Severe Hematochezia Research Articles

Origin, Clinical Characteristics and 30-Day Outcomes of Severe Hematochezia in Cirrhotics and Non-cirrhotics.

The sites of origin, causes and outcomes of severe hematochezia have not been compared between cirrhotics and non-cirrhotics. In cirrhotics versus non-cirrhotics presenting with severe hematochezia, we aimed at (1) identifying the site and etiology of gastro-intestinal bleeding and independent predictors of bleeding from the upper gastrointestinal tract versus small bowel or the colon, (2) comparing 30-day clinical outcomes, and (3) proposing an algorithm for management of severe hematochezia. In this cohort study from two university-based medical centers, 860 consecutive patients with severe hematochezia admitted from 1995 to 2011 were prospectively enrolled with 160 (18.6%) cirrhotics. We studied (a) general clinical and laboratory characteristics of cirrhotics versus non-cirrhotics, (b) predictors of bleeding sites in each patient group by multiple variable regression analysis, and compared (c) 30-day outcomes, including rebleeding, surgery and deaths. Cirrhosis independently predicted an upper gastrointestinal source of bleeding (OR 3.47; 95% CI 2.01-5.96) as well as history of hematemesis, melena in the past 30days, positive nasogastric aspirate, prior upper gastrointestinal bleeding or use of aspirin or non-steroidal anti-inflammatory. The most prevalent diagnoses were esophageal varices (20%) in cirrhotics and colon diverticular bleeding (27.1%) in non-cirrhotics. Thirty-day rates of rebleeding, surgical interventions and deaths were 23.1 versus 15% (P=0.01), 14.4 versus 6.4% (P<0.001), and 17.5 versus 4.1% (P<0.001), in cirrhotics versus non-cirrhotics, respectively. Cirrhosis predicted an upper gastrointestinal site of bleeding in patients presenting with severe hematochezia. The 30-day rates of rebleeding, surgery, and death were significantly higher in cirrhotics than in non-cirrhotics.

Obscure Overt GI Bleed: A Case of CMV Ileitis in an Immunocompetent Patient

Obscure GI bleeding is an unidentified source of GI bleeding after a negative EGD, colonoscopy and barium small bowel follow-through. Up to 75% of these patients have a bleeding source in the small intestine. We present a patient with recurrent severe hematochezia, with negative upper endoscopy, colonoscopy and visceral angiogram, who was found to have bleeding Ileal ulcers on video capsule endoscopy with retrograde balloon enteroscopy showing bleeding vessels and pathology consistent with Cytomegalovirus. A 52-year-old male with history of Granulomatosis with Polyangiitis (GPA) and end stage renal disease (ESRD) presented with five episodes of Hematochezia. He was off immunosuppression for more than four years. Colonoscopy showed large amount of blood in the colon with moderate diverticuli but no active bleeding. A subsequent EGD was negative. Over the next 2 days, patient had multiple episodes of hematochezia. He underwent a tagged RBC scan, which showed blood in the terminal ileum but the visceral angiogram was negative for active bleeding. A video capsule endoscopy showed ulcerations in proximal to mid ileum. Retrograde balloon push enteroscopy showed ulcers at 135 cm from entry site in Ileum and two bleeding vessels were clipped. Results of ulcer biopsy showed intracellular inclusion bodies suggestive of Cytomegalovirus (CMV), which was confirmed with Immunostains and patient was started on oral Valganciclovir. CMV is known to cause severe infections in immunocompromised patients, but is usually mild and self-limiting in immunocompentent patients. CMV can involve any segment of the gastrointestinal tract, but most commonly involves the colon and small bowel involvement is rare. Most common presenting symptoms include fever, abdominal pain, diarrhea and bleeding per rectum, however massive transfusion dependent GI bleeding, intestinal perforation and intestinal obstruction have been reported. Diagnosis of CMV enteritis is usually made by histopathology which shows intracellular granules combined with Immunostains positive for CMV. Viral cultures and PCR are also helpful. Differential diagnosis of CMV enteritis involves colitis caused by C. difficile, ischemia, colonic malignancies and inflammatory bowel diseases. Treatment involves administration of IV Ganciclovir or oral Valganciclovir. It has been suggested that immunocompetent patients usually tend to recover spontaneously and do not need treatment. However it is hard to define the criteria of immunocompetency. In our case the patient was off immunosuppressant's for over four years, although it can be argued that presence of comorbidities like GPA and ESRD creates a state of relative immunosuppression. Our case highlights the diagnostic dilemma in patients with obscure GI bleed and additionally, is a rare presentation of CMV ileitis in a immunocompetent patient.Figure 1Figure 2Figure 3

