- 1. An 81-Year-Old Man with Massive Rectal Bleeding Prepared by:
Dr. Mohammad Shaikhani.
2. History:
- 81-year-old man was admitted to this hospitl for massive rectal
bleeding.
- He had abdominal fullness, nausea, rectal urgency& passed a
mixture of bright-red blood and soft stool
- No abdominal or rectal pain, heartburn, or dyspepsia,no
vomiting or dysphagia.
- CXR & Plain abd XR were normal.
- Every year for the past few years, he had an episode of
LGIB.
- Two years earlier, COLONOSCOPY revealed diverticulosis
throughout the colon, blood throughout the colon but no active
bleeding, no blood or mucosal abnormalities in the terminal ileum;
OGD revealed superficial erosions & altered blood in the
stomach, thought to be consistent with trauma from a NGT,
superficial erosions in the duodenum, without active bleeding.
3. History:
- H/O HT, hyperlipidemia,CHF, CAD with AMI & DES ,COPD,
pulmonary fibrosis, gout,, spinal osteomyelitis, hip fracture.
- He was a widower who lived alone.
- He had consumed alcohol daily , smoked in the past; stopped
drinking several months earlier , stopped smoking several years
earlier.
- No family H/O GIT cancer.
- He was allergic to penicillin,erythromycin, clindamycin,
vancomycin.
- Medications included buprenorphinenaloxone, digoxin, modafinil,
verapamil, aspirin,furosemide, escitalopram, simvastatin,
folate,potassium chloride, finasteride, quinine,
pantoprazole,galantamine, a multivitamin.
- During the previous 5 months, he had used oxygen
supplementation at home.
4. O/E:
- Moderate respiratory distress
- Oxygen saturation 80% while he was breathing ambient air, which
improved to 92% with oxygen
- The jugular venous pulse was visible at 10 cm.
- There were crackles in both lungs.
- The abdomen was soft, with hyperactive bowel sounds; no
tenderness, distention, or hepatosplenomegaly was present.
- Red and maroon blood was present in the rectum.
- No hemorrhoids were seen.
- The feet were warm, the pulses were full, and the remainder of
the examination was normal.
- Serum electrolytes were normal; creatine kinase cardiac
isoenzymes , troponin I were negative.
5. O/E:
- Insulin, sodium polystyrene sulfonate, ondansetron, furosemide,
esomeprazole, albuterol, normal saline (1 liter), fresh-frozen
plasma (2 units), packed red cells (4 units) were administered IV;
BP rose as high as 110 to 117/45 to 60 mm Hg, with PR 90 to 95.
A
- NGT placed, gastric lavage revealed no blood in the stomach.
Hematochezia continued.
- Approximately 7 hours after arrival, a CV catheter was
inserted, , additional red cells (3 units) were infused.
- Dyspnea worsened, with respirations up to 32 per minute, the
trachea was intubated.
- A diagnostic procedure was performed.
6. Investigations:
- This patient had a transient response but required ongoing
resuscitation.
- Studies to determine the location of the hemorrhage had to be
selected carefully to avoid unnecessary delays in definitive
care.
7. 8. Investigations:
- Selective superior mesenteric arteriography revealed active
extravasation of contrast material from a proximal jejunal
branch& was catheterized superselectively with a
microcatheter.
- Arteriography through the microcatheter revealed focal
extravasation of contrast material and pooling in the jejunum.
- There was a suggestion of increased vascularity at the site of
contrast-material extravasation.
- We suspected a small-bowel tumor or diverticulum.
- We decided to embolize the bleeding vessel with the
understanding that this would temporarily stop the bleeding and
enable better hemodynamic stability, so that the patient could
safely be taken to the operating room
- The bleeding vessel was embolized with two coils and a Gelfoam
pledget
- His hemodynamic status improved after embolization.
- The catheter was left in the jejunal branch to help the surgeon
identify the bleeding segment quickly.
- The patient was sent to the operating room.
9. 10. 11. 12. 13. 14. 15. 16. Jejuna diverticulosis
- Acquired ,seen throughout SI: 79% duodenum, 18%jejunum&
ileum, 3% in all three segments.
- By UGl series, frequency of duodenal diverticula is 6 -7%
- The overall frequency of jejunoileal diverticula is 0.7%.
- Autopsy: prealence as high as 4.6%,most commonly seen in men in
the seventh or eighth decade of life.
- 35% are associated with diverticula of colon, 26% with
diverticula ofduodenum, 2% with diverticula of the esophagus.
- 46% have complications, as compared with 13% of patients with
duodenal diverticulosis.
- Symptoms, including pain, malabsorption due to bacterial
overgrowth, seen in 40% with small-intestine diverticulosis.
- Presentations with acute symptoms are seen in 18% & include
perforation, diverticulitis, hemorrhage.
- GIB is characteristically acute / massive
- The diagnosis is rarely made preoperatively with an acute
onset.
- It had a small neck-sac ratio, renders them difficult to
diagnose with oral contrast , because of poor filling of the
sac.