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Minimally Invasive Approach toIntestinal Bleeding
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231
Embolization has shown to lower mortality compared to emergent surgery and is
successful 90–95%. The goal of embolization is to decrease the blood ow to the
bleeding site enough to achieve hemostasis, while collaterals prevent ischemia to
adjacent tissues. Failed endoscopic treatment is an indication for embolization by
interventional radiology as well as massive GI bleeding that requires over fourunits
of blood or hemorrhagic shock. Embolization can be done with a temporary agent
or permanent device. Micro-coils are the preferred agent used for GI bleeds. An
angiogram is rst done to identify the bleeding site, and then agent is then delivered
via a vascular catheter into the selected artery. A completion angiogram is repeated
to conrm hemostasis.
Variceal bleeding accounts for about 10% of UGI bleeds and can be treated with
combination therapy including medical management (vasopressin and beta blockade) and endoscopic variceal band ligation. Sclerotherapy is also an option, but it is
less effective than banding. Variceal ligation is like hemorrhoidal banding, with
placement of small elastic bands in the distal esophagus. Rebleeding may require
additional therapies designed at decreasing portal hypertension.
Operative intervention for an UGI bleed is required in about 5% of patients and
carries a mortality upward of 25–30%. Emergent operative intervention should only
be considered in patients who have failed repeat attempts at endoscopic approaches
and embolization. In hemodynamically stable and symptomatic patients, endoscopic and radiologic options can be exhausted and repeated before surgical management is considered.
By the time surgery is considered, these patients are usually unstable, and therefore the use of the laparoscopic approach is not typically utilized. Unstable patients
may not be able to tolerate the pneumoperitoneum. For the open approach, a midline laparotomy is performed. Bleeding gastric ulcers should be treated with resection if technically feasible due to the risk of malignancy. Intraoperative endoscopy
can be useful in identication and localization of the bleeding ulcer. If the location
of the ulcer is not amenable for resection, a gastrotomy is most often performed followed by biopsy to rule out malignancy. Here, oversewing of the ulcer for hemostasis is performed. Biopsies should be taken from all four quadrants of the ulcer edge
for maximum diagnostic yield. If the ulcer is present along the lesser curvature at
the incisura and the ulcer requires resection, an antrectomy with a gastroduodenostomy (Bilroth I) or gastrojejunostomy (Bilroth II) reconstruction should be
considered.
For duodenal ulcers, persistent bleeding is typically caused by an ulcer in the
posterior wall which has eroded into the gastroduodenal artery. Ligation of the GDA
is most effective for hemostasis. The duodenum is mobilized by performing a
Kocher maneuver, and a duodenotomy made with a longitudinal incision along the
anterior wall of the stomach, starting approximately 2cm proximal to the pylorus,
extending through the pylorus and onto the anterior wall of the duodenum for
approximately 3–4cm in length. The gastroduodenal artery is then ligated by placing three sutures in a gure of eight fashions at the site of the bleeding vessel within
the ulcer, in the superior, inferior, and medial positions. This three-point ligation
(visualizing the face of a clock: 12, 3, and 6) with permanent suture is imperative
232
Gastroduodenal artery
Transverse pancreatic artery
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Fig. 1 Three-point
ligation of gastroduodenal
artery. In Asensio, Ciof
(Eds.) Atlas of Trauma/
Emergency Surgical
Techniques. Philadelphia,
PA: Elsevier/Saunders
A. M. Kapil and K. A. Davis
given the collateral blood supply from the transverse pancreatic arteries (see Fig.1).
When performing the three-point ligation, it is important to be cognizant of the
location of the ampulla of Vater. A probe or small catheter may be used in the
ampulla to help identify its location and prevent injury to the common bile duct.
After hemorrhage control is obtained, the longitudinal duodenotomy is then closed
in a transverse fashion, thereby constructing a Heineke-Mikulicz pyloroplasty.
2 Lower GI Bleed
A patient with lower GI bleed presents with hematochezia, rarely with melena even
if the bleed is originating in the right colon. Patients with a lower GI bleed usually
have normocytic RBCs, while iron deciency anemia suggests a chronic bleed.
