Related Experiment Videos
[Massive hemorrhage caused by colonic diverticulosis]
P L Colombo1, A Todde, M Belisomo
1Cattedra di Chirurgia Apparato Digerente, Università di Pavia-I.R.C.C.S. Policlinico San Matteo.
Insights
Massive colonic bleeding from diverticular disease is challenging. Angioarchitecture of diverticular walls contributes to hemorrhage, requiring advanced diagnostic and surgical approaches for effective management.
Area of Science:
- Gastroenterology
- Abdominal Surgery
- Vascular Biology
Background:
- Massive colonic hemorrhage from diverticular disease presents significant challenges in emergency abdominal surgery.
- The pathogenesis of bleeding diverticulosis is linked to the unique angioarchitecture of the colonic diverticular wall, where vasa recta penetration can lead to arterial rupture.
Purpose of the Study:
- To review the diagnostic modalities and surgical management strategies for massive colonic hemorrhage secondary to diverticular disease.
Main Methods:
- Review of diagnostic techniques including barium enema, colonoscopy, radionuclide bleeding scans, and emergency arteriography.
- Discussion of surgical interventions such as segmental resection, subtotal colectomy, and intraoperative management strategies.
Main Results:
- Colonoscopy has positive findings in 41.5%-83.7% of patients; radionuclide scans show 86%-94% sensitivity.
- Emergency arteriography localizes bleeding sources in 58%-86% of cases and is successful with vasopressin or embolization in 47%-92% of patients.
- Blind resections in elderly patients have high rebleeding rates (>60%) and mortality (30%).
Conclusions:
- Diagnostic imaging like arteriography is crucial for localizing bleeding in diverticular disease.
- Surgical treatment varies from segmental resection for localized bleeding to subtotal colectomy for diffuse or right-sided hemorrhage.
- Management decisions must consider patient factors, bleeding localization, and potential risks of rebleeding and mortality.
Abstract:
Massive hemorrhage from diverticular disease of the colon is a very difficult problem in abdominal emergency surgery. The pathogenesis of bleeding colonic diverticulosis is strictly correlated to the angioarchitecture of the colonic diverticular wall. Here the vasa recta penetrate the colonic wall from the serosa to the submucosa through connective tissue septa. Injurious factors arising from the colonic or diverticular lumen can produce an eccentric damage to the luminal side with intimal thickening, segmental weakening of the artery and its rupture with massive bleeding. Conventional barium enema is not able to show the source of the hemorrhage in the majority of the bleeding patients; colonoscopy, as primary emergency procedure, has significant positive findings in 41.5%-83.7% of patients. Radionuclide bleeding scans have a sensitivity rate of 86%-94%. Emergency arteriography localizes the bleeding source in higher rates ranging from 58% to 86% and is successful after intraarterial infusion of vasopressin or embolization in 47%-92% of patients. Surgical treatment for continued bleeding from diverticular disease is controversy. Segmental resection should be performed on patients with localized bleeding sources (positive arteriogram). Laparotomy, anterograde irrigation and intraoperative colonoscopy are indicated in patients with multiple bleeding sites and negative arteriography. Because the right colon is the most common site of bleeding in same cases is necessary to perform a subtotal colectomy with ileorectal anastomosis. Blind resections particularly in the elderly patients present high rebleeding rate (> 60%) and high mortality (30%) with sepsis accounting for the majority of deaths.