Severe Lower Gastrointestinal Bleeding Research Articles

Acute Hemorrhagic Rectal Ulcer Presenting With Severe Lower Gastrointestinal Bleeding: A Case Report of an Emerging Entity

Acute Hemorrhagic Rectal Ulcer Presenting With Severe Lower Gastrointestinal Bleeding: A Case Report of an Emerging Entity

A Rare Cause of Severe Lower Gastrointestinal Bleeding in Ulcerative Colitis Patients in Remission: Giant Pseudopolyps

A Rare Cause of Severe Lower Gastrointestinal Bleeding in Ulcerative Colitis Patients in Remission: Giant Pseudopolyps

Meso-ileal ectopic varicose vein with uterine systemic shunt as an uncommon cause of severe lower gastrointestinal bleeding in patient with mild portal hypertension.

Abstract Ectopic varicose veins of the small intestine are an uncommon cause of gastrointestinal bleeding in patients with portal hypertension. We present the case of a 52-year-old female patient with mild portal hypertension and repeat episodes of lower gastrointestinal bleeding because of meso-ileal ectopic varicose vein with systemic uterine shunt secondary to previous pelvic surgery, radiological findings and treatment performed.

Comparison of scoring systems for predicting clinical outcomes of acute lower gastrointestinal bleeding: A prospective cohort study.

This study aimed to determine the performance of the Oakland, Glasgow-Blatchford, and AIMS65 scores in predicting the clinical outcomes of acute lower gastrointestinal bleeding (LGIB). This prospective cohort study was conducted from July 2020 to July 2021. Patients admitted with acute lower gastrointestinal bleeding were enrolled. The Oakland, Glasgow-Blatchford, and AIMS65 scores were calculated. The primary outcome was validating the performance of the scores in predicting severe LGIB; secondary outcomes were comparing the performance of the scores in predicting the need for blood transfusion, hemostatic interventions, in-hospital rebleeding, and mortality. Receiver operating characteristic curves were calculated for all outcomes. The associations between all three scores and the primary outcomes were calculated using multivariate logistic regression analysis. Patients with acute LGIB (n=150) were enrolled (88 [58.7%] men and mean age: 63.6±17.3years). The rates of severe LGIB, need for blood transfusion, hemostatic intervention, in-hospital rebleeding, and in-hospital mortality were 54.7%, 79.3%, 10.7%, and 3.3%, respectively. The Oakland and Glasgow-Blatchford scores had comparable performance in predicting severe LGIB, need for blood transfusion, and mortality, outperforming the AIMS65 score. All scores were suboptimal for predicting hemostatic interventions and rebleeding. Our results demonstrate the predictive performances of the Oakland score and the GBS are excellent and comparable for severe LGIB, the need for blood transfusion, and in-hospital mortality in patients with acute LGIB. Thus, GBS could be considered as an alternative predictive score for stratification of the patients with acute LGIB.

A comprehensive review and update on acute severe lower gastrointestinal bleeding in Crohn’s disease: a management algorithm

Abstract Acute severe lower gastrointestinal bleeding is a rare but potentially fatal complication of Crohn's disease (CD), affecting between 0.6% and 5.5% of CD patients during their lifelong disease course. Managing bleeding episodes effectively hinges on vital resuscitation. Endoscopic evaluation and computed tomography play crucial roles in accurate identification and intervention. Fortunately, most bleeding episodes can be successfully managed through appropriate conservative treatment. Medical therapies, particularly infliximab, aim to induce and maintain mucosal healing and serve as the leading treatment approach. Minimally invasive procedures, such as endoscopic hemostasis and angio-embolization, can achieve immediate hemostasis. Surgical treatment is only considered a last resort when conservative therapies fail. Despite achieving hemostasis, the risk of rebleeding ranges from 19.0% to 50.5%. The objective of this review is to provide a comprehensive and updated overview of the clinical manifestations, diagnostic methods, therapeutic approaches, and prognostic outcomes associated with acute severe gastrointestinal bleeding in CD. Furthermore, we aimed to propose a management algorithm to assist clinicians in the effective management of this condition.

