Massive Lower GI Bleeding Research Articles

S2105 Isolated Cecal Varices: A Rare Cause of Hematochezia

INTRODUCTION: Ectopic varices (outside gastro-esophageal region) are uncommon in patients with portal hypertension (PH) and account for 5 % of all variceal bleeding cases. Isolated cecal varices (ICV) without pancolonic varices are extremely rare with only handful of cases reported so far. Here we present a case of bleeding from ICV in patient with alcoholic cirrhosis. CASE DESCRIPTION/METHODS: A 55-year-old male with history of alcoholic cirrhosis (last alcohol use 1 y ago), CKD3 was admitted with 1 day history of hematochezia and dizziness. Hemoglobin on admission was 5.8 gm/dL, platelet 126 b/L and INR 1.4. After initial resuscitation, he underwent EGD which revealed non-bleeding grade 2 esophageal varices which were banded. He continued to have hematochezia. He subsequently underwent colonoscopy which revealed a 4 cm area of granularity in cecum. This area was biopsied following which sudden spurting of blood was seen. He was sent for emergent abdominal CT angiography, which came back negative for active arterial bleeding. Retrospectively, the area of granularity in cecum was thought to represent an ICV. There was spontaneous cessation of bleeding and the patient was discharged in next few days. Two months later, he presented to our hospital for similar episodes of lower GI bleeding. EGD showed non-bleeding grade 1 esophageal varices. Due to suspected bleed from ICV, patient was taken for emergent TIPS. Mesenteric angiogram showed contrast extravasation from a large cecal varix. TIPS and coil embolization of cecal varix was performed resulting in hemostasis. DISCUSSION: Ectopic varices occur in the small intestine, biliary system, colon, rectum, and surgical ostomy sites and can develop in the setting of PH, prior abdominal surgery, vascular thrombosis, or anomalies of the venous outflow vessels. ICV without pancolonic involvement are extremely rare as less than 20 cases have been reported so far in English literature. Almost all the reported cases have presented with massive lower GI bleeding. Usually EGD is performed to rule out more common upper GI bleeding from esophageal varices. CT angiography may be obtained but extravasation may only be seen in the venous phase. No- bleeding ICV can be missed on colonoscopy as over-insufflation can cause the collapse of such varices. Exsanguinating ICV are usually treated by performing emergent TIPS with or without adjunctive variceal embolization.Figure 1.: Colonoscopy showing area of granularity in cecum representing cecal varix (left). Active bleeding seen when this area was mistakenly biopsied (right).Figure 2.: Abdominal angiogram showing large isolated cecal varix with extravasation of contrast.Figure 3.: Fluoroscopic image showing coil embolization of the cecal varix.

Lower Gastrointestinal Bleeding Caused by Meckel’s Diverticulum

Meckel’s diverticulum is a congenital anomaly of gastrointestinal tract with an incidence of 2% in the general population. It occurs due to the persistence of omphalomesenteric duct during embryonic period of life. It may be asymptomatic or can manifest as intestinal obstruction or massive lower GI bleeding. It usually presents before the age of 2 years and may contain ectopic tissue. Here, we are reporting a case of 7-year-old child with Meckel’s diverticulum presenting as painless bleeding per rectum and anemia.

Abdominal Pain, Hypotension With Rectal Bleeding: A Unique Presentation of Emphysematous Cholecystitis From Squamous Cell Carcinoma of Gallbladder (GB)

