What is the indication for vasoconstrictive therapy for lower gastrointestinal (GI) bleeding (LGIB)?

Updated: Jul 26, 2019
  • Author: Burt Cagir, MD, FACS; Chief Editor: BS Anand, MD  more...
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Answer

In patients in whom the bleeding site cannot be determined with the use of colonoscopy and in patients with active, brisk lower gastrointestinal bleeding (LGIB), angiography with or without a preceding radionuclide scan should be performed to locate the bleeding site as well as to intervene therapeutically.

Initially, vasoconstrictive agents, such as vasopressin (Pitressin), can be used. In an experimental study of treatment of LGIB by selective arterial infusion of vasoconstrictors, such as epinephrine with propranolol and vasopressin, although epinephrine and propranolol drastically reduced mesenteric blood flow, these agents also caused a rebound increase in blood flow and recurrent bleeding.

Vasopressin is a pituitary hormone that causes severe vasoconstriction in the splanchnic bed. Vasoconstriction reduces the blood flow and facilitates hemostatic plug formation in the bleeding vessel. Vasopressin infusions are more effective in diverticular bleeding, which is arterial, as opposed to angiodysplastic bleeding, which is of the venocapillary type. The results are less than satisfactory in patients with severe atherosclerosis and coagulopathy.

Intra-arterial vasopressin infusions begin at a rate of 0.2 U/min, with repeat angiography performed after 20 minutes. The bleeding stops in about 91% of patients receiving intra-arterial vasopressin but recurs in up to 50% of patients when the infusion is stopped. [56] If the bleeding persists, the rate of the infusion is increased to 0.4-0.6 U/min. Once the bleeding is controlled, the infusion is continued in an intensive care setting for 12-48 hours and then tapered over the next 24 hours. In patients with rebleeding, surgery should be considered.


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