hospital

Background: An urgent colonoscopy within 24 hours in acute lower gastrointestinal bleeding (LGIB) is now controversy with limited of benefit compare to elective colonoscopy. An alternative modality such as CT angiogram or CT whole abdominal has play an important role in diagnosed and localised bleeding site in emergency setting. Objective: This study is aim to report a descriptive data of incidence and prevalence of acute LGIB and therapeutic modality from 2 centers of Ramathibodi Hospital. Materials and Methods: A retrospective reviewed of adult patients who had acute LGIB in 4 years of Acute Care Surgery service of Ramathibodi Hospital and one year service of Chakri Naruebodindra Medical Institute. An exclusion criteria were patients who had associated gastrointestinal perforation or dead on arrival. A descriptive data were analysed and reported. Results: A 127 patients were enrolled, an average age is 69 year-old. Of these, there are 74.01% admitted without hemorrhagic shock. An average hospital stay is 3 days (1 to 5). Anti-coagulant and anti-platelet usage are 40.16%. Average haemoglobin on admission is 9.69±2.43 g/dL. Overall mortality rate is 4.72%. Most common cause of acute LGIB are diverticular bleeding 34.65% and colitis 17.32%. Only 9.82% underwent urgent colonoscopy. There are 95.28%, 1.57%, 0.79%, and 1.57% of successful nonoperative management, therapeutic endoscopy, transarterial catheter embolization and surgery, respectively. Only patients who had post-polypectomy bleeding underwent urgent therapeutic endoscopy intervention. Conclusion: In hemodynamic stable, urgent colonoscopy is not mandate in routine. In acute massive LGIB which hemodynamic unstable, the CT angiography follow by arterial embolisation or urgent colonoscopy are recommend for diagnosed, localised the bleeding site, and also endoscopic intervention especially in post-procedure bleeding. Keywords: Lower gastrointestinal bleeding; Urgent colonoscope; CT angiogram; Abdominal CT scan

Ileal Dieulafoy lesion arose 15\u2009years after partial small bowel resection for meconium obstruction of the neonate: a case report

BackgroundAnastomotic or perianastomotic ulcers present with symptoms such as chronic anaemia and occult bleeding as long-term complications of bowel resection performed in infancy.Case presentationHerein, we describe a 15-year-old girl with a history of surgery for meconium obstruction without mucoviscidosis in infancy who was hospitalized with chief complaints of presyncope and convulsions. Seven hours after admission, she developed melena and went into shock. An emergency laparotomy was performed, and a Dieulafoy lesion was detected near the site of ileal anastomosis from the surgery that had been performed during infancy.ConclusionsAlthough overt massive lower gastrointestinal bleeding necessitating emergency care is rare in the long term after infant bowel resection, Dieulafoy lesions can cause serious bleeding, requiring rapid life-saving haemostatic procedures.

Rare cause of lower gastrointestinal bleeding: Iliac aneurysmo-colonic fistula after endovascular treatment.

A 59-year-old male visited our department for examination of positive fecal occult blood test. The patient was scheduled for colonoscopy. However, he was admitted to our hospital urgently for rupture of left internal iliac artery aneurysm (IIAA) (Fig. 1). IIAA was managed by coil embolization and stent graft. Two weeks after the discharge, the patient visited our department because of intermittent hematochezia. Colonoscopy revealed a submucosal tumor-like protrusion with a fistulous tract in the sigmoid colon (Fig. 2a). Computed tomography demonstrated an iliac aneurysm with thrombus and air bubbles, fistulizing to the sigmoid colon (Fig. 2b). The patient was treated by an iliac artery aneurysm resection, stent graft removal, right common femoral artery–left common femoral artery bypass, and colostomy. Although iliac aneurysmo-colonic fistula is a rare condition, it can cause acute and massive lower gastrointestinal bleeding. In addition to arterial intervention such as endovascular therapy, abdominal or pelvic surgery, pelvic malignancy, and infection are also known causes of fistula formation. For the secondary aneurysmo-colonic fistula that occurs after endovascular therapy, as in our case, surgical treatment is often selected instead of repeat endovascular treatment. Our case suggests that aneurysmo-colonic fistula should be considered as one of the differential diagnoses among acute lower gastrointestinal bleeding, in patients with a history of recent endovascular therapy in large vessels in proximity to the colon.

