What are the preoperative details of surgical resection for lower gastrointestinal (GI) bleeding?

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

Acute lower gastrointestinal bleeding (LGIB) is a common clinical entity and is associated with significant morbidity and mortality (10-20%). As noted earlier, high-risk factors are advanced patient age (>60 y), the presence of multiorgan system disease, transfusion requirements (>4 units), need for operation, and recent physiologic/physical stress (eg, surgery, trauma, sepsis).

As discussed earlier, three major aspects are involved in managing LGIB. The initial priority is to treat the shock. Second, localization of the source of bleeding is required to perform the third task—formulating an interventional plan.

Insert a nasogastric (NG) tube in all patients. A clear bile-stained aspirate generally excludes bleeding proximal to the Treitz ligamentum. After the initial resuscitation, undertake a search for the cause of the bleeding to precisely locate the bleeding point.

Following accurate localization by angiography, bleeding can be temporarily controlled with either angiographic embolization or vasopressin infusion to stabilize the patient in anticipation of semiurgent segmental bowel resection. Segmental bowel resection is performed in the next 24-48 hours following correction of the patient's physiologic parameters, which include hypotension, hypothermia, acute hemorrhagic anemia, and deficient coagulation factors.

Use selective mesenteric embolization in high-risk patients for whom the operative management is associated with a prohibitive risk of morbidity and mortality. If mesenteric embolization is used, these patients must be carefully monitored for bowel ischemia and perforation. Any evidence of ongoing bowel ischemia and/or unexplained sepsis following mesenteric embolization requires exploratory laparotomy to resect the affected bowel segment. Perform subtotal colectomy with ileoproctostomy in patients with nonlocalized LGIB or bilateral sources of colonic hemorrhage.


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