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Mayo ClinicDivision of
Colon & Rectal Surgery
Integrated Care For
Digestive Disease
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Non-Tumoral BleedingDiverticular Disease & Angiodysplasia
Eric J. Dozois, MD
Division of Colon and Rectal Surgery
Mayo ClinicRochester, Minnesota
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Lower GI BleedBackground
• 1% of acute hospital admissions• Mortality ranges from 5% – 40%• 85% - will stop spontaneously• 15% - require aggressive
resuscitation, multiple diagnostic modalities & intense medical and surgical management
Hoedema et al. Dis Colon Rectum 2005;48:2010
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Common Causes of Major LGIBMayo Clinic 1988 – 1996, 1018 pts*
Diverticulosis 30%Post-polypectomy 7%Ischemia 6%Ulcerations 6%Malignancy 5%Angiodysplasia 4%Radiation proctopathy 2%Inflammatory bowel disease 2%
*Permission from CJ Gostout, MD
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Common Causes of Major LGIBMayo Clinic 1988 – 1996, 1018 pts*
Diverticulosis 30%
Angiodysplasia 4%
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Diverticular Bleeding Non-inflammatory Pathogenesis
Vasa Recta
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Diverticular Bleeding
• Most patients have minor bleeding
• 30% - 50% have massive bleeding
• Spontaneously resolves in 70% - 80%
Browder etal. Ann Surg 1986 Nov;204(5):530-6. Gostout et al. J Clin Gastroenterol 1992;14(3):260-7.
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Diverticular Bleeding
• Re-bleeding in 20% - 30%**
• 1/3 of major LGIB in elderly*
*Leitman, etal. Ann Surg 1989;209:175 **Breen et al. Semin Colon Rectal Surg 1997;8:128
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Diagnosis - Diverticular Bleeding
• Diagnostic Options:1. Colonoscopy**
2. Tagged RBC scan
3. Mesenteric Angiogram
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Diagnosis by Colonoscopy
Study N Specific Dx Endo Tx
Chaudhry (’98) 85 82 17Kok (’98) 190 148 10Jensen (’00) 121 100 10Antuaco (’01) 39 29 4
Green (’05) 50 48 17
Total 485 438 58 (88%) (12%)
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Non-Surgical Intervention
• Therapeutic Endoscopy:– Epinephrine injection – 4 quadrants– Multipolar cautery– Endoscopic hemoclip– Combination therapy – Epi & clips
• Super-Selective Angiography:– Constriction - vasopressin– Embolization – gelfoam, microcoil
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Epinephrine + Gold Probe Cautery
Diverticular Bleeding
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QuickClip 2(Olympus)
Triclip(Wilson-Cook)
Resolution(Boston Scientific)
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Endoscopic Clipping
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Endoscopic Clipping
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Endoscopic Hemo Clips for Acute Colonic Diverticular Bleeding
Mayo Clinic Experience
• Methods:– Study cohort identified from the
prospectively collected GIBT database (1989-2005)
– Clinical, endoscopic & outcome data were assessed
DDW 2006 With permission by LM Wong Kee Song
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Results – Diverticular Bleeding
Patients (n = 28)Mean Age 78 (47-92)
Transfusions 5 (0-17)
R colon/L colon 10 / 18No. clips used 3 (1-6) Follow-up (mos) 9 (1-59)
DDW 2006 With permission by LM Wong Kee Song
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Results - Diverticular Bleeding
Immediate hemostasis 28/28 (100%)
Recurrent bleeding 4/28 (14%)
Long-term hemostasis 25/28 (89%)
Endoscopy complications 0/28 (0%)
Surgical intervention 3/28 (11%)
Bleed-related mortality 0/28 (0%)
DDW 2006 With permission by LM Wong Kee Song
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Surgical Intervention
• Surgical intervention will ultimately be required in 24% - 78% who bleed chronically*
• In 18% - 25% urgent intervention is necessary due to persistent instability despite aggressive resuscitation**
*McGuire HH. Ann Surg 1994;220:653 **Bokhari et al. Dis Colon Rectum 1997;39:191
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Surgical Intervention
• Elective (Acute or Chronic):– 2 or more episodes of transfusion
dependant bleeding
• Emergent (Unstable):– Stabilized first - endoscopic or
angiographic technique (bridge!)
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Surgical Management
• Identified:
• Directed segmental resection
• Unidentified:
• Intraoperative colonoscopy
• Blind hemicolectomy
• Blind subtotal colectomy
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Colectomy, Re-bleed Rate & Mortality
Parkes et al. Am Surg 1993;59:676
Operation Re-bleed Morbidity
Mortality
Dir. Seg 14% -- --
Subtotal 0% -- --
Blind Seg. 42% 83% 57%
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Angiodysplasia
• AVMs, vascular ectasias, angiomas
• Common source of LGIB in elderly
• 15% have massive bleeding
• 85% intermittent, subacute bleeding
• Recurrence rate 25%
• Often multi-focal, (R) colon common
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Angiodysplasia in GI Tract
Colon is most common site in GI tract
– Cecum 37% – Ascending colon 17% – Transverse colon 7% – Descending colon 7% – Sigmoid colon 18% – Rectum 14%
Hocter W. et al. Endoscopy 1985 Sep;17(5):182-5.
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Angiodysplasia
• In some series, it accounts for 20% - 30% of LGI bleeding, and may be the most frequent cause in patients over the age of 65.
• Can present with occult blood loss or acute bleeding, causing orthostasis or hypotension
Boley et al. Gastroenterology 1977;72:650-60. Browder et al. Ann Surg 1986;204(5):530-6.
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Diagnosis - Angiodysplasia
• Diagnostic Options:1. Colonoscopy**
2. Tagged RBC scan
3. Mesenteric Angiogram*• Selective Angiogram
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Pooling of Contrast in Cecum
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Non-Surgical Intervention
• Therapeutic Endoscopy:– Cautery, epinephrine, argon beam coag.– Perforation risk (*R colon) – Argon beam is preferred modality
• Super-Selective Angiogram:– Treatment of choice for Sb angiectasias– Vasopressin, embolization
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Angiodysplasia Jejunum
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Surgical Management
• Persistent transfusions or life threatening hemorrhage may be arrested with angiogram directed therapy to stabilize for surgery
• Endoscopic or angiographic localization (tattoo) (bridging) can improves outcome
• Multi-focal dz may require subtotal colectomy
• Avoid blind segmental colectomy
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Conclusions
Diverticular & Angiodysplastic Bleeding
• Chronic vs. Acute presentation
• Therapeutic endoscopy and angiography may cure or temporize disease
• Surgery reserved for chronic transfusion requirements or life-threatening bleeding
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Conclusions
Diverticular & Angiodysplastic Bleeding
• Both are multi-focal disease processes & require localization for directed surgical therapy
• Collaborative effort by the radiologist, endoscopist & surgeon optimizes patient care