S823 The Impact of a CT Angiography-Guided Protocol for Severe Lower Gastrointestinal Bleeding on Utilization and Outcomes

S823 The Impact of a CT Angiography-Guided Protocol for Severe Lower Gastrointestinal Bleeding on Utilization and Outcomes

Severe Lower Gastrointestinal Bleeding Due to Choriocarcinoma with AVM to the Ileum: A Case Report

Background: Choriocarcinoma and other placental tumors are rare, and metastasis to the gastrointestinal, especially the small bowel, is extremely rare. Furthermore, about 5% of all metastasis belongs to the GI tract. Case Presentation: We reported an 18 -year-old patient with severe GI bleeding. Serum BHCG level was 57322 mIU/mL. CT angiography and Pelvic MRI suggested a metastatic arteriovenous malformation to the small bowel. In surgery, we detected the AVM from the right side of the uterus to the ileum, and pathological findings confirmed the choriocarcinoma with metastatic AVM to the ileum. Conclusion: Chemotherapy started after surgery, and the patient was asymptomatic on follow-up after 14 months. The results showed that GTN was a differential diagnosis when patients are referred with these signs and symptoms. ConclusioN: Findings from this study suggest a high prevalence of paradoxical VL suppression but not immune CD4 gain in the studied subjects following cART. Larger studies are needed to corroborate these findings.

International on-line questionnaire about severe lower gastrointestinal bleeding management: Do we have it clear?

International on-line questionnaire about severe lower gastrointestinal bleeding management: Do we have it clear?

How to manage lower gastrointestinal bleeding in 2022?

Lower gastrointestinal bleeding (LGIB), originating mainly in the colon, rectum and anus, occurs most often in older patients (7th decade) with co-morbidity, half of whom have coagulation abnormalities due to anti-coagulant or anti-aggregant therapy. In three cases out of four, bleeding regresses spontaneously but can recur in up to one third of patients. The main causes are diverticular disease, vascular disorders (hemorrhoids, angiodysplasia) and colitis. Ten to 15% of patients present in hypovolemic shock. The main problem is to determine the precise location and etiology of bleeding. First-line steps include correction of hemodynamics, correction of coagulation disorders and transfusion, as necessary. Rectal digital examination allows differentiation between melena and hematochezia. In patients with severe LGIB, upper endoscopy can eliminate upper gastro-intestinal bleeding (UGIB). Computerized tomography (CT) angiography can pinpoint the source. If contrast material extravasates, the therapeutic strategy depends on the cause of bleeding and the general status of the patient: therapeutic colonoscopy, arterial embolization and/or surgery. In the absence of severity criteria (Oakland score≤10), ambulatory colonoscopy should be performed within 14 days. Discontinuation of anticoagulant and/or antiplatet therapy should be discussed case by case according to the original indications.

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline.

Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.

Clinical characteristics, interventions and outcomes of acute lower gastrointestinal bleeding: A multicenter study in Vietnam

Despite many medical advances, acute lower gastrointestinal bleeding in Asia has been increasing gradually and has resulted in substantial mortality. The study aimed to describe the clinical characteristics, interventions, and outcomes of acute lower gastrointestinal bleeding in Vietnamese people. A multicenter cohort study was prospectively and retrospectively conducted in patients presenting with acute lower gastrointestinal bleeding in Vietnam. Severe lower gastrointestinal bleeding was defined as persistent bleeding within the first 24 hours and/or recurrent bleeding after 24 hours of stability accompanied by a reduction in hematocrit of ≥ 20% and/or transfusion of ≥ 2 units of red blood cells. The clinical characteristics, interventions, and adverse outcomes were recorded. There were 811 patients with a male:female ratio of 1.07 and a mean age of 61 years. A total of 85.6% of patients presented with hematochezia. The common causes of acute lower gastrointestinal bleeding were hemorrhoids (28.6%), diverticulosis (9.7%), and unknown origin (16%). The rates of blood transfusion, endoscopic therapy, radiologic intervention, and surgery were 39.8%, 8.6%, 0.5%, and 7.3%, respectively. Severe lower gastrointestinal bleeding was observed in 222 (27.4%) patients. In-hospital deaths were recorded in 17 (2.1%) patients. The majority of in-hospital deaths were due to unstable comorbidities. Hemorrhoids were the most common cause of acute lower gastrointestinal bleeding. The rates of blood transfusion, endoscopic hemostasis, interventional radiology, and surgery were 39.8%, 8.6%, 0.5%, and 7.3%, respectively. A total of 27.4% of cases progressed to severe bleeding.