Rare presentation of Crohn’s Disease: Massive lower gastrointestinal bleeding

While mild gastrointestinal bleeding is common in Crohn's disease, massive gastrointestinal bleeding is extremely rare. In this case, we present a Crohn's patient who presented with massive lower gastrointestinal bleeding. A literature review of such a rare presentation in Crohn's disease will be discussed.

Massive Gastrointestinal Bleeding Due to Jejunal Diverticula in a Community Hospital: A Case Report and Review of Diagnostic and Therapeutic Options

Small bowel diverticula are rare and often asymptomatic. Severe lower gastrointestinal bleeding from jejunal diverticula is rarely reported and, therefore, should be considered a differential diagnosis in all cases of lower gastrointestinal bleeding with nonconclusive gastroscopy and colonoscopy. In this case report, we discuss a case of a 75-year-old male with massive lower gastrointestinal bleeding from jejunal diverticula. Initial gastroscopy did not reveal the source of bleeding. Repeat upper endoscopy with a pediatric colonoscope identified jejunal diverticula as the likely source of bleeding. Angiography identified the site of extravasation, and successful angioembolization was done by interventional radiology.

Pleomorphic leiomyosarcoma of colonic mesentery: an unusual cause of lower GI bleed - case report and literature review

Mesenteric masses are infrequent lesions ranging from benign cyst to aggressive malignancies and often present as diagnostic and therapeutic challenge. The mesentery is a frequent recipient of metastasis from the gastrointestinal tract, pancreas, and biliary cancers. Primary mesenteric tumours are relatively rare, mostly mesenchymal in origin and benign in nature. Examples include gastrointestinal stromal tumours and smooth muscle tumours. Pleomorphic leiomyosarcoma of mesocolon is extremely rare with a reported incidence of 1:350,000. So accurate preoperative diagnosis of mesenteric soft tissue tumours is generally difficult. It accounts for less than 1% of the malignant tumours found in colon. Leiomyosarcoma is a malignant tumour arising from smooth cell lineage. These tumours occur most commonly in middle aged individuals. We describe a case of pleomorphic leiomyosarcoma arising from the colonic mesentery in a 27-year-old male patient, with massive lower gastrointestinal bleed (LGI bleed) causing drop in haemoglobin level from 9 mg/dl to 6 mg/dl. Ultrasonography and CECT abdomen suggestive of (17.5×11.6×10.6) cm mass in left side upper abdomen in splenic hilar region. Left hemicolectomy with excision of mass with splenectomy and distal pancreatectomy done. The diagnosis was based on histopathological evaluation using immunohistochemistry (IHC). Histopathological report suggestive of pleomorphic leiomyosarcoma with SMA and vimentin positivity on immunohistochemistry but CD 34 and CD 117 were negative, differentiating it from GIST.

S3453 Cavernous Hemangioma: A Rare Cause of Massive Lower Gastrointestinal Bleeding

INTRODUCTION: Hemangiomas are benign vascular tumors that rarely occur in the gastrointestinal tract. However, only 37 cases of small intestine hemangioma were reported from 2000 to 2018. Small bowel hemangiomas may cause massive lower gastrointestinal bleeding. In this report, we present a case of massive, and recurrent lower GI bleeding caused by a cavernous hemangioma of the small intestine. CASE DESCRIPTION/METHODS: A 32-year-old man came to the ER frequent episodes of large bloody bowel movements with a drop of Hb level, and he was transferred to MICU. The upper and lower endoscopy showed a large amount of blood with clots throughout the colon with no source of bleeding. A massive transfusion (of a total of 34 units) was given. Surgery and interventional radiology recommended Superior mesenteric artery arteriography, which demonstrated brisk bleeding from a jejunal branch overlying the left upper quadrant. Embolization of the bleeding jejunal branch was performed. A few days after, the patient developed other episodes of rectal bleeding. Capsule endoscopy revealed active small bowel bleeding, originating most likely from the proximal and mid-small intestine. Small intestine resection was performed, and the specimen analysis showed a cavernous hemangioma, measuring 1.2 × 1 × 0.8 cm. DISCUSSION: Hemangiomas are benign vascular neoplasms that can appear anywhere in the body, including the GIT, and it is considered as 0.05% of all gastrointestinal tumors. The jejunum is the most common site of occurrence. Hemangiomas may be solitary or multiple. Multiple hemangiomas are usually associated with the presence of similar lesions in other organs, such as liver and skin. Hemangiomas of GIT typically originate from the submucosal vascular plexus and extend from the submucosa to the muscular layer of the intestinal wall and they may extend beyond the serosa, involving the mesenteric, retroperitoneal, or pelvic fat. Histologically, hemangiomas classified into capillary, cavernous, and mixed. Initial investigations usually include upper and lower endoscopy. However, in most cases, these investigations are normal. CT angiography, MRI, radionuclide imaging, selective angiography, double-balloon enteroscopy, and capsule endoscopy could be used to identify the lesion. Surgical resection has conventionally been used for the treatment of intestinal hemangiomas. In recent years, less invasive therapeutic interventions, such as non-surgical endoscopic treatment and minimally invasive laparoscopic surgery, have become more common.