PTU-051 Diagnostic yield of oesophago-gastro-duodenoscopy as the initial investigation for patients presenting with haematochezia

<h3>Introduction</h3> It is suggested that 15% of patients presenting with haematochezia will have an upper gastrointestinal (UGI) source of bleeding.¹Current surgical school of thought recommends oesophago-gastro-duodenoscopy (OGD) as first-line investigation for patients with haematochezia.²More recent thinking suggests that a nasogastric lavage should be undertaken in this patient group to identify an UGI source of bleed.²We aimed to investigate whether the reported figure was an accurate representation and whether OGD should be undertaken primarily. <h3>Method</h3> Patients who presented with haematochezia were identified between January 2010 and June 2014, using clinical coding. Data collected included demographics, presentation, initial haemoglobin and urea serum levels, OGD findings and results from further endoscopic investigation. <h3>Results</h3> A total of 231 patients were identified (mean age 68 years, 55% male). Of these, 42 underwent OGD as first-line investigation. The majority of these (73%) had a normal endoscopy. The following pathologies where identified in the remaining endoscopies; duodenitis (7%), gastric ulcer (4%), gastritis (2.3%), oesophagitis (2.3%), oesophageal telangiectasia (2.3%), gastric erosions (2.3%), oesophageal ulcer (2.3%) and oesophageal varices (2.3%) Of those with a normal OGD, 80% had a further lower GI endoscopy. 60% of these patients had a clear LGI pathology accounting for their presentation. These findings demonstrate that of the patients who underwent OGD first line, only 7% had significant UGI pathology at OGD (peptic ulcer, oesophageal varices) with 2% actively bleeding (oesophageal varices). The mean haemaglobin for this population was 98 g/L (range 32–142 g/L). The median serum urea level was 9.2 mmol/L (range 1–13.2 mmol/L). In those with a normal OGD, 35% had a raised serum urea (mean 8.3 mmol/L, range 1.0–46.2 mmol/L). Whilst in those with an identified attributable UGI pathology, serum urea was raised in 100% of the cases (mean 8.8 mg/dl, range 7.9–9.9 mg/dl.) <h3>Conclusion</h3> We suggest an incidence of UGI pathology leading to haematochezia of 7%, which is far lower that the quoted figure of 15%. We therefore challenge surgical recommendation that OGD should be the first line investigation in this patient group unless haemodynamic instability or clinical suspicion is suggestive. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 1988;95(6):1569–74 Jensen DM, Ghassemi KA. Lower GI Bleeding: epidemiology and management. Curr Gastroenterol Rep. 2013;15(7):333

