[Emergency surgery in severe lower gastrointestinal hemorrhage]

There are no conclusive studies that would allow us to distinguish between patients with severe lower gastrointestinal hemorrhage (LGIH) who require emergency surgery and those who do not. The aim of the present study was to determine the clinical and epidemiological factors that would allow us to distinguish between severe LGIH requiring emergency surgery and self-limiting LGIH and to analyze the surgical management of these patients.

We reviewed 175 patients with LGIH (severe rectal bleeding with a decrease in hematocrit > or = 10 points or transfusion of at least three units of packed red blood cells) treated between 1980 and 2002 and selected 28 patients (16%) who required emergency surgery. The control group consisted of patients with LGIH who did not require surgery. Student's t-test and the Chi-squared test were used in the statistical analysis.

Comparison of severe LGIH requiring emergency surgery with self-limiting LGIH revealed three variables that could serve as a guide to differentiating between these entities, namely: age less than 80 years (p = 0.013), the presence of hypotension on arrival at the emergency department (p < 0.0001), and cause of bleeding (p < 0.0001). Among patients requiring emergency surgery, the origin was ano-rectal in nine (32%) and consequently the approach used was perianal. In the remaining patients (n = 19) the abdominal approach was used. In 10 patients, etiologic diagnosis was not available before surgery and the source of bleeding was identified during the intervention in 6 of these patients. In the four remaining patients without etiological diagnosis before surgery, subtotal colectomy was performed. In the remaining patients, local resection of the affected area was performed (3 right hemicolectomies, 9 small bowel resections, and 3 resections of Meckel's diverticulum). Morbidity was 18% and mortality was 7%.

Distinguishing between self-limiting LGIH and LGIH requiring emergency surgery is difficult. In our series, the only factors predictive of emergency surgery were hemodynamic instability on arrival at the emergency department and age less than 80 years. Cause of bleeding is not a predictive factor as it generally unknown at symptom onset.