S2189 Appendicular Ulcer- A Rare Cause of Lower GI Bleed

INTRODUCTION: Although lower gastrointestinal bleeding (LGIB) is not uncommon, appendicular ulcer as cause is extremely rare. Here, we present a case of young male who presented with LGIB due to appendicular ulcer. CASE DESCRIPTION/METHODS: 30-year-old healthy Asian male presented with loss of consciousness following 3 episodes of painless massive LGIB. On arrival, he was hemodynamically unstable which improved following immediate resuscitation with a bolus of fluids and 2 units of packed red blood cells. On examination, he was very pale, tachycardic and obtunded while abdominal examination was benign. Rectal examination showed bright red blood with no evidence of external hemorrhoids. Initial labs showed hemoglobin of 10 mg/dL. He underwent an urgent upper endoscopy and colonoscopy which showed gastric erosions and diffuse blood in the entire colon with poor visualization of the source of bleed, respectively. He underwent Meckel's scan as well as CT abdomen with negative results. Repeat colonoscopy was done on the following day which showed 7 mm ulcer at appendiceal orifice that was thought to be the source of LGIB due to increased vascularity around the orifice. He was discharged the very next day with recommendation to follow up with outpatient surgery. Due to the concern for malignancy, patient underwent partial Cecectomy and the biopsy of the surgical specimen showed an early appendicular abscess with no evidence of granulomatous findings or malignancy. DISCUSSION: Diverticulosis, angiodysplasia, inflammatory disease are the most common causes for LGIB. LGIB due to appendicular ulcer is an extremely rare cause with only few cases reported so far. Urgent colonoscopy needs to be considered in the hemodynamically unstable patient as it will offer a therapeutic intervention as well. Although it is very efficient and a safe tool for evaluation of LGIB, the chances of finding an appendicular origin bleeding is rare. Treatment needs to be individualized. Although colonoscopy hemostasis can be considered, surgical treatment plays an important role in the management of appendicular bleeding. Open or laparoscopic appendectomy can be considered for local appendicular bleeding but cecectomy , ileo-cecectomy and right hemicolectomy also needs to be considered based on the operative findings. With this case, we would like to educate about the possibility of appendicular ulcer bleedings to be considered as part of differential diagnosis of LGIB, especially in young male patients.

Colonic varices: a rare complication of pancreatic cancer

A 55-year-old man was diagnosed with pancreatic cancer of the uncus and received chemotherapy (modified FOLFIRINOX). Ten months later, he was admitted to our hospital with massive lower gastrointestinal bleeding. Contrast-enhanced CT showed ascending colon varices caused by the occlusion of the superior mesenteric vein (SMV) due to pancreatic cancer invasion. Colonoscopy revealed tortuous varices with red spots in the ascending colon. The patient received blood transfusions and was discharged; however, he was hospitalized for recurrent massive lower gastrointestinal bleeding 3 months later. During this readmission, we performed the transileocolic vein obliteration method due to SMV stenosis and the absence of an obvious shunt. He experienced an uneventful post-operative recovery, and contrast-enhanced CT after 2months revealed no recurrence of colonic varices. Ectopic varices are portosystemic venous collaterals resulting from portal hypertension occurring in any locations other than the esophagogastric region. Colonic varices have rarely been reported before. Patients with pancreatic cancer may present with gastrointestinal bleeding caused by tumor bleeding or esophagogastric varices; however, ectopic varices such as colon varices, a rare complication of pancreatic cancer, should be considered in patients with obscure gastrointestinal bleeding.

Adhesive subacute small bowel obstruction presenting with gross rectal bleeding

Abstract The pathogenesis of massive lower gastrointestinal bleed (LGIB) due to angio-dysplasia and ulceration is rare and not well understood. We discuss an unusual presentation of a child with painless massive LGIB arising from chronic intestinal adhesions causing subacute small bowel obstruction and angio-dysplastic ulceration but without any clinical or radiological evidence of bowel obstruction.