Endoscopic Management of Acute Lower Gastrointestinal Bleeding

Lower gastrointestinal bleeding (LGIB) continues to be a problem for physicians. Acute LGIB is defined as bleeding that emanates from a source distal to the ligament of Treitz. Although 80% of all LGIB will stop spontaneously, the identification of the bleeding source remains challenging and rebleeding can occur in 25% of cases. Diverticular bleeding remains the most common cause of lower GI bleeding. Lower Gastrointestinal Bleeding encompasses a wide clinical spectrum ranging from occult bleeding to overt hematochezia until massive hemorrhage with shock requiring emerging hospitalization. Some patients with severe hematochezia require urgent attention to minimize further bleeding and complications. Colonoscopy is the diagnostic procedure of choice in most patients with Lower GI bleeding and its role in the treatment of lower GI bleeding has been shown to be an efficacious and safe method even if a therapeutic endoscopy occurred in about 30% of patients. The optimal timing of colonoscopy in LGIB remains to be determined. CT angiography is used in the setting of acute Lower GI bleeding correctly depicts the presence and location of active or recent hemorrhage, as well as the potential cause, in about 80-85% of case. Nuclear scintigraphy has been proposed as a diagnostic screening prior to angiography, increasing the likelihood of positive angiographic results or as a tool for localization for surgery but had multiple limitations. Superselective mesenteric angiography remains the cornerstone of management of patients with acute LGIB but it is an invasive and time-consuming procedure. Emergent surgery should be considered only as a last resort and is rarely needed to prevent death from exanguination. The golden standard for surgical treatment of acute severe LGIB should be directed segmental resection based on aggressive preoperative identification of the bleeding site. This article reviews the causes, clinical presentation, diagnostic methods, endoscopic treatment of LGIB and management of specific LGI bleeding lesions.

Cow's milk allergy: color Doppler ultrasound findings in infants with hematochezia

Objectiveultrasound (US) has been an important diagnostic tool to identify several cau- ses of gastrointestinal bleeding. Infants with cow's milk allergy (CMA) may present hema- tochezia and the confirmation of the diagnosis can be difficult. The aim of this study is to describe grayscale and color Doppler ultrasound findings in patients with CMA. Methodswe retrospectively studied 13 infants with CMA. All infants presented severe hematochezia and abdominal pain. All underwent an US study with the diagnosis of aller- gic colitis. This diagnosis was based on clinical findings, recovery after infant or mother exclusion diets in the case of exclusive breastfeeding and positive oral challenge test. Resultsthe mean age ranged from 1 to 6 months (mean = 3.53). Seven out of 13 infants (53.8%) had grayscale and color Doppler sonographic repeated after exclusion diet. Twelve out of 13 (92,3%) showed abnormalities at US and CDUS at beginning. The positive findings suggesting colitis were thickened bowel walls and increased vascularity, espe- cially in the descending and sigmoid colon. Colonoscopy and histopathological findings were compatible with allergic colitis. After a diet change the 13 infants recovered and their oral challenge tests were positive. ConclusionDoppler US may be very useful in diagnosing secondary colitis, such as CMA, and to exclude several other abdominal diseases that can emulate this disease.

Comparison of clinical effectiveness of the emergent colonoscopy in patients with hematochezia according to the type of bowel preparation

Colonoscopy (CFS) is a valuable diagnostic tool in patients with hematochezia. However, the optimal preparation method of emergent CFS for hematochezia has not been defined. We investigated the clinical effectiveness of bowel preparation of patients with hematochezia using polyethylene glycol (PEG) solution and glycerin or water enemas. The medical records of the past 7 years were reviewed. Patients presenting with hematochezia that occurred within 24 h before admission were eligible for the study. All patients underwent CFS within 24 h after visiting the emergency room for hematochezia. Patients were classified into two groups according to the preparation method used (enema vs. PEG). Overall, 194 patients (125 enema vs. 69 PEG) were enrolled. The diagnostic rate of bleeding focus was lower in the enema group than in the PEG group (84% vs. 97.1%, P = 0.008). Performance of endoscopic hemostasis at the initial CFS was more frequent in the enema group than in the PEG group (40.8% vs. 10.1%, P < 0.001). The rate of repeated CFS was higher in the enema group than in the PEG group (44.0% vs. 18.8%, P < 0.001). Post-polypectomy bleeding (n = 33) was diagnosed during the initial study and was treated endoscopically. In cases of post-polypectomy bleeding, CFS (93.9%) was performed after an enema in all but two cases. In hematochezia patients, the PEG group showed a higher diagnostic rate and lower rate of repeated CFS. However, emergent CFS after an enema only seems to be useful in patients with severe hematochezia or if the bleeding focus can be presumed.

