Vikram S. Kumar
Gillian Lieberman, MD
Lower GI Bleeds
Vikram Sheel Kumar, Harvard Medical School Year III
Gillian Lieberman, MD
September 2002
2
Vikram S. Kumar
Gillian Lieberman, MD
Mr. X, 78 years old, presents w/ maroon
stool and eighteen hours of prior bleeding per
rectum.
maroon/bright red: think lower GI bleed
And if melena: think upper GI, right?
Not necessarily, there is enough overlap between the two groups
that you would want further studies!
Index Case
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Vikram S. Kumar
Gillian Lieberman, MD
A single contrast Barium
enema shows multiple
outpouches throughout the
course of colon.
Courtesy Dr. Herbert Gramm
What fits
the DDX
for these?
She looks like an
Aunt Minny
(w/ diverticulosis)
to me!
Before we order tests, let’s check his history
4
Vikram S. Kumar
Gillian Lieberman, MD
Diverticulosis of the transverse
colon
Multiple
Diverticula
Double contrast barium study
Courtesy Dr. Herbert Gramm
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Vikram S. Kumar
Gillian Lieberman, MD
Note how the diverticula
appear on the mesenteric
side of the colon.
Source: © 2002 UpToDate
Originally from Textbook of Gasteroenterology, Yamada, 95
The Vasa recta penetrate
the circular muscle layer
of the colon, weakening
the wall.
Origins of diverticula
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Vikram S. Kumar
Gillian Lieberman, MD
• Sigmoid colon most common
• Rectum and bladder can mimic
sigmoid
Source: http://www.vh.org/Providers/Textbooks/ElectricGiNucs/AnatImages/BleedSites.html
Most common sites of GI Bleeds
Most Common
Causes of Lower GI
Bleeds
Diverticulosis
Angiodysplasias
IBD
Ano-rectal disease
Neoplasia
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Vikram S. Kumar
Gillian Lieberman, MD
Place a Nasogastric tube
No blood
Colonoscopy Institute upper GI bleed w/u
Identify source
Treat as appropriate
Negative/>>Blood
Scintigraphy
Arteriography
Blood
Approach to locate a Lower GI Bleed
(9) Diagnostic accuracy
of 72 - 86 % in patients
(10) Diagnostic accuracy rates range
from 24 to 91 %
(11) Success of 14 to 72%
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Vikram S. Kumar
Gillian Lieberman, MD
Let us assume we find nothing on
colonoscopy.. welcome to nuclear medicine
Scintigraphy : radionuclide in, gamma particles out recorded by
an external scintillation camera.
Scintillation is random fluctuation of EM field strengths about
the mean.
Source: Introduction to Nuclear Medicine, GE Medical Systems (www.gemedical.com)
It can detect blood
flow at .1cc/min
Vikram S. Kumar
Gillian Lieberman, MD
What type of Technetium do we use
for medical imaging?
Isotope Half Life
Tc-95 20.0 hours
Tc-95m 61.0 days
Tc-96 4.28 days
Tc-96m 51.5 minutes
Tc-97 2600000.0 years
Tc-97m 90.0 days
Tc-98 4200000.0 years
Tc-99 2.13E7 years
Tc-99m 6.0 hours
Tc-100 14.2 minute
Tc-99m 6.0 hours
Source: http://www.nobel.se/chemistry/laureates/1951/seaborg-bio.html
Source: http://www.atomicmuseum.com/tour/nuclearmedicine.cfm
Glenn Seaborg, the proposer of the
Actinide series in the Period Table, co-
discovered Tc-99m with Emilio Segre.
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Vikram S. Kumar
Gillian Lieberman, MD
Companion Patient 1: Mr. Y, a 77 year old man
with ESRD, presents with bright blood per rectum
Common
Iliac
Arteries
Spleen
Liver
Aorta
IVC
Stomach
Heart
BIDMC PACS
Tc-99m is
labeled to
autologous
RBCs
11
Vikram S. Kumar
Gillian Lieberman, MD
Dynamic scintigraphy performed with a
1 frame/min resolution for 48 minutes
There is radioactive uptake ascending from the cecum
to the colon.
12
Vikram S. Kumar
Gillian Lieberman, MD
Changing lookup color
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Vikram S. Kumar
Gillian Lieberman, MD
Companion Patient 2: This patient had
an ascending bleed from the cecum.
Courtesy: Kevin Donohoe, MD
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Vikram S. Kumar
Gillian Lieberman, MD
Companion Patient 3: Notice the bleed
through the small bowel
Courtesy: Kevin Donohoe, MD
15
Vikram S. Kumar
Gillian Lieberman, MD Index case
Back to Mr. X. After a positive scintigraph, a
mesenteric angiogram is performed
AP View Mask Mask subtracted
"78 year old man with hx of diverticulosis
and right hemicolectomy now with
recurrent LGIB of obscure source.