CME Exam 1: An Unusual Cause of Acute Massive Lower Gastrointestinal Bleeding

CME Exam 1: An Unusual Cause of Acute Massive Lower Gastrointestinal Bleeding

Clinical Features and Outcomes of Ulcerative Colitis Complicated with Acute Massive Lower Gastrointestinal Hemorrhage

To analyze the clinical features and prognosis of ulcerative colitis(UC)complicated with acute massive lower gastrointestinal bleeding(LGIB). Methods Eleven patients hospitalized in Peking Union Medical College Hospital from January 2006 to December 2017 for treatment of UC,suffering from acute massive LGIB,were enrolled and descriptively analyzed. Results The proportion of UC patients with acute massive LGIB was 0.7% among all 1486 UC patients hospitalized during the study period.The disease was moderately or severely active in these 11 patients,among whom 9 patients(81.8%)had chronic relapsing pancolitis.Cytomegalovirus infection was present in 5 patients,among whom 4 patients received antiviral treatments.All the 11 patients received treatments including food and water fasting,rehydration,blood transfusion,and use of somatostatin.Four patients received emergency surgical treatment after the first episode of massive bleeding,and 3 of them suffered from re-bleeding after the surgery.Among the remaining seven patients,two underwent emergency total colectomy+subtotal rectectomy+ileostomy and three received elective total resection of colon and rectum or total colectomy+subtotal rectectomy+ileostomy.Thus,9 patients underwent emergency surgery,1 patient did not receive surgey during follow-up,and 1 patient was lost to follow-up. Conclusions Acute massive LGIB is a manifestation of active UC and can be associated with poor prognosis.Optimized perioperative management is important for improving the outcomes of such patients.

Finding the Dieulafoy’s Lesion: A Case of Recurrent Rectal Bleeding in an Immunosuppressed Patient

A Dieulafoy's lesion (DL) is rare cause of acute gastrointestinal bleeding defined as a vascular abnormality of the submucosa. With a high prevalence for the stomach and upper gastrointestinal tract, it is rarely observed in the lower gastrointestinal tract. Its prevalence is rare accounting for less than 2% of all cases of acute gastrointestinal bleeding. The etiology of DL is unknown. Common comorbidities include cardiovascular disease, kidney disease, diabetes, alcohol abuse, liver disease, and chronic NSAID use. Few cases involving chronic steroid use and immunosuppressive treatment have been reported. The most common diagnostic and treatment modality is endoscopy with refractory cases treated with arterial embolization by angiography. We present a case involving a patient with significant comorbidities on chronic immunosuppression with a life-threatening, massive lower gastrointestinal bleed from a DL in the rectum.

Recurrent ruptured abdominal aneurysms in polyarteritis nodosa successfully treated with infliximab.

Systemic polyarteritis nodosa (PAN) is a rare form of necrotizing vasculitis in children. Recurrent episodes of abdominal aneurysm ruptures are uncommon and life-threatening condition in children. Failures of response to immunosuppressive medications and radiological intervention also lead to high mortality. Some reports suggested that tumor necrosis factor (TNF) might have role in the inflammation of this disease. After an English-language literature review, this is the first case report in children of recurrent abdominal-ruptured aneurysms with a failure of conventional therapy but successfully treated with anti-TNF-α monoclonal antibody. We herein describe a 9-year-old girl who presented with chronic abdominal pain, hypertension, and massive lower gastrointestinal bleeding. The disease was refractory to conventional treatment, including administration of a corticosteroid, cyclophosphamide, and intravenous immunoglobulin, and recurrent-ruptured aneurysms developed in the gastrointestinal tract. Arterial embolization during angiography resulted in temporary improvement of the gastrointestinal bleeding. Infliximab, a chimeric anti-tumor necrosis factor-α monoclonal antibody, was initiated and resulted in disease remission with resolution of the gastrointestinal bleeding and abdominal pain. Anti-TNF therapy might be another treatment option for refractory disease to prevent ongoing inflammation that could lead to aneurysmal dilatation or even rupture. However, early recognition of refractory disease and aggressive treatment in the early course of the disease are crucial to reduce morbidity and mortality.