Unlike an UGI bleed, patients usually have normal BUN-creatinine ratio. Any
patient presenting with a lower GI bleed should have an upper GI bleed ruled out.
After initial assessment of a patient’s hemodynamic stability, a colonoscopy is
the next step in diagnosis and treatment. The most common causes of acute severe
LGIB include diverticulosis, angioectasia, post-polypectomy bleeding, and ischemic colitis.
A colonoscopy allows for identication of the bleed about 50% of the time.
However, an unprepped bowel can decrease the rate of cecal intubation preventing
the identication of bleeding sites. It is imperative to carefully inspect the colonic
mucosa both on insertion and withdrawal since culprit lesions often bleed intermittently and may be missed when not actively bleeding. The endoscopist should intubate the terminal ileum to rule out proximal blood suggestive of a small bowel
Minimally Invasive Approach toIntestinal Bleeding
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233
lesion or rarely an upper source. An adult or pediatric colonoscope with a large
working channel (at least 3.3mm) should be used because the larger working channel facilitates suctioning of blood, clots, and residual stool and allows for the passage of large diameter (e.g., 10Fr) endoscopic hemostasis tools. Endoscopic therapy
options for acute LGIB include injection (most commonly dilute epinephrine), contact thermal therapies (bipolar/multipolar electrocoagulation, heat probe), noncontact thermal therapy (argon plasma coagulation), through-the-scope clipping
devices, and band ligation. Endoscopic clips are an attractive treatment modality for
diverticular bleeding. Compared to contact thermal therapies, clips avoid the theoretical risk of transmural injury and perforation in the thin-walled colon. Control of
diverticular bleeding using clips can be accomplished either by targeted clip placement directly on the bleeding stigma or by closure of the diverticular orice in a
“zipper-like” fashion resulting in bleeding tamponade (see Fig.2).
If a colonoscopy is unsuccessful in identication of the source of the bleed, then
imaging studies can be helpful inlocalizing the source (see Fig. 3). Classically, a
nuclear scintigraphy (tagged RBC study) was the next line for investigation, as it is
highly sensitive for bleeding and can identify bleeding rates of less than 0.5cc/min.
More recently, CT angiography has been used to identify bleeding sources, either to
guide future embolization or to guide surgical intervention in an actively bleeding
patient who transiently responds to resuscitation. A mesenteric angiogram can allow
Fig. 2 Algorithm for the management of patients presenting with acute LGIB stratied by bleeding severity. From LL, Gralnek IM.ACG Clinical Guideline: Management of Patients With Acute
Lower Gastrointestinal Bleeding [published correction appears in Am J Gastroenterol. 2016
May;111(5):755]. Am J Gastroenterol. 2016;111(4):459–474, with permission
234
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a b
A. M. Kapil and K. A. Davis
c
d
e
Fig. 3 Identication of LGI bleed. From Takeuchi N, Emori M, Yoshitani M, Soneda J, Takada M,
Nomura Y. Gastrointestinal Bleeding Successfully Treated Using Interventional Radiology.
Gastroenterology Res., with permission. (a) Endoscopy with massive clots over stomach. (b)
Contrast enhanced CT with extravasation from the posterior walls of the lower stomach body. (c)
Angiogram reveals extravasation from the posterior gastric artery. (d) A microcatheter in the posterior gastric artery. (e) The artery has been successfully occluded. (f) Endoscopy reveals Bormann
3 type cancer at the posterior walls of the lower gastric body
for treatment as well as diagnosis, although higher rates of bleeding are required for
identication (1–2cc/min). All three of these radiographic modalities will be successful if the patient is actively bleeding at the time of the study. Embolization
Minimally Invasive Approach toIntestinal Bleeding
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during angiography can be done as well if an active bleed is identied at that time.
As described in UGI bleed, embolization can be done using a temporary or permanent agent. However, there is more concern for ischemia in the colon after embolization because there are fewer collateral vessels in the colon. Patients who undergo
embolization for colonic hemorrhage should be closely monitored for ischemia and/
or perforation in the post-procedural time frame.