Carcinoma of GB is a rare tumor which presents significant diagnostic challenges. We present a case of an elderly woman who presented with abdominal pain and hematochezia was found to have septic shock from emphysematous cholecystitis in the setting of squamous cell carcinoma of the gallbladder. A 70 year old woman with past medical history of hypertension, anemia, CKD Stage III and DVT on warfarin presented with diffuse abdominal pain and bright red rectal bleeding. Her initial blood pressure was 74/38 mm hg with significant epigastric tenderness on exam. Rectal exam revealed hematochezia. Labs revealed hemoglobin of 9.7 g/dL. Initially believed to have lower GI bleed in the setting of supratherapeutic INR (3.1) she was transfused fresh frozen plasma and packed red blood cells. In view of significant epigastric tenderness CT scan of abdomen was done which revealed a markedly distended stone-containing GB with wall thickening, fat stranding and gas anteriorly dependent within the GB concerning for emphysematous cholecystitis. She was treated with IV antibiotics with emergent cholecystectomy. Pathology of the GB was significant for poorly-differentiated squamous cell carcinoma with positive cystic duct lymph node and acute cholecystitis with cholelithiasis. Cancer of the GB is an uncommon malignancy comprising just 0.6% of all new cancer diagnoses, and just 3.7% of all new digestive system cancer diagnoses in 20161. Histologic subtypes include adenocarcinoma, and squamous/adenosquamous carcinoma with an incidence of 90% and 1.7-12% respectively. Occurring primarily in the elderly with a 3:1 predominance in women3,4, GB carcinoma is a highly aggressive disease entity. Due to the lack of typical presenting symptoms GB cancer is usually diagnosed in advanced stages. In certain instances, patients may present with complaints of abdominal pain, nausea and vomiting and are eventually diagnosed with cholecystitis as the tumor obstructs outflow of bile. Aim of treatment is surgical resection when possible. Our case was clinically challenging as the initial presentation was consistent with massive lower GI bleeding but the CT scan of the abdomen helped us reach to the correct diagnosis and treatment. It is important for physicians to think of a broad differential diagnosis as sometimes the disease presentation is not straight forward like in our case where in the presenting complaint of rectal bleeding eventually led to a diagnosis of squamous cell cancer of GB.1241_A.tif Figure 1: Axial view of emphysematous gallbladder with foci of anteriorly dependent air.1241_B.tif Figure 2: Coronal view of markedly distended gallbladder with multiple stones, irregularly thickened wall and pericholecystic fluid.

J-Pouch Ectopic Varices: A Rare Cause of Lower GI Bleed

Variceal bleeding is a life-threatening complication of portal hypertension in patients with cirrhosis. Varices are portosystemic venous shunts that arise as a result of portal hypertension, most commonly located in the gastroesophageal (GE) area. Ectopic varices (ECV) are enlarged portosystemic venous collaterals located anywhere outside of the GE region. ECV bleeds are uncommon but can lead to significant morbidity and mortality. We present a rare case of lower GI bleeding from a small bowel varix in a J-pouch. A 34-year-old female with a history of ulcerative colitis status post total proctocolectomy with ileal pouch-anal anastomosis (IPAA or J-pouch) and primary sclerosing cholangitis with compensated cirrhosis was transferred to our hospital for an overt, obscure GI bleed. She initially presented to an outside hospital (OSH) with hematochezia and syncope. EGD, push enteroscopy, pouchoscopy, and capsule endoscopy at the OSH all failed to find the source of bleeding. Due to continued overt bleeding requiring 14 U of packed RBCs over 10 days, she was transferred to our medical center. Repeat EGD found no blood and no gastroesophageal varices. Pouchoscopy revealed red blood and clots in the J-pouch, but normal underlying mucosa and no obvious source of bleeding. A tagged RBC scan was positive for bleeding localized to a loop of small bowel in the right lower quadrant. CT-angiogram demonstrated a large ectopic venous collateral adjacent to the IPAA (Fig. 1) which was supplied by the superior mesenteric vein and drained by the right gonadal vein (Fig. 2), consistent with a small bowel varix. This ECV was the most likely cause of her recurrent bleeding. She underwent TIPS with reduction of portosystemic gradient from 25 to 11 mmHg and significant decompression of the ECV, rendering selective embolization unnecessary. She was discharged 5 days later and had no further bleeding at a 2 month follow-up visit. ECV account for 1-5% of all variceal bleeding episodes. Small bowel varices are most commonly seen in patients with portal hypertension and prior abdominal surgery. A triad of portal hypertension, hematochezia without hematemesis, and previous abdominal surgery should prompt evaluation for small bowel varices via CT scan with both arterial and venous phases. This case illustrates that, although rare, small bowel varices can present as massive lower GI bleeding and require a multidisciplinary approach with therapy tailored based on institutional expertise.Figure: CTA venous phase showing large venous collateral adjacent to J-pouch consistent with small bowel varix.Figure: Venogram illustrating enlarged superior mesenteric vein (SMV) filling varix with outflow tract through the right gonadal vein (R Gonadal V.).

Stromal tumour of the ileum: An unusual cause of massive gastrointestinal bleeding

Background: Gastrointestinal stromal tumour are rare gastrointestinal tumour that probably originate from the interstitial cells of Cajal and 95% express a specific molecular marker. They occur most commonly in the stomach (60%) followed by the small intestine (30%) and may present with gastrointestinal bleeding. Case Report: A 40year old man presented with passage of frank blood per rectum with associated haemodynamic instability necessitating several units of blood transfusion. Following adequate resuscitation, lower and upper GI endoscopy done were negative and subsequently had emergency laparotomy for continued gastrointestinal bleeding. We found a bleeding ileal tumour which was resected. Histopathology confirmed gastrointestinal stromal tumour. Conclusion: small bowel stromal tumour rarely and unusually presents with massive lower GI bleeding. Diagnosis may be delayed due to inaccessibility of the small bowel to routine upper and lower GI endoscopy. Mesenteric angiography, radionuclide RBC, capsule endoscopy, push enteroscopy depending on the fitness of the patient, may aid diagnosis. Prompt surgical resection and adjuvant imatinib therapy for malignant variants is the treatment of choice.

