Mayo ClinicDivision of

Colon & Rectal Surgery

Integrated Care For

Digestive Disease

Non-Tumoral BleedingDiverticular Disease & Angiodysplasia

Eric J. Dozois, MD

Division of Colon and Rectal Surgery

Mayo ClinicRochester, Minnesota

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

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

Common Causes of Major LGIBMayo Clinic 1988 – 1996, 1018 pts*

Diverticulosis 30%

Angiodysplasia 4%

Diverticular Bleeding Non-inflammatory Pathogenesis

Vasa Recta

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.

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

Diagnosis - Diverticular Bleeding

• Diagnostic Options:1. Colonoscopy**

2. Tagged RBC scan

3. Mesenteric Angiogram

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%)

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

Epinephrine + Gold Probe Cautery

Diverticular Bleeding

QuickClip 2(Olympus)

Triclip(Wilson-Cook)

Resolution(Boston Scientific)

Endoscopic Clipping

Endoscopic Clipping

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

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

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

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

Surgical Intervention

• Elective (Acute or Chronic):– 2 or more episodes of transfusion

dependant bleeding

• Emergent (Unstable):– Stabilized first - endoscopic or

angiographic technique (bridge!)

Surgical Management

• Identified:

• Directed segmental resection

• Unidentified:

• Intraoperative colonoscopy

• Blind hemicolectomy

• Blind subtotal colectomy

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%

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

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.

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.

Diagnosis - Angiodysplasia

• Diagnostic Options:1. Colonoscopy**

2. Tagged RBC scan

3. Mesenteric Angiogram*• Selective Angiogram

Pooling of Contrast in Cecum

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

Angiodysplasia Jejunum

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

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

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