Diverticular bleed

[Bobblehead]

60yo with hypertension presents to the ER with blood on the toilet paper. He had a 4 unit diverticular bleed with a positive tagged RBC scan in the splenic flexure and left sided diverticuli (non-bleeding) on colonoscopy 12 months ago so he heads straight for the ER. His baseline Hgb is 11 and he arrives with a Hgb of 10. He has a large grossly bloody BM on arrival to the ER that evening and is mildly dizzy but otherwise fine.

After admission to the medical floor he undergoes a negative tagged RBC scan followed by a negative mesenteric angiogram the following morning. No more bleeding throughout the day but his Hgb is 8 the following morning and he subsequently has another large bloody bowel movement the night of the first hospital day with mild dizziness and a drop in his Hgb to 6. He did not get any blood products prior to this for whatever reason.

He's now transferred to the ICU where he has another grossly bloody bowel movement but remains stable otherwise. Notable finding now though is that his SBP drops to 60 and he becomes tachycardic when sitting up. He's told to lie back down while the first unit of blood begins to infuse and is watching TV comfortably in the room.

Options at this point?

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[SLUser11]

60yo with hypertension presents to the ER with blood on the toilet paper. He had a 4 unit diverticular bleed with a positive tagged RBC scan in the splenic flexure and left sided diverticuli (non-bleeding) on colonoscopy 12 months ago so he heads straight for the ER. His baseline Hgb is 11 and he arrives with a Hgb of 10. He has a large grossly bloody BM on arrival to the ER that evening and is mildly dizzy but otherwise fine.

After admission to the medical floor he undergoes a negative tagged RBC scan followed by a negative mesenteric angiogram the following morning. No more bleeding throughout the day but his Hgb is 8 the following morning and he subsequently has another large bloody bowel movement the night of the first hospital day with mild dizziness and a drop in his Hgb to 6. He did not get any blood products prior to this for whatever reason.

He's now transferred to the ICU where he has another grossly bloody bowel movement but remains stable otherwise. Notable finding now though is that his SBP drops to 60 and he becomes tachycardic when sitting up. He's told to lie back down while the first unit of blood begins to infuse and is watching TV comfortably in the room.

Options at this point?

If he shows signs of instability, such as hypotension refractory to IVF and blood, then he needs to go to the OR, likely for a subtotal colectomy and end ileostomy (can't assume the bleed is in the splenic flexure at this point).

In this case, where the patient is more stable, the old answer was 6 units of blood=trip to the OR, of course this is more variable in real life. For this patient, I think the first line treatment would be therapeutic and diagnostic colonoscopy.

That is, of course, assuming that you've already ruled out an upper GI bleed.

Either way, you should probably call a surgeon if you haven't already.

As for Tagged RBC scans, their results can be useful sometimes and not useful other times. The best bet is to get it immediately when the patient is bleeding, otherwise they're worthless. This becomes an issue because people always bleed in the middle of the night, and Nuclear Medicine techs never want to come in during the night, and will invariably ask if they can do it "first thing in the morning."

 

[Eta Carinae]

I might also chime in:
Platelet count
PFA, TEG (thromboelastogram) for platelet function
Coags
Fibrinogen etc
Could necessitate cryo or platelets or FFP transfusion

 

[SLUser11]

I might also chime in:
Platelet count
PFA, TEG (thromboelastogram) for platelet function
Coags
Fibrinogen etc
Could necessitate cryo or platelets or FFP transfusion

Basic labs (plt count, coags) would have been obtained initially.

If you are saying that the patient may be developing a coagulopathy secondary to PRBC infusion, associated with massive transfusion, then I would say that the patient's colon should be in a bucket.

Doesn't really apply to this patient, since he's getting his first unit of blood. I'm not sure how fibrinogen levels or giving cryo and FFP at this point would help.


Really at this point the patient needs a colonoscopy.

 

[Eta Carinae]

Basic labs (plt count, coags) would have been obtained initially.

If you are saying that the patient may be developing a coagulopathy secondary to PRBC infusion, associated with massive transfusion, then I would say that the patient's colon should be in a bucket.

