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Uncontrollable GI Bleed Mamoun A. Rahman. Case 1 RT. 57 yrs-old lady BGhx: -Rectal cancer...
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Transcript of Uncontrollable GI Bleed Mamoun A. Rahman. Case 1 RT. 57 yrs-old lady BGhx: -Rectal cancer...
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Uncontrollable GI Bleed
Mamoun A. Rahman
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Case 1
RT. 57 yrs-old lady BGhx: -Rectal cancer -Pre-operative adjuvant chemotherapy: 5FU based -low anterior resection Medications: - Losec 20 mg Od
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Presentation
C/O: Lower abdominal pain for 3-4 days Admitted Next morning: PR bleeding, bright red Weak and anxious O/E: - Pale - Pulse: 98 - BP: 106/64 - Abdomen: stoma; soft, non tender. - DRE: clotted blood, nil active bleeding
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Lab results
Hb: 10.1 ALP: 141 PCV: 0.30 GGT: 151 WBC: 6.8 Bil: 3
Urea: 4.7 Cr: 95 Na: 137 K: 4.3
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Few hours later
Had another episode of PR bleed Hb: 8.3 PCV: 0.24 Received 2 unit of RCC
Patient “stabilized” PR bleeding continuing - pulse: 109 CT angiography
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On arrival in X-Ray
Anxious Tachypnoeic Cold and clammy Pulse: 125 BP: 70/50 Unstable
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Resuscitation by surgical team
O2 Trendelenburg position 3 IV lines Received Hartmann’s solution and Gelofusin Tranfusion with 2 units O –ve blood ICU informed Urgent angiography
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Angiography & embolization
Bleeding in the pelvis Ruptured aneurysm
branch of internal iliac artery
Anterior branch of IIA embolized
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Post embolization
Transferred to ICU Pulse: 144 BP: 140/65 Chest: course crepitations
Received Frusemide 40 mg Remained stable, melaena only
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Case 2
TY
52 yrs-old lady
Background history: - Recurrent cholangitis - ERCP and stent
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C/O - Epigastric pain - Fever - Pale stool - Dark urine O/E - Jaundiced - Temp: 41 - Tender RUQ Lab results - Cholestatic picture
Ur 13.1
Cr 138
Na 135
K 4.4
Cl 110
Hb 11.6
HCT 36.1
WBC 4.7
Neut 3.78
Bil 113.9
ALT 131
ALP 270
GGT 278
Amylase 10
CRP 352
PT 11.6
INR 1.1
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USS
Cotracted, thick-walled GB, multiple stones CBD: 14 mm, stones
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ERCP performed Sphincterotomy and CBD
clearance Bleeding from sphincter site Adrenalin injected Continued to ooze
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Post ERCP
Haematemesis Melaena Dizzy Pulse: 90 BP: 139/67 Hb:9.7 INR: 1.2 CT Angiogram:
- ?Arterial haemorrhage at ampulla
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Embolization
Bleeding from branches of GDA and Superior pancreaticodudenal artery
Embolization performed with coil and gel foam
SMA angiogram: normal
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Day 1 Post Embolization
Seen by team as a consult Vitals stable Hb: 6.6 INR: 1.37 Transfused 4 units of RCCs
and 1 unit FFP IV fluids and Abx continued Repeat ERCP:
- No further bleeding. Stent inserted
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Post repeat ERCP
Remained asymptomatic No further GI bleeding Discharged with planned ERCP and
Cholecystectomy in 6 weeks’ time
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Superselective embolization of
lower GI hemorrhage
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Etiologies of Lower GI bleeding
Most common in the elderly Variety of causes : - Diverticular disease (10% to 20% risk)
- Neoplasia ( Ca colon causes 5% of major bleeding) Boley et al, Am J Surg 1979
- Angiodysplasia (right colon, <10% risk)
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Evaluation
Recurrent minor bleeding: colonoscopy Severe but intermittent, stable patient: Tc-
99M RBC scanning Hemodynamically unstable patient:
angiography Helical CT: 80% accurate in some series
Ernst et al, Eur Radiol 2003
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History
Rosch and Bookstein, early 1970s
Ischemic complications was13% to 33%
Throughout the 1980s it was a taboo
Dissatisfaction with vasoconstriction methods led renew interest in embolization in 1990s
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Coaxial Microcatheters
Range in size from 2.5 to 3 F
5-French catheter may be used to select a first-order vessel
microcatheter can be advanced through this catheter more distally
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Superselective Catheterization
Distal arteries, close to bleeding points
Embolic material is deployed
It limits the segment of bowel at risk for ischemia
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Choice of embolic
Gel foam Polyvinyl alcohol
particles Microcoils some combination
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Published experience
Guy et al, 1992, reported 10 superselective embolization procedures in nine patients. All procedures were successful
Gordon et al, 1997: 17 cases of microcatheter embolization using microcoils, gel foam, and polyvinyl alcohol particles. Success rate was 76%. No bowel ischaemia
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Published experience
>100 successful embolization have been reported 1997 – 2002
Clinical success ranged from 44% to 91% Ischemic complications ranged from 0% to
6%
Funaki et al, AJR, 2001 Bandi et al,
J Vasc Interv Radiol, 2001
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Published experience
Tan et al, 2008. 265 patients underwent angiography for GI bleeding.
32 ( 12%) had superselective embolization for lower GI hemorrhage
In 31 patients (97%) technical success was achieved
7 had re-bleed 1 had bowel ischaemia
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Limitations of embolization
Colonic bleeding is multifactorial
- Diverticular bleed vs. Angiodysplasia
Patients who are not actively bleeding
Difficult vascular anatomy or severe atherosclerotic disease
“Symptomatic treatment”
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Summary
Minimally invasive techniques have replaced surgical resection as the initial therapies of choice
Superselective embolization and endoscopic treatment appear complementary
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Thank you