NOBLADS-External Validation of a Risk Scoring System for Severe Acute Lower Gastrointestinal Bleeding.

Acute lower gastrointestinal bleeding is a common cause of hospital admission. NOBLADS is a lower gastrointestinal bleeding clinical risk score. This study aimed to externally validate NOBLADS in predicting severe acute lower gastrointestinal bleeding and clinical outcome. Observational retrospective study. This study was performed in a single large tertiary hospital. Patients who were admitted with acute lower gastrointestinal bleeding during a 15-month period and underwent endoscopic evaluation were included. Patients with chronic lower gastrointestinal bleeding or acute lower gastrointestinal bleeding who were admitted for other conditions were excluded. Primary outcome was acute severe lower gastrointestinal bleeding (classified as severe if requires transfusion of >2 units of packed red blood cells and/or produces a >20% hematocrit fall). Secondary outcomes: red blood cells requirement, therapeutic intervention and hospital stay duration. NOBLADS score was applied to all patients. Its accuracy to predict acute severe bleeding and secondary outcomes were studied using receiver operating characteristic analysis. A total of 173 patients (50.3% males, age 69 ± 17 years) were included. The most common lower gastrointestinal bleeding etiologies were diverticular bleeding (18.5%) and ischemic colitis (15.6%). Fifty patients (28.9%) presented criteria for severe bleeding and 33 patients required instrumental intervention: endoscopic (n = 28), surgical (n = 4), and radiologic (n = 1) therapy. NOBLADS score was significantly different according with acute lower gastrointestinal bleeding causes (p < 0.001) and accurately predicted severe bleeding (area under the receiver operating characteristic curve 0.923 ± 0.018 (p < 0.001)). NOBLADS ≥2 detected acute severe lower gastrointestinal bleeding with 100% sensitivity/62.4% specificity, identifying the need for higher red blood cells requirement (3.6 vs 0.08, p < 0.001), therapeutic intervention (38% vs 13%, p < 0.001), and longer hospital stay (12.8 vs 3 days, p < 0.001). Unicenter retrospective study; number of unprepared sigmoidoscopies/left side colonoscopies; comparison between NOBLADS and other scoring systems was not performed. NOBLADS is a practical, highly accurate tool and predicts the need of in-hospital management, early colonoscopy, red blood cells transfusion, and longer hospital stay in patients admitted with acute lower gastrointestinal bleeding. See Video Abstract at http://links.lww.com/DCR/B748.NOBLADS: VALIDACIÓN EXTERNA DE UN SISTEMA DE PUNTUACIÓN DE RIESGO PARA HEMORRAGIA DIGESTIVA BAJA AGUDA GRAVE. La hemorragia digestiva baja aguda es causa común de admisión hospitalaria. NOBLADS es una puntuación de riesgo clínico de hemorragia gastrointestinal baja. Este estudio tuvo como objetivo validar externamente NOBLADS en la predicción de hemorragia digestiva baja aguda grave y sus resultados clínicos. Estudio observacional retrospectivo. Realizado en un gran hospital terciario. Se incluyeron todas aquellas personas ingresados con hemorragia digestiva baja aguda durante un período de 15 meses y que fueron sometidos a evaluación endoscópica. Se excluyó la hemorragia digestiva baja crónica o la hemorragia digestiva baja aguda en pacientes ingresados por otras afecciones. El resultado pricipal fue la hemorragia digestiva baja grave aguda (clasificada como grave si requiere >2 transfusiones de glóbulos rojos y / o produce una caída del hematocrit >20%). Las medidas de resultados secundarias fueron: requerimiento de glóbulos rojos, intervención terapéutica y duración de la estancia hospitalaria. Se aplicó la puntuación NOBLADS a todos los pacientes. Se estudió su precisión para predecir la hemorragia aguda grave y los resultados secundarios mediante análisis ROC. Se incluyeron 173 pacientes (50,3% varones, edad 69 ± 17 años). La etiología de hemorragia digestiva baja más frecuentes fueron: la hemorragia de orígen diverticular (18,5%) y la colitis isquémica (15,6%). 50 pacientes (28,9%) presentaron criterios de sangrado severo y 33 pacientes requirieron intervención instrumental: terapia endoscópica (n = 28), quirúrgica (n = 4), radiológica (n = 1). La puntuación NOBLADS fue significativamente diferente según las causas de hemorragia digestiva baja aguda (p <0,001), siendo precisa para predecir hemorragia grave (AUC 0,923 ± 0,018 (p <0,001). NOBLADS ≥2 detectó hemorragia digestiva baja aguda grave con 100% de sensibilidad / 62,4 % de especificidad, identificando la necesidad de mayor requerimiento de glóbulos rojos (3.6 vs 0.08, p <0.001), intervención terapéutica (38% vs 13%, p <0.001) y estadía hospitalaria más prolongada (12.8 vs 3 días, p <0.001). Estudio retrospectivo Unicentrico; número de sigmoidoscopias / colonoscopias del lado izquierdo no preparadas; no se realizó comparación entre NOBLADS y otros sistemas de puntuación. NOBLADS es una herramienta práctica y altamente precisa que predice la necesidad de manejo hospitalario, colonoscopia precoz, transfusión de glóbulos rojos y estadía hospitalaria más prolongada en pacientes ingresados con hemorragia digestiva baja aguda. Consulte Video Resumen en http://links.lww.com/DCR/B748. (Traducción-Dr. Xavier Delgadillo).