Doesn't really apply to this patient, since he's getting his first unit of blood. I'm not sure how fibrinogen levels or giving cryo and FFP at this point would help.


Really at this point the patient needs a colonoscopy.

My point is to make sure underlying platelet dysfunction and coagulopathy are ruled out.

Platelet dysfunction or thrombocytopenia can manifest as GI Bleed; Upper>Lower but just to cover basics.

Pt sounds like a surgical candidate ultimately.

Agree with colonoscopy.

 

[Bobblehead]

To follow-up, the patient ended up getting a repeat angiogram the following morning which was positive for a blush/bleed and was coiled at that time.

This topic recently came up at one of the noon conferences and the advice from the GI discussant was to prep these people for a colonoscopy as an unprepped colonoscopy would be less effective. Of course, the institutional reality isn't as academic and mostly the GI service will refuse to perform endoscopy, as it did in this particular case. The rationalization in this instance was that they're convinced it's a low yield procedure and they are almost never successful in locating the bleeding diverticulum.

 

[SLUser11]

To follow-up, the patient ended up getting a repeat angiogram the following morning which was positive for a blush/bleed and was coiled at that time.

This topic recently came up at one of the noon conferences and the advice from the GI discussant was to prep these people for a colonoscopy as an unprepped colonoscopy would be less effective. Of course, the institutional reality isn't as academic and mostly the GI service will refuse to perform endoscopy, as it did in this particular case. The rationalization in this instance was that they're convinced it's a low yield procedure and they are almost never successful in locating the bleeding diverticulum.

Coiling a colonic bleed can be very dangerous, and is not usually endorsed as a primary mode of therapy....especially if the bleed is in a "watershed area" or the patient has any previous bowel surgeries. Some people are proponents of angio with catheter-directed vasopressin infusion, which usually works as a temporizing measure (since patients often rebleed), but can also be associated with the same risks of ischemia.

As far as the worries about an unprepped colon, one of the only good things about intraluminal blood is that it is a strong cathartic. Otherwise, a couple quick enemas may help you....I've used tap water with relatively good success....and you can always prep the colon if the patient is stable, like in this case. Either way, you usually do end up needing the endoscopic "power sprayer" to help wash away some blood.

The benefit of colonoscopy is that it is both diagnostic and therapeutic. You know if you're dealing with diverticulosis or an AVM or a bleeding cancer, in contrast to angio with coiling, where all you know is that you're dealing with bleeding.

Either way, colonoscopy is usually higher up on your algorithm for a LGIB than embolization. If your GI docs are refusing to do these, just remind them that it's the standard of care, and recommended by the American Society for Gastrointestinal Endoscopy, the American College of Gastroenterology, and the American Gastroenterological Association, so......

 

[jdh71]

I might also chime in:
Platelet count
PFA, TEG (thromboelastogram) for platelet function
Coags
Fibrinogen etc
Could necessitate cryo or platelets or FFP transfusion

Just get the coags. You'd have the platelets on the CBC that told you the Hgb was low, and it's pretty hard to have a coagulopathy without irregular coags

 

[michelleDO]

According to the FCCS book someone presenting with severe GIB

1. Assessment and PE -

Level of consciousness - intubate, vitals, signs of hypoperfusion,
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place NGT must rule out upper GI bleed which can be brisk enough as can be seen as Lower GI bleed
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check for hemrhoids - internal or external - can be massive
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Labs, type cross match, coags

2. Resuscitation deem necessary - always done first while working up diagnosis - use NS and pRBC, CVP

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3. diagnositic/therapeutic - agree with SLUser11 that endoscopy with therapy if unsuccessful consider surgery then angiography with embolization use with unstable patients or when not candidate for surgery

GI endoscopy is important both upper and lower GIB for dx, tx, anticipation of rebleeding and planning other diagnostic intervention.

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of course correct coagulopathy
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If suspect of sepsis always initiate early empiric antibiotic treatment-improve mortality - more likely yes with diverticulitis
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don't forget somatostatin/octreotide to buy you time awaiting endo or angio for upper variceal bleed
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always always PPI drip bolused then follow with 72 hours of drip. and continous care