Step 9: Surgery

•Surgery is usually reserved for patients who are having life-threatening bleeding, and other hemostatic techniques have failed to control the bleeding.

•An emergency operation for lower GI hemorrhage is ultimately required in 10–25% of patients.

•The usual indications for an operation are hemodynamic instability, clinical deterioration, transfusion requirements of more than 6 units, and persistent or recurrent hemorrhage.

•In real-life situations, it is usually difficult to make decisions based solely on criteria, and, therefore, surgical consultation should be obtained early in the course of severe bleeding.

•Surgery is also used in patients with recurrent diverticular hemorrhage.

•Surgery in lower GI bleeding is associated with high morbidity and mortality, and localization of the bleeding source before surgery is important for better outcomes. For this, per operative panendoscopy or laparoscopic assisted endoscopy may be done.

Suggested Reading

1.Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol. 2010;8:333–43.

This review summarizes the available evidence regarding colonoscopy and radiographic studies in the management of acute LIB.

2.Barnert J, Messmann H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol. 2009;6:637–46.

A comprehensive review for the management of lower GIT bleeding.

3.Song WK, Baron TH. Endoscopic management of acute lower gastrointestinal bleeding. Am J Gastroenterol. 2008;103:1881–7.

Although prior descriptions of LGI hemorrhage have encompassed bleeding sources beyond the ligament of Treitz, small intestinal bleeding represents a distinct entity whose management algorithm has been redefined by the advent of capsule and double-balloon endoscopy.

4.Barnert J, Messmann H. Management of lower gastrointestinal tract bleeding. Best Pract Res Clin Gastroenterol. 2008;22:295–312.

A comprehensive review of lower GIT bleeding.

5.Das A, Wong RC. Prediction of outcome in acute lower