A fatal case of severe gastrointestinal and renal involvement in Henoch–Schönlein purpura

Henoch-Schönlein purpura (HSP) is an immune-complex mediated vasculitis affecting small vessels with dominant IgA deposits. It is seen mostly in children, with a self-limiting disease, but can present with more severe clinical features in older patients, such as gastrointestinal (GI) involvement, with a propensity for rapid progression. In this report, we describe our experience with a male HSP patient who presented with pneumonia, palpable purpuric rash, severe GI involvement with hemodynamic compromise and acute kidney injury. Even though we escalated therapy over time given the lack of response with each previous strategy, with corticosteroids and cyclophosphamide, he developed massive lower gastrointestinal hemorrhage that was not responsive to any supportive measure and died as a result of hemorrhagic shock. There was no established protocol that guided this treatment due to lack of rigorous data, which emphasizes the need for more studies on adult HSP in order to establish the optimal management for HSP patients with severe gastrointestinal manifestations.

Intestinal Tuberculosis Presenting as Massive Lower Gastrointestinal Bleeding: A Rare Presentation in Child

Background: Intestinal tuberculosis is a form of extra pulmonary tuberculosis that can involve any part of the gastrointestinal tract. It can present with nonspecific symptoms like chronic abdominal pain, anorexia, fatigue, fever, night sweats, weight loss, diarrhea, constipation, or blood in the stools. Acute presentation including intestinal obstruction and perforation have been reported in the literature; however massive lower gastrointestinal bleeding as one of the presenting symptom is rare. The management includes anti-tubercular drugs along with surgical intervention in acute presentation. Case characteristic: 11-year-old girl was admitted with complaints of fever and vague abdominal pain for one-week duration. Observation/intervention: The child was having recent weight loss, hypo albuminemia and strongly positive Manteaux test. Ultrasound abdomen revealed multiple pre and para aortic lymphadenopathy. The Computerised tomography (CT) guided biopsy from lymph node was planned but the child developed massive lower gastrointestinal bleeding which was managed surgically. Conclusion: The child underwent hemi-colectomy with ileostomy and intestinal tuberculosis was confirmed by biopsy. The patient was discharged home on anti-tubercular drugs with further follow up. Message: Intestinal tuberculosis should be considered as one of the differential diagnosis in a child presenting with massive lower gastrointestinal bleeding.

Dieulafoy Lesion of the Rectum

Dieulafoy's lesion (DL) is a well-recognized cause of upper gastrointestinal bleeding (GIB). DL is a dilated, aberrant, submucosal, arterial vessel usually located in the proximal stomach and duodenum. It accounts for less than five percent of cases of GIB, but can cause massive, life-threatening bleeding due to its arterial nature. The etiology of DL is unknown. Common comorbidities includes cardiovascular disease, kidney disease, diabetes, alcohol abuse and chronic NSAIDs use. The most common diagnostic and treatment modality is endoscopy. Refractory cases can be treated with arterial embolization, and uncontrollable hemorrhage may be treated with emergent resection. We present the case of a patient with life-threatening, massive lower GIB from DL in the rectum. A 59 year old female with a history of microcytic anemia, diabetes, hypertension, was admitted to the Intensive Care Unit with Goodpasture disease (GD) resulting in respiratory and renal failure. She received cyclophosphamide, prednisone, and plasmapheresis with improvement of her respiratory function, but without improvement in her kidney function. One month into admission the patient suffered a hemodynamically significant GIB requiring transfusion and admission to the ICU. Colonoscopy revealed a rectal ulcer and large fecalith. She was diagnosed with a stercoral ulcer. One week later, she was readmitted to the ICU in hemorrhagic shock and found to have a hemoglobin of 5.2 g/dl. Mesenteric arteriography showed active extravasation in the rectum. Temporary embolization using gel foam was performed which stopped active bleeding. Colonoscopy showed a single pulsatile visible artery protruding from the rectal mucosa, a DL, which was treated with injection of epinephrine and application of a single hemoclip. DL of the rectum is a very rare cause of massive GIB, described almost exclusively in case reports or case series. The pathophysiologic mechanism of these lesions is not well defined, but is thought to occur as a result of localized mucosal ischemic damage and acquired vascular ectasia which erodes through threatened mucosa. Our patient was treated with cyclophosphamide and steroids which may have contributed to poor mucosal healing predisposing her to a rectal DL. DL is often considered as a cause of upper GIB. This patient presented in hemorrhagic shock from a rectal DL causing a massive lower GIB.1931_A Figure 1. Mesenteric arteriography with contrast extravasation1931_B Figure 2. Endoscopic visualization of a rectal dieulafoy's lesion