Section: Colorectal Sub-section: Acute colorectal Curriculum: Curriculum, page 24
Aetiology
- Degenerative - diverticular
- Neoplastic – polyps, cancer
- Inflammatory – IBD, colitis
- Vascular – ischaemic, angioectasias, Dieulafoy’s lesion
- Iatrogenic - post-polypectomy, postop
Investigations/Management
- Majority are self-limiting, expectant management
- Exclude upper GI source
- For stable patients, bowel prep and colonoscopy
- Can endoscopically manage with adrenaline injection, clip, diathermy or polypectomy
- For active bleeding, CTA.
- Red cell technetium scan
- Takes several hours. False localisation rate (25%)
- Angiography – usually super-selective vessels. Better accuracy when done soon after CTA.
- Surgery
- Indications:
- Transfusion requirements > 6 units
- Ongoing or recurrent haemorrhage not responding to non-operative option
- Persistent haemodynamic instability
- Best to localise prior to operating if possible.
- Lower mortality rate for segmental resection vs total colectomy.
- Can utilise on-table endoscopy.
- Indications:
Approach to unstable patient with massive GI bleeding
- Assess and resuscitate
- MTP
- TXA
- Reverse any anticoagulation
- If unstable
- Theatre for OGD (intubated)- if massive bleeding with haemodynamic instability it is most likely to be UGI rather than lower GI
- If does not localise
- Keep intubated and T/F to CTA to localise bleeding
- Then for angioemoblisation or surgical resection of bleeding
- Can consider on table colonscopy but this is often difficult due to blood
- If unclear location but thought to be lower GI then subtotal colectomy the recommended surgery