Refractory lower gastrointestinal bleeding in a patient with parkes weber syndrome

Parkes Weber syndrome (PWS) is a rare disorder of limb hypertrophy and vascular abnormalities, including arteriovenous malformations (AVMs). To the best of our knowledge, this is the first case of a refractory lower gastrointestinal bleeding due to AVMs in a patient with PWS. We describe the case of a 54-year-old woman with PWS who presented with refractory lower gastrointestinal bleeding due to extensive AVMs in the sigmoid colon and rectum. We review her colonoscopy and computed tomography imaging and ultimate surgical management, including a low anterior resection and diverting loop ileostomy. In rare cases, PWS can cause severe lower gastrointestinal bleeding. It is imperative to understand the role of surgical intervention in such cases of refractory lower gastrointestinal bleeding.

Ischemic colitis as a cause of severe hematochezia: A mini review.

Ischemic colitis (IC) is a common cause of severe lower gastrointestinal bleeding (LGIB) in the elderly. There are very few studies of patients with IC as a cause of severe LGIB in the literature. This article aims to review diagnosis, colonoscopic findings, medical treatment, and outcomes of patients with IC as a cause of severe hematochezia. The majority of IC patients with severe hematochezia can be successfully managed with medical treatment. Colonoscopic hemostasis with hemoclips is safe and feasible in treating major stigmata of recent hemorrhage in focal ischemic ulcers. Colon surgery is indicated in patients who fail medical treatment and/or have severe ongoing bleeding, clinical deterioration, or peritoneal signs. Overall, the morbidity rates in patients with IC range from 10% to 79%. Clinical outcomes in patients who need colon surgery for IC are worse than those treated with medical management. Patients who develop hematochezia from IC during hospitalization for other medical conditions have worse clinical outcomes than those with an outpatient start of bleeding. Further research is warranted for the prevention, early diagnosis, and treatment of patients with severe hematochezia from IC.