Life-threatening Bleeding as a Complication of the Zassi Bowel Management System: A Case Report

Introduction: The Zassi Bowel Management System (BMS) is used increasingly in the ICU as a means of fecal diversion. The device can be used on patients with either diarrhea or fecal incontinence. Diversion, collection, and containment of stools for bedridden patients is key in preventing incontinence and infection from fecal exposure and contamination. Case: A 71-year-old man with a medical history of coronary artery disease S/P CABG was admitted for an esophagectomy for esophageal stromal cancer. The patient developed fecal incontinence while in the ICU, and was placed on the Zassi BMS, which was inserted four times during the patient's stay for a mean duration of 5.75 days with an average 10.67 days between each insertion. The first and second insertions and subsequent removal were uneventful. The day after the third insertion of the BMS, the patient developed severe hematochezia, with an initial hemoglobin drop of 2 grams. Anoscopy revealed prolapsed internal hemorrhoids and a rectal ulcer. Nine units of PRBCs were required for resuscitation. An urgent colonoscopy revealed a 3-4 cm bleeding circumferential rectal ulcer, 10 cm from the anal verge (Image 1). Epinephrine injections and application of bicap cautery were used to attempt hemostasis. Despite these measures, bleeding persisted and the patient underwent IR embolization of a tributary of the right pelvic branch of the internal iliac artery. With no further episodes of bleeding, he was discharged to a long-term care facility. Discussion: Cases of complications such as rectal bleeding and pressure necrosis occurring well before the 29-day recommended regimen may be under-reported. We report a case of severe, life-threatening rectal bleeding as a complication of the device, used within the recommended time frame.Figure

Cow's milk allergy: color Doppler ultrasound findings in infants with hematochezia

Objectiveultrasound (US) has been an important diagnostic tool to identify several causes of gastrointestinal bleeding. Infants with cow's milk allergy (CMA) may present hematochezia and the confirmation of the diagnosis can be difficult. The aim of this study is to describe grayscale and color Doppler ultrasound findings in patients with CMA. Methodswe retrospectively studied 13 infants with CMA. All infants presented severe hematochezia and abdominal pain. All underwent an US study with the diagnosis of allergic colitis. This diagnosis was based on clinical findings, recovery after infant or mother exclusion diets in the case of exclusive breastfeeding and positive oral challenge test. Resultsthe mean age ranged from 1 to 6 months (mean=3.53). Seven out of 13 infants (53.8%) had grayscale and color Doppler sonographic repeated after exclusion diet. Twelve out of 13 (92,3%) showed abnormalities at US and CDUS at beginning. The positive findings suggesting colitis were thickened bowel walls and increased vascularity, especially in the descending and sigmoid colon. Colonoscopy and histopathological findings were compatible with allergic colitis. After a diet change the 13 infants recovered and their oral challenge tests were positive. ConclusionDoppler US may be very useful in diagnosing secondary colitis, such as CMA, and to exclude several other abdominal diseases that can emulate this disease.

Hemostatic powder as rescue therapy in a patient with H1N1 influenza with uncontrolled colon bleeding

A 51-year-old patient was admitted to our intensive care unit with fulminant respiratory failure secondary to influenza A (H1N1) requiring urgent extracorporeal membrane oxygenation treatment. The patient developed severe hematochezia. Urgent colonoscopy revealed a 3-cm, oozing, bleeding ulcer located opposite the ileocecal valve, which was initially treated successfully with the injection of fibrin glue. However, the bleeding recurred (Fig. 1A), and, in view of the patient's critical condition, Hemospray (Cook Medical, Winston-Salem, NC) treatment was considered as an ultimate rescue therapy.