Surgery for continuing massive hemorrhage is reserved for hemodynamic instability, massive transfusion requirements, and persistent hemorrhage despite other interventions. If the bleeding is localized and other interventions continue to fail, a segmental
colectomy can be done; however, this is associated with a rebleed rate of up to 15%. On
the other hand, the subtotal colectomy has a high morbidity and mortality rate.
A subtotal colectomy is preferred for the hemodynamically unstable patient with
an unknown source of bleeding. A large midline incision would be made allowing
adequate exposure. The resection would be from terminal ileum to proximal rectum.
After resection, if the patient continued to be hemodynamically unstable, a damage
control approach should be taken. A temporary abdominal closure would be done,
and the patient is left in discontinuity. This allows for further resuscitation in the
ICU, and the patient would be brought back when she or he is stable. At the second
look laparotomy, a decision can be made if for an ileorectal anastomosis versus an
ileostomy.
If the patient is hemodynamically stable, a laparoscopic approach to a segmental
colectomy can be attempted. In both, right and left laparoscopic colectomies, the
patient will be positioned in a lithotomy position. For a right colectomy, the ports
would be placed in similar fashion to a laparoscopic appendectomy. A 12mm periumbilical port and additional 5mm ports in the left lower quadrant and suprapubic
region are placed, with an additional port in the left upper quadrant. The cecum and
the hepatic exure would be mobilized, taking care not to injure the duodenum
which lies below. The 12mm supraumbilical port can be upsized to allow for extraction of the colon. A laparoscopic left colectomy can be done in a similar fashion
with the working ports on the right side of the abdomen. If the patient is adequately
resuscitated at the time of surgery, reanastomosis is feasible and should be favored
over stoma formation.
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3 Small Bowel Bleeding
Massive small bowel bleeding is rare, accounting for 0.4% of all intestinal bleeds;
thus, no effective method has been established for diagnosis. If upper and lower
endoscopy are negative in the face of continued bleeding, the small bowel needs to
be evaluated. A CT angiogram, arteriography, and nuclear scintigraphy can again
help with localization of these bleeds. Wireless capsule endoscopy, double balloon
enteroscopy, and a radionuclide Meckel’s scan can also be used to localize bleeding
sites in the small intestine. In patients who are unstable and require exploration, ontable push enteroscopy can be helpful in identifying the bleeding site, as intestinal
peristalsis may cause blood to accumulate distal to the site of hemorrhage
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A. M. Kapil and K. A. Davis
Case reports and small studies however have evaluated the usefulness of laparoscopic approach to diagnosis and treatment in resuscitated patients with normal
vital signs. A laparoscopic evaluation of the small bowel can help to identify the
source of small bowel bleeding if the portion of bowel is lled with blood. The
intestinal wall should be explored for local prominence, pitting, overlapping, and
abnormal mesentery. The suspected bleeding segment should be palpated carefully
with clamps to feel its hardness, exibility, and activity. If a Meckel’s diverticulum
is identied while laparoscopically evaluating the bowel, a small bowel resection
can be done. The resected bowel should include a few centimeters of small bowel
distal to the Meckel’s diverticulum, because the bleeding site would likely be distal
to the diverticulum.
In conclusion, nonsurgical management, including medical therapy, resuscitation, and correction of coagulopathy, remains the primary management for GI
bleeding. The minimally invasive techniques in these diseases focus on endoscopy.
Again the acute care surgeon should be familiar with doing therapeutic endoscopy.
Endoscopy and interventional radiology treatments decrease mortality in these
patients and have high rates of success. Surgery is a last line of treatment as it carries a high morbidity and mortality. The laparoscopic approach can be utilized in
selective patients, but as the indication for surgery is most likely to be continued
instability, the open approach is most often utilized.
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Further Reading
Ahad S, Figueredo EJ.Laparoscopic colectomy. Med Gen Med. 2007;9(2):37.
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Blatchford O, Murray WR, Blatchford M.A risk score to predict need for treatment for upper-
gastrointestinal haemorrhage. Lancet. 2000;356(9238):1318–21.
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Casas A, Gadacz T. Laparoscopic management of peptic ulcer disease. Surg Clin N Am.
