Severe acute lower gastrointestinal bleeding: risk factors for morbidity and mortality

Abstract

It is difficult to predict which patients are going to need urgent surgery in severe acute LGIB; only the presence of hypotension on arrival at the emergency ward would lead us to suspect a negative outcome for the hemorrhage. In severe acute LGIB, morbidity and mortality is high, and this is mainly due to the high level of associated comorbidity and the need for urgent surgery. It is necessary for strict hemodynamic monitoring of the patients at risk if we want to improve outcomes. The bleeding relapse rate is high in LGIB, although generally, it is not severe.

The water method is effective in difficult colonoscopy—it enhances cecal intubation in unsedated patients with a history of abdominal surgery

“…Others reported that in patients with difficult colonoscopy due to lower gastrointestinal bleeding 23,24 , including those with sigmoid resection and immediate post-operative hemorrhage 25 , the source of bleeding could be diagnosed more readily when the colonic lumen was filled with water. The use of water as an adjunct to air insufflation described almost three decades ago facilitated passage through segments of severe diverticulosis.…”

“…Characteristics pertaining to past history included abdominal and/or pelvic surgery 8,12,30,31 , diagnosed left-sided diverticulosis 31 , incomplete colonoscopy (due to redundant colon, difficult sigmoid or difficult sedation) 32 , unsatisfactory (poor) bowel preparation 33 and irritable bowel syndrome 31 . Characteristics associated with current colonoscopy included difficult anatomy 28 , patient pain or discomfort 28,30 , symptoms of inflammatory bowel diseases 12 , prolonged insertion time (>480 sec), technically difficult insertion 12 , lower gastrointestinal bleeding 24 , obstructing malignancy 28 , severe inflammation 28 , poor bowel preparation 12,28,30 , failure to reach the cecum 34,35 , unsedated colonoscopy 3,18,21,22,36 and colonoscopy following gastroscopy 31 . Methods reported to minimize patient discomfort or enhance cecal intubation during colonoscopy were reviewed 37 and included the use of pediatric colonoscope, variable stiffness colonoscope, gastroscope, computer assisted colonoscope, magnetic endoscope imaging, hypnosis, patient inhalation of nitrous oxide, listening to music, distraction by audio stimuli, or simply allowing the patients to participate in administration of the sedation medication.…”

Therapeutic and interventional endoscopy for gastrointestinal bleeding

“…Another factor determining the outcome of hemostatic procedures is knowledge of the limitations of hemostatic techniques and timing [47][48][49][50][51][52][53][54][55]. Delayed decision to refer the patient to surgery and irrational repeated attempts to achieve hemostasis can be just as devastating as bleeding by itself.…”

“…Bleeding usually occurs in the neck or in the base of the diverticulum and, in 75-80% of cases, stops spontaneously. Therefore, the diagnosis is often made by finding diverticula on colonoscopy in the absence of another identifiable cause of lower GI bleeding (50%) [55][56][57][58]. However, this assumption may be challenged, now that we know that the small bowel is an important source of obscure GI bleeding!…”

“…However, this assumption may be challenged, now that we know that the small bowel is an important source of obscure GI bleeding! Rarely, a clot is seen inside the diverticulum that has bled (20%) [51,[53][54][55][56][57][58]. Patients with a single self-limited episode of diverticular hemorrhage can be managed conservatively.…”