Lower GI Bleeding: Epidemiology and Management

Gastrointestinal (GI) bleeding from the colon is a common reason for hospitalization and is becoming more common in the elderly. While most cases will cease spontaneously, patients with ongoing bleeding or major stigmata of hemorrhage require urgent diagnosis and intervention to achieve definitive hemostasis. Colonoscopy is the primary modality for establishing a diagnosis, risk stratification, and treating some of the most common causes of colonic bleeding, including diverticular hemorrhage which is the etiology in 30% of cases. Other interventions, including angiography and surgery, are usually reserved for instances of bleeding that cannot be stabilized or allow for adequate bowel preparation for colonoscopy. We discuss the colonoscopic diagnosis, risk stratification, and definitive treatment of colonic hemorrhage in patients presenting with severe hematochezia.

Sa1471 Independent Predictors of Lesion Localization and Outcomes in Cirrhotic and Non-Cirrhotic Patients With Severe Hematochezia by Bivariate and Multivariate Analyses

Independent predictors of location and outcomes of cirrhotics vs. non-cirrhotics presenting with severe hematochezia have not been previously reported. The aims of the study were (1) to identify independent predictors of bleeding localization (upperGI, small bowel or colon) in cirrhotic and non-cirrhotic patients, (2) to identify predictors of outcomes (rebleeding, surgery and death) at 30 days after initial hemorrhage in patients with severe hematochezia, and (3) to determine if cirrhosis is a risk factor of 30 day outcomes.

Sa1632 Urgent Capsule Endoscopy for Bleeding Site Localization & Lesion Diagnosis of Patients With Severe Hematochezia

There is no agreement about the best strategy for diagnosis of patients presenting with severe hematochezia. For patients with severe hematochezia, our aims were: 1) to determine diagnostic yield of urgent capsule endoscopy (UCE) for bleeding site localization in the gut & for etiologic or lesion diagnosis & 2) to compare results with red blood cell (RBC) scan &/or angiogram (eg. standard angiography, CT, or MR angiogram) & with endoscopy (colonoscopy ±push enteroscopy).

Rectal Ischemia Mimicked Tumor Mass

Ischemic proctitis is a rare disease which is usually encountered in elderly with comorbidities. We present a case of an 80-year old man with severe coronary disease who presented with severe hematochezia and hypotension. Endoscopy revealed a rectal mass 3-4 cm above the dental line and rectosigmoid mucosal inflammation compatible with ischemic colitis. The rectal insult was so intense that it resembled a neoplasmatic lesion. We discuss the causes, the prognostic factors, and the clinical and therapeutic challenges of this rare, albeit life-threatening entity, and we review the relative literature. A percentage of 10%–20% of patients with ischemic colitis usually have a distal potentially obstructing lesion or disorder such as cancer, diverticulitis or fecal impaction. Ischemic colitis, when mucosal and submucosal edema is severe and hemorrhagic nodules are large enough, can mimic a neoplasmatic lesion. The best treatment approach is a conservative management initially with a close clinical followup and after stabilization a repetition of rectal endoscopy with new biopsies. Early recognition of this clinical entity is of paramount importance to implement appropriate therapy (conservative or surgical) and avoid potentially fatal treatment of presumed inflammatory or infectious bowel diseases.

Massive right-sided colon diverticular bleeding complicated by the transfusion related acute lung injury (TRALI)

Abstract Colonic diverticulosis is a condition which causes extensive bleeding of the lower gastrointestine in 40–50% of cases. In particular, right-sided diverticulosis, although uncommon requires lifesaving colectomy. Transfusion related acute lung injury (TRALI) is a transfusion reaction, which can occur after administration of various blood products. Although life threatening, it can be completely reversed usually within 72 to 96 hours. Here, we report a case of a young Caucasian male hospitalized due to severe anemia, hematochezia and extensive blood loss, all due to lower gastrointestinal hemorrhage from right-sided diverticulosis. These conditions were overlooked endoscopically and diagnosed then treated surgically with the right-sided hemicolectomy. During postoperative course, four hours after the last transfusion, patient developed fever, hypoxia and noncardiogenic pulmonary oedema, but made complete recovery through aggressive oxygen support within 96 hours. The aim of this case was to review current literature, to draw attention to a serious and under-diagnosed transfusion reaction, as well as discuss possible explanations for the diagnostic difficulties that occurred in this case.