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stratication, diagnosis, and management: 2016 practice guidance by the American Association
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hep.28906. Epub 2016 Dec 1. Erratum in: Hepatology. 2017 Jul;66(1):304.
Greco L, Koller S, Philp M, Ross H.Surgical management of lower gastrointestinal hemorrhage:
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Lau JY, Sung JJ, Lee KK, Yung MY, Wong SK, Wu JC, Chan FK, Ng EK, You JH, Lee CW, Chan
AC, Chung SC.Effect of intravenous omeprazole on recurrent bleeding after endoscopic treat-
ment of bleeding peptic ulcers. N Engl J Med. 2000;343(5):310–6. https://doi.org/10.1056/
NEJM200008033430501.
Lee CW, Sarosi GA Jr. Emergency ulcer surgery. Surg Clin North Am. 2011;91(5):1001–13.
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inhibitor therapy in peptic ulcer bleeding. BMJ. 2005;330(7491):568. https://www.proquest.
com/scholarly- journals/systematic- review- meta- analysis- proton- pump/docview/1777629388/
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Am J Gastroenterol. 2016;111(4):459–74.
Takeuchi N, Emori M, Yoshitani M, Soneda J, Takada M, Nomura Y.Gastrointestinal bleeding
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Bowel Ischemia
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FrancescoPata, AntonioPata, GianlucaPellino,
GaetanoGallo, andGiancarloD’Ambrosio
The term “bowel ischemia” encompasses a wide range of diseases, ranging from
self-limiting conditions, usually responding to conservative treatment, to surgical
emergencies, associated with high mortality rates. In acute setting, according to
anatomy, different pathogenesis, and clinical evolution, we can classify them in two
main categories: acute mesenteric ischemia (AMI) and colon ischemia (CI), also
named ischemic colitis (IC). Bowel ischemia may also be secondary to other pathologies, such as strangulated hernia and intestinal occlusion, but, in these cases, it
should be regarded as a complication of the related disease and falls outside the
scope of the present chapter.
While AMI is a surgical emergency with high mortality, CI may be treated con-
servatively in most cases, and surgery is indicated in case of gangrene, perforation,
or unresponsive disease (Table1). In this chapter, we provide an overview of the
F. Pata (*)
Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, Italy
Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
A. Pata
Cardiology Unit, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
G. Pellino
Department of Advanced Medical and Surgical Science, Università degli Studi della
Campania “Luigi Vanvitelli”, Naples, Italy
Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
G. Gallo
Department of Surgery, Sapienza University of Rome, Rome, Italy
G. D’Ambrosio
Department of General Surgery, Surgical Specialties and Organ Transplantation, Sapienza
University, Rome, Italy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. Coccolini et al. (eds.), Mini-invasive Approach in Acute Care Surgery,
Hot Topics in Acute Care Surgery and Trauma,
https://doi.org/10.1007/978-3-031-39001-2_18
239
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Table 1 Differences between acute mesenteric ischemia (AMI) and colon ischemia (CI)
Acute mesenteric ischemia (AMI)
Incidence 1:1000 hospital admission 15–17 cases/100,000 person-years
Site Small bowel Large Bowel
Mechanism Usually occlusive (90%): embolism,
arterial trombosis, venous trombosis
Clinical
features
Main
Diagnostic
tool
Treatment Usually surgical: resection of
Prognosis Poor Favorable
Mortality 50–90% according to lenght of the
Special
subtype
Acute onset abdominal pain out of
proportionin comparison tondings
of clinical examination
CTA (Computed tomography
angiography)
ischemic bowel +/− revascularization
in occlusive pathology if early
recognized
intestinal segmented affected and the
delay of surgery
VenousAcute Mesenteric
Ischaemia (VAMI): Mild symptoms,
younger patients, usually medical
therapy (unfractioned o low-weight
heparin) if no gangrene. Better
prognosis. Usually associated with
hypercoagulable conditions
Colon ischemia (CI)
Usually not occlusive: transient
ipoperfusion +/− colonic wall more prone
to ischemia (drugs, medical/surgical
conditions)
Abdominal pain, urgency for defecation,
rectal bleeding (or bloody diarrhea)
Colonoscopy (aCT scan with intravenous
contrast is often required before
endoscopy to exclude perforation,
gangrene or other disease)
Medical (conservative). Surgery in case of
gangrene/fuliminat IC or unresponsive
disease for 2–3weeks
10% (85% spontaneous resolution in
2–3weeks)
Isolated Right Colon Ischemia (IRCI):
more frequently occlusive mechanism.