Severe ileum bleeding following adjuvant capecitabine chemotherapy for locally advanced colon cancer: a case report and review of the literature

BackgroundCapecitabine is a prodrug that is enzymatically converted to its active form, fluorouracil (also called 5-fluorouracil), which is commonly used as adjuvant chemotherapy in colorectal cancer patients. Severe gastrointestinal bleeding induced by capecitabine is rare. Here, we are presenting the first case report of surgery specimen assisted diagnosis of this uncommon condition.Case presentationA 63-year-old Chinese male with a history of colon adenocarcinoma and right hemicolectomy presented with severe lower gastrointestinal bleeding 2 days after finishing capecitabine administration during the first cycle of XELOX adjuvant chemotherapy. Because of the negative findings of active bleeding points by digital subtraction angiography (DSA) or colonoscopy, emergency laparotomy and partial enterectomy were performed. The bloody diarrhea had resolved after surgery and a terminal ileitis was diagnosed after pathological examination of the surgical specimen.ConclusionsTerminal ileitis induced by capecitabine is likely to be underreported. It should be considered more often as a cause of severe gastrointestinal bleeding during or after treatment with capecitabine agents. Emergency surgery may achieve satisfactory outcomes if endoscopic hemostasis is ineffective.Highlights of this case1. Gastrointestinal bleeding following capecitabine treatment in colorectal cancer patients might be life-threatening.2. Terminal ileitis induced by capecitabine should always be considered in the differential diagnosis of severe gastrointestinal bleeding.3. Awareness of the risk factors such as deficiency of dihydropyrimidine dehydrogenase, advanced age, or right colectomy may aid in reducing capecitabine-related morbidity.4. When severe bleeding occurs, emergency surgery may achieve satisfactory outcomes if medical and endoscopic interventions are ineffective.

A clinical predictive model for risk stratification of patients with severe acute lower gastrointestinal bleeding

BackgroundLower gastrointestinal bleeding (LGIB) is a common presentation of surgical admissions, imposing a significant burden on healthcare costs and resources. There is a paucity of standardised clinical predictive tools available for the initial assessment and risk stratification of patients with LGIB. We propose a simple clinical scoring model to prognosticate patients at risk of severe LGIB and an algorithm to guide management of such patients.MethodsA retrospective cohort study was conducted, identifying consecutive patients admitted to our institution for LGIB over a 1-year period. Baseline demographics, clinical parameters at initial presentation and treatment interventions were recorded. Multivariate logistic regression was performed to identify factors predictive of severe LGIB. A clinical management algorithm was developed to discriminate between patients requiring admission, and to guide endoscopic, angiographic and/or surgical intervention.Results226/649 (34.8%) patients had severe LGIB. Six variables were entered into a clinical predictive model for risk stratification of LGIB: Tachycardia (HR ≥ 100), hypotension (SBP < 90 mmHg), anaemia (Hb < 9 g/dL), metabolic acidosis, use of antiplatelet/anticoagulants, and active per-rectal bleeding. The optimum cut-off score of ≥ 1 had a sensitivity of 91.9%, specificity of 39.8%, and positive and negative predictive Values of 45% and 90.2%, respectively, for predicting severe LGIB. The area under curve (AUC) was 0.77.ConclusionEarly diagnosis and management of severe LGIB remains a challenge for the acute care surgeon. The predictive model described comprises objective clinical parameters routinely obtained at initial triage to guide risk stratification, disposition and inpatient management of patients.

Risk factors and prognostic value of acute severe lower gastrointestinal bleeding in Crohn's disease.