Localize the source of GI bleed.”
BIDMC PACS
Angio can detect blood flow
at .5 cc/min
16
Vikram S. Kumar
Gillian Lieberman, MD
A view of the IMA
Source: Henry Gray (1825–1861). Anatomy of the Human Body. 1918. www.bartleby.com
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Vikram S. Kumar
Gillian Lieberman, MD
An Angiographers view of the
world
IMA
Ascending branch
of the Left Colic Artery
Haustra
Aorta
Small Intestine
Catheter injecting
Ioversol/Optiray
Source: BIDMC PACS and consultation with Dr. Mastromatteo
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Vikram S. Kumar
Gillian Lieberman, MD
The mesenteric arteriogram was
performed to localize the lesion.
19
Vikram S. Kumar
Gillian Lieberman, MD
A more oblique view to focus in
the area of suspected extravasation
Note the
extravasation of
contrast in the left
side of the pelvis.
This is the bleeding
site.
Transcatheter infusion of vasopressin caused cessation of the
bleeding with no recurrence on repeat angiogram.
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Vikram S. Kumar
Gillian Lieberman, MD
Summary
• Use your radiology knowledge to pin-point the etiology of
a presentation.
• Rule out an Upper GI Bleed via NG aspirate.
• Order a colonoscopy to study the bowel and rule out
carcinoma.
• Use scintigraphy to localize subtle bleeds.
• Follow up with angiography and tx.
• Do not be afraid to repeat tests if you are surprised by a
result.
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Vikram S. Kumar
Gillian Lieberman, MD
References
1. Peter D, Dougherty J. Evaluation of the patient with gastrointestinal bleeding: an evidence based
approach. Emerg Med Clin North Am. 1999;17:239-261.
2. Cinematic Nuclear Scintigraphy Reliably Directs Surgical Intervention for Patients With
Gastrointestinal Bleeding Brian B. O'Neill, MD et al. Archives of Surgery, Vol. 135 No. 9,
September 2000
3. Use of technetium-labeled red blood cell scintigraphy in the detection and management of
gastrointestinal hemorrhage. Voeller G, Bunch G, Britt L.
Surgery. 1991;110:799-804.
4. Accurate localization and surgical management of active lower gastrointestinal hemorrhage with
technetium-labeled erythrocyte scintigraphy.
Suzman M et al. Ann Surg.1996;224:29-36.
5. Lower Gastrointestinal Bleeding, Burt Cagir, MD and E. Cirincione
(http://www.emedicine.com/med/topic2818.htm)
6. Harrison’s Online: Chapter 44: Gastrointestinal Bleeding, Colonic Sources of Bleeding
7. Harrison’s Online: Chapter 283: Gastrointestinal Endoscopy
8. Approach to the patient with Acute Gastrointestinal bleeding,
(http://jeffline.tju.edu/CWIS/DEPT/GI/education/pdfs/approach.pdf)
9. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge.
Jensen DM; Machicado GA. Gastroenterology 1988 Dec;95(6):1569-74
10. Imbembo, AL, Bailey, RW. Diverticular disease of the colon. Textbook of Surgery, 14th ed,
Sabiston, DC Jr (Ed), Churchill Livingstone 1992. p.910.
11. UpToDate, Colonic diverticular bleeding
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Vikram S. Kumar
Gillian Lieberman, MD
Acknowledgements
• Gillian Lieberman, MD
• Michael Mastromatteo, MD
• Kevin Donohoe, MD
• Herbert Gramm, MD
• Larry Barbaras and Cara Lyn D’amour
• Pamela Lepkowski
Lower GI Bleeds
Slide Number 2
Slide Number 3
Diverticulosis of the transverse colon
Slide Number 5
Slide Number 6
Slide Number 7
Let us assume we find nothing on colonoscopy.. welcome to nuclear medicine
Slide Number 9
Companion Patient 1: Mr. Y, a 77 year old man with ESRD, presents with bright blood per rectum
Dynamic scintigraphy performed with a �1 frame/min resolution for 48 minutes
Changing lookup color
Companion Patient 2: This patient had an ascending bleed from the cecum.
Companion Patient 3: Notice the bleed through the small bowel
Index case�Back to Mr. X. After a positive scintigraph, a mesenteric angiogram is performed
A view of the IMA
An Angiographers view of the world
The mesenteric arteriogram was performed to localize the lesion.
A more oblique view to focus in the area of suspected extravasation
Summary
References
Acknowledgements