Mo1156 Location of Bleeding Sites and Diagnoses are Different in Cirrhotics and Noncirrhotics Presenting With Severe Hematochezia

Mo1156 Location of Bleeding Sites and Diagnoses are Different in Cirrhotics and Noncirrhotics Presenting With Severe Hematochezia

Su1044 Endoscopic Hemostasis for Severe Hematochezia in the Elderly: Population-Based Data From a Large Consortium of Diverse Endoscopy Practices in the United States

Su1044 Endoscopic Hemostasis for Severe Hematochezia in the Elderly: Population-Based Data From a Large Consortium of Diverse Endoscopy Practices in the United States

1172 How to Find, Diagnose and Treat Definitive Diverticular Hemorrhage During Urgent Colonoscopy in Patients With Severe Hematochezia: Results & Outcomes of a Large Prospective Study

1172 How to Find, Diagnose and Treat Definitive Diverticular Hemorrhage During Urgent Colonoscopy in Patients With Severe Hematochezia: Results & Outcomes of a Large Prospective Study

1169 Endoscopic Hemostasis Is Rarely Used for Severe Hematochezia: Population-Based Data From a Large Consortium of Diverse Endoscopy Practices in the United States

1169 Endoscopic Hemostasis Is Rarely Used for Severe Hematochezia: Population-Based Data From a Large Consortium of Diverse Endoscopy Practices in the United States

A Hypereosinophilic Syndrome Presenting as Eosinophilic Colitis

Hypereosinophilic syndrome (HES) has three defining features: marked hypereosinophilia for at least 6 months, no confirmed etiology for the eosinophilia, and eosinophilia-related symptoms or organ dysfunction. However, a shorter period of hypereosinophilia with symptoms requiring eosinophil-lowering therapy is also acceptable. We report a case of HES presenting as eosinophilic colitis. Although hypereosinophilia was present for 3 months, this patient needed to be treated with eosionphil-lowering therapy for severe hematochezia. After systemic corticosteroid therapy, symptoms caused by organ involvement were dramatically improved.

Ischemic colitis as a cause of severe hematochezia: risk factors and outcomes compared with other colon diagnoses

Risk factors and outcomes of severe hematochezia from ischemic colitis compared with other colonic diagnoses have not been well studied. Our purposes were (1) to compare demographics and outcomes of patients hospitalized with severe hematochezia from ischemic colitis compared with other colonic diagnoses, (2) to compare inpatient and outpatient start of bleeding from ischemic colitis, and (3) to describe potential risk factors. Prospective cohort study. Tertiary referral academic centers. Patients referred for gastroenterology consultation for severe hematochezia. Colonoscopic therapy was provided as indicated. Rebleeding, surgery, and length of hospital stay after colonoscopy. Of 550 patients in the past 12 years with severe hematochezia from colonic sources, the cause in 65 patients (11.8%) was ischemia. Ischemic colitis was found more often in females, in patients taking anticoagulant agents, in patients with severe lung disease, those with higher creatinine levels, those with higher glucose levels, and those with more fresh frozen plasma transfusions. Five patients with focal lesions had colonoscopic hemostasis. Major 30-day outcomes of ischemic colitis patients were significantly worse than patients with other colonic diagnoses. Patients with inpatient (vs outpatient) ischemic colitis had significantly more and more severe comorbidities at baseline and significantly higher rates of rebleeding, surgery, and more days spent in hospital and in the intensive care unit. Two-center study. Major 30-day outcomes in ischemic colitis patients were significantly worse than in patients with other colonic diagnoses. Comparing outpatient and inpatient start of ischemic colitis, inpatients had significantly worse outcomes.