Less frequently associated with diarrhea/
rectal bleeding. Worse prognosis. Fivefold
need for surgery and a higher mortality
(twofold). Usually associated with atrial
brillation, coronary artery disease and
severechronic kidney disease
F. Pata et al.
epidemiology, pathogenesis, diagnosis, and clinical management of bowel ischemia, highlighting the role of mini-invasive surgery in this setting.
1 Acute Mesenteric Ischemia
1.1 Introduction
Acute mesenteric ischemia (AMI) is a relatively rare condition, accounting 1 per
1000 acute admissions in Europe and in the USA [1, 2]. The median age is 70years
[3], but any age can be affected. As the incidence increases with the age, many
patients present several comorbidities and the clinical features are misleading, the
diagnosis is often late, and the high mortality is ranging from 60 to 80% [4]. “The
diagnosis is impossible, the prognosis hopeless, and the treatment useless”, a frequently cited quote by Cokkinis in 1930 [5], describes the challenge represented by
AMI in the current practice.
The common pathogenetic mechanism is represented by an inadequate perfu-
sion or insufcient venous drainage of a territory tributary of the superior
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mesenteric artery (SMA) sufcient (for amount and time) to injure the small
bowel wall, leading, if untreated, to ischemia, gangrene, and perforation. The extension of bowel loop ischemia, the timing of surgery, and preexisting patient diseases
are the main determinants of mortality.
241
1.2 Etiopathogenesis
Four types of AMI can be identied according to the characteristic mechanisms of
ow disruption [3, 6–8]:
1. Embolic acute mesenteric ischemia (EAMI) (45%)
2. Thrombotic acute mesenteric ischemia (TAMI) (25%)
3. Nonocclusive mesenteric ischemia (NOMI) (20%)
4. Venous acute mesenteric ischemia (VAMI) (10%)
The etiology may justify some differences in the past medical history, clinical
picture, and prognosis. TAMI occurs as a complication of an atherosclerotic plaque
usually at the origin of the superior mesenteric artery, so patients may have an history of postprandial abdominal pain, weight loss, and “food fear” (angina abdomi-
nis) and frequently present an history of other atherosclerotic disease and associated
factors, as myocardial infarction, stroke, arterial hypertension, and diabetes [9]. As
usually involves the origin of SMA, TAMI may result in a global ischemia of the
small bowel and right colon, and the prognosis is poor. Emboli usually lodge
3–10cm distal to the origin of SMA, distally to the origin of pancreatic-duodenal
artery and middle colic artery, so EAMI spares the rst jejunal loops and the transverse colon [10]. Atrial brillation and a recent episode of arterial embolism are,
respectively, detected in one-half and one-third of patients, and the onset of symptom is dramatic [11]. NOMI usually occurs in critically ill, shocked patients for an
episode of low cardiac output, with mesenteric hypoperfusion, often exacerbated by
vasoactive drugs. As patients are often mechanically ventilated, unconscious ICU
patients, the diagnosis is very challenging and clinical presentation misleading.
VAMI is usually a consequence of a slow process, symptoms tend to be milder,
with a more insidious outset, and the patients presents lately, some days after the
onset of symptoms with a gradually worsening abdominal pain evolving over
3–10days, but with further delayed presentations in some patients [12]. As the arterial perfusion is preserved and an irreversible ischemia happens lately, a prompt
anticoagulant therapy resolves the disease in the majority of cases without surgery.
Patients are younger than other groups and hypercoagulable states are the main
causative factor.
1.3 Clinical Presentation andDiagnosis
AMI usually presents with acute abdominal pain disproportionated to ndings
of clinical examination. Nausea, vomiting, and diarrhea may be present [13].
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