BACKGROUNDAcute severe lower gastrointestinal bleeding (LGIB) is an uncommon but challenging complication of Crohn’s disease (CD).AIMTo identify the predictors of acute severe LGIB and to evaluate the impact of acute severe LGIB on the subsequent clinical course in CD patients.METHODSA retrospective inception cohort study was conducted in 75 CD patients with acute severe LGIB and 1359 CD patients without acute severe LGIB who were diagnosed between February 1991 and November 2019 at Asan Medical Center, a tertiary university hospital in Korea. Multivariable analysis with Cox proportional hazard regression was performed to identify the risk factors for acute severe LGIB. A matched analysis using 72 patients with bleeding and 267 matched patients without within the cohort was also conducted to investigate whether acute severe LGIB is a predictor of clinical outcomes of CD. RESULTSMultivariable Cox regression analysis revealed that early use of thiopurines [hazard ratio (HR): 0.23, 95% confidence interval (CI): 0.12-0.48; P < 0.001] and female sex (HR: 0.51, 95%CI: 0.27-0.94; P = 0.031) were significantly associated with a lower risk of acute severe LGIB. The cumulative risks of behavioral progression and intestinal resection were not significantly different between the two matched groups (P = 0.139 and P = 0.769, respectively). The hospitalization rate was higher in the bleeding group than in the matched non-bleeding group (22.1/100 vs 13.2/100 patient-years; P = 0.012). However, if hospitalizations due to bleeding episodes were excluded from the analysis, the hospitalization rate was not significantly different between the bleeding group and the matched non-bleeding group (14.5/100 vs 13.2/100 patient-years; P = 0.631).CONCLUSIONEarly use of thiopurines may reduce the risk of acute severe LGIB. History of acute severe LGIB may not have a significant prognostic value in patients with CD.

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.

Risk factors for rebleeding in Crohn's disease patients with acute severe lower gastrointestinal bleeding: With special reference to the role of anti-tumor necrosis factor therapy.

Acute severe lower gastrointestinal bleeding (LGIB) in patients with Crohn's disease (CD) is uncommon; however, it is a potentially life-threatening complication, and its recurrence is common. We thus aimed to identify the predictors for rebleeding in CD patients with acute severe LGIB and particularly focused on whether anti-tumor necrosis factor (TNF) therapy lowers the risk of rebleeding compared with conventional medical therapy (CMT) or surgery. The risk of rebleeding was analyzed in 131 CD patients with acute severe LGIB. Patients were classified into the CMT group (n=99), anti-TNF therapy group (n=22), and surgery group (n=10). No patients in the surgery group received anti-TNF therapy. During the median follow-up of 98months after the first episode of acute severe LGIB, rebleeding occurred in 50.5%, 18.2%, and 30.0% of the CMT group, anti-TNF therapy group, and surgery group, respectively (P=0.015). The cumulative risks of rebleeding at 1 and 10years were 20.0% and 64.7% in the CMT group, 13.6% and 18.4% in the anti-TNF therapy group, and 0% and 40.7% in the surgery group, respectively (P=0.020). Multivariable Cox regression analysis showed that anti-TNF therapy was associated with a lower risk of rebleeding compared with CMT (hazard ratio, 0.303; 95% confidence interval, 0.108-0.849; P=0.023). In CD patients with acute severe LGIB, anti-TNF therapy may reduce the risk of rebleeding compared with CMT. Although surgery is considered effective in preventing early rebleeding, concomitant anti-TNF therapy may be helpful in further lowering the long-term risk of rebleeding.

A rare case of left gastric pseudoaneurysm and colonic perforation following chronic pancreatitis

Acute Necrotizing Pancreatitis Is A Very Serious Disease That May Lead To Severe Systemic And Catastrophic Local Complications. One Of The Rare Local Complications Is Left Gastric Pseudoaneurysm, Another Even More Rare Complication Is Colonic Perforation. Here, We Present A Case Of Acute On Alcoholic Chronic Pancreatitis Complicated By Large Pseudocyst, Presented With Severe Lower Gastrointestinal Bleeding And Hemorrhagic Shock, Treated By Urgent Exploration Which Revealed The Presence Of Both Left Gastric Pseudoaneurysm And Colonic Perforation And Dealt With By Transfixing Ligation Of Bleeding Vessel And Loop Ileostomy.