Total abdominal colectomy for control of massive lower gastrointestinal bleeding

From 1957-1990 four patients underwent total abdominal colectomy with primary ileoproctostomy for control of massive lower gastrointestinal hemorrhage at Field Memorial Community Hospital in the rural community of Centreville, Mississippi. Surgery was performed emergently in two cases, and urgent/electively in the two remaining cases. Bleeding was controlled in each case. Upper Gastrointestinal and rectal bleeding were excluded, but further attempts to localize bleeding were not performed due to the difficulty of obtaining these studies at our hospital and the questionable likelihood of localizing the bleeding site. Many authors recommend an aggressive diagnostic workup including radio-labeled RBC scintigraphy and mesenteric angiography to localize colonic bleeding. Their aim is to perform a directed colonic resection for control of bleeding. However, most authors support total abdominal colectomy in cases where 1) hemodynamic instability does not allow extensive preoperative evaluation 2) there is a recurrent bleeding 3) more than one site is visualized as bleeding 4) there is widespread diverticulosis in a good-risk patient or 5) diagnostic procedures are unavailable. The low morbidity and good bowel function achieved following total abdominal colectomy, combined with the unavailability of diagnostic radiographic studies leads us to recommend total abdominal colectomy for control of massive lower gastrointestinal bleeding. The mortality of the procedure can be minimized by operating in a timely manner, prior to 10 units transfusion or 4 units within 24 hours, or operating in cases of recurrent bleeding.