Acute lower gastrointestinal haemorrhage

We enjoyed reading the excellent review by Edwards and Maskell (BMJ
2009; 339:b4156) on the topic of imaging in acute lower GI haemorrhage.
The review was illustrated with the case of an 81 year old woman who
presented with rectal bleeding and haemodynamic compromise and who
unfortunately died from complications after a right hemi-colectomy. CT
angiography was used effectively to locate the source of bleeding in the
proximal colon and was followed by immediate surgical intervention. We
wondered whether in this case less invasive alternatives to surgery such
as therapeutic angiography or colonoscopy should have been considered
prior to surgery. Many hospitals will not have access to emergency
therapeutic angiography however colonoscopy is widely available, can be
performed in theatre and will not delay surgery. Successful endoscopic
therapy has been described in the context of severe diverticular bleeding
(1-3) utilizing adrenaline injection, thermal therapy (bi-polar
coagulation or argon plasma coagulation) or endoscopically-placed clips.

A major concern when colonoscoping patients with lower GI bleeding in the
context of extensive diverticulosis is difficulty in locating the bleeding
point when the colonic lumen and multiple diverticula are blood-filled.
However in this case CT angiography had already localized the bleeding
source to the proximal transverse colon which would make an endoscopic
search for the bleeding point considerably easier and more focused. Even
if bleeding could not be stopped, colonoscopy provides an opportunity to
tattoo or place clips distal to the bleeding point to definitively guide
colonic resection. In our view all on-call bleeding services should have
provision for performing emergency colonoscopy to attempt to reduce the
need for surgery, particularly in elderly and co-morbid patients who are
at high risk postoperatively.

References:

1. Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy
for the diagnosis and treatment of severe diverticular hemorrhage. N Engl
J Med. 2000;342(2):78-82.

2. Bloomfeld RS, Rockey DC, Shetzline MA. Endoscopic therapy of acute
diverticular hemorrhage. Am J Gastroenterol. 2001;96(8):2367-2372.

3. Rino Y, Imada T, Iwasaki H, Tanabe H, Toyoda H, Kato N, et al.
Hemostasis of colonic diverticular bleeding with hemoclips under
endoscopic control: report of a case. Hepatogastroenterology.
1999;46(27):1733-1735.

Competing interests:
None declared