Arterio-colonic Fistula Secondary to Radiation-induced Large Bowel Necrosis

Introduction: Massive lower GI bleeding can be life threatening, especially when the source of bleed is not controlled. In this case, the large bowel was found to be necrotic due to intracolonic tamponading by blood from an ileac artery--colon fistula. Case Presentation: A 60-year-old woman was brought to ED after a pre-syncopal episode following a bloody bowel movement with cramping abdominal pain. She had history of Hodgkin's and non-Hodgkin's lymphoma s/p chemotherapy, stem cell transplantation and external beam radiation.The excised left external iliac lymph nodes had shown spread of malignancy. She was on warfarin for recurrent DVTs. She was afebrile, with BP 80/62 mmHg and PR 106/min. Her abdomen was distended with diffuse tenderness, and bowel sounds were present. Labs showed Hct: 25% (baseline 32%), Hgb: 8.5 g/dl, WBC: 14,000/mm3, platelets: 560,000/mm3, INR: 3.4, BUN: 23, creatinine: 1.0 and ALP: 350. The last colonoscopy was positive for hemorrhoids and adenomatous polyps that were resected. In the ICU, anticoagulation was reversed. History of malignant spread to the region prompted consideration of radiotherapy as the cause of colitis or bowel necrosis. The patient did not tolerate the colonoscopy preparation. Tagged RBC scan demonstrated bleeding in the left colon. CT revealed free fluid with a massively dilated colon. Angiography, however, showed no extravasations. Overnight, she developed signs of peritonitis, mandating an emergent laprotomy. Ascending colectomy was performed for a non-perforated necrotic right colon distended with fresh blood and clots. Post operatively, she became pressor dependent, the wound VAC drained frank blood, hematocrit dropped further, and ten units of PRBCs were transfused in total. Repeat laprotomy showed blood in the abdomen with massively dilated and necrotic left colon. Pressure on the left common iliac artery controlled the bleeding. Intra-operatively, a fistula was found between the left external iliac artery and the friable left colon; this was cauterized. A femoro-femoral graft was constructed and the rectal stump was connected to a drain. Discussion: The prevalence of iliac artery-enteric fistulas is not well documented. They are described mostly secondary to malignancies and radiotherapy. In this case, radiotherapy for metastatic lymph node disease led to bowel necrosis and fistula formation. Selective mesenteric angiography is insufficient to demonstrate bleeding from the iliac arteries, but in our case, a negative preoperative angiogram was also due to a blood tamponaded colon. Suspected early, bowel necrosis could have been prevented. Definitive management entails bowel resection, arterial ligation and extra-anatomic bypass.

Letter to the Editor: A Case of Behçet's Disease with Massive Lower Gastrointestinal Bleeding

1 with great interest. They presented a 30-year-old man case of Behcet's disease who came with massive gastrointestinal bleeding. Laparotomy was needed after unsuccessful angiography. We would like to share our experience of Behcet's disease case very similar to the Kim et al's case report. Our patient was a 43-year-old man with known Behcet's disease since 4 years ago on colchicine who presented with massive lower GI bleeding. Blood pressure was 90/70 mmHg, respiratory rate 22/minute, heart rate 120/minute. On admission, hemoglobin was 9 g/dL. So 1 bag packed cell and 2 liters normal saline 0.9% were administered. The patient was conscious. Upper endoscopy was normal, so in the next step colonoscopy was performed which showed too much blood and clots only in the lumer to see the muosal lesion. Angiography was not available in our center. However, massive lower GI bleeding was continued, so he was taken for exploratory laparotomy and total colectomy with end ileostomy was performed. During laparotomy colon was full of blood. Pathology of colon showed neutrophilic infiltration. The complications of Behcet's disease, which most frequently require surgery, are perforation and bleeding. 2 The aim of writing this letter was to say that in patients with Behcet's disease who came with severe and persistent rectal bleeding, total colectomy might be necessary especially in centers without necessary equipments.

Isolated, Idiopathic Splenic Vein Thrombosis, Presenting with Massive Lower GI Bleeding.

Isolated, also called idiopathic, splenic vein thrombosis (SVT) is a very rare clinical condition, which usually results in left-sided portal hypertension and isolated fundal varices. This syndrome is a rare cause of mostly upper, gastrointestinal bleeding. There are only a few hundreds of cases reported in the literature. Colonic varices are even much rarer, 0.07% post mortem autopsies, and 0.2% in a prospective large endoscopic trials. Pancreatic disorders, including malignancies are the most common underlying causes for SVT. Congenital aneurysm of the splenic vein is one of the theoretical explanations of the Isolated, Idiopathic SVT.Case report: A 53 year old Caucasian female with history of hypertension, and no history of smoking or alcohol abuse, presented with chronic lower gastrointestinal bleeding. Upper endoscopy and flexible colonoscopy revealed perigastric varices without any source of acute bleeding. A bleeding scan demonstrated marked splenomegaly and source of bleeding from left colon. Mesenteric angiogram during venous phase showed splenic vein thrombosis and extensive perigastric varices. In addition, a single large left colonic varix from the lower pole of the spleen was identified as the source of bleeding. The patient was treated with splenic artery embolization with coils, followed by splenectomy, without any major complication. Coagulation studies 8 weeks after the procedure did not show any hypercoagulable state.Conclusion: The Isolated, Idiopathic SVT, itself is a very rare syndrome. Our center has reported four cases of SVT, secondary to medical conditions, such as; pancreatic malignancy, MRSA sepsis, and multi-organ failure. Upper gastrointestinal bleeding has been more frequently reported than lower bleeding. Interestingly, in our case report, a single colonic varix secondary to SVT was proved to be the cause of chronic lower gastrointestinal bleeding. SVT should be suspected in any patient with a triad of gastric varices, splenomegaly, and normal liver function tests, who presents with gastrointestinal bleeding secondary to left sided or so called “sinistral” portal hypertension. Mesenteric angiography with venous phase is the gold standard for the diagnosis of SVT, as endoscopic studies may not be diagnostic of this syndrome. Splenectomy is the only and definitive procedure of choice in the patients with isolated SVT, followed by post splenectomy vaccination.

Massive Lower GI Bleeding from an Uncommon Source

Massive Lower GI Bleeding from an Uncommon Source

INTESTINAL TUBERCULOSIS PRESENTING WITH SEVERE LOWER GI BLEEDING

A 28-year-old Vietnamese woman who immigrated to the US in 1993 presented to the ED with 5 days of LLQ abdominal pain and 5 bloody bowel movements in the past day. She felt feverish and had some nausea and vomiting. She lost several pounds in the past few weeks. She had no prior history of GI bleeding or abdominal pain or diarrhea. Her only medical history was a vaginal delivery one year ago and possible reactive PPD in the past. She smoked, drank 2 beers a month, and denied illicit drug use. She had no travel since 1993, but did have food items shipped from Vietnam. Her only family history was a brother who had a renal transplant in 1993. On exam, she had a temperature of 99.6° F, pulse of 108, and blood pressure of 91/51. She was awake and alert. Pertinent findings of physical exam included tachycardia, a clear chest, hyperactive bowel sounds, mild upper abdominal tenderness, and streaks of dark red blood on rectal exam. Labs included a hemoglobin of 9.1 that dropped to 4.9 over 6 hours and normal liver injury tests, coagulation factors, white cell count, and platelet count. Obstruction series showed mildly dilated loops of distal small bowel and reticular opacities in the upper lung fields. Stool culture and O&P were normal. A colonoscopy was performed and showed nodular, erythematous mucosa with ulcerations around the ileocecal valve. The remainder of the cecum and terminal ileum appeared normal. Biopsies were obtained. The endoscopic findings were suggestive of Crohn's disease, but given the abnormal chest radiography and possible history of reactive PPD, TB was also considered. Biopsies were sent for pathology and bacterial and AFB stains and cultures. The histology showed chronic inflammatory changes, submucosal noncaseating granulomas, and crypt abscesses. Pulmonary evaluation for underlying TB included a CT of the Chest showing cavitary areas in upper lobes. Bronchoscopy was normal and bronchial washings had negative AFB staining and culture. Colonic tissue staining for AFB was negative. Colonic tissue culture grew Mycobacterium tuberculosis by nuclear hybridization. Cases of TB have risen in the US in the past 15 years, but intestinal tuberculosis remains very uncommon, and massive lower GI bleeding is an uncommon presentation for intestinal tuberculosis. It is often difficult to distinguish from Crohn's disease. The diagnosis requires high clinical suspicion and diligent evaluation with multiple biopsies.

Rectal Dieulafoy’s lesion presenting as massive lower GI bleeding

Rectal Dieulafoy’s lesion presenting as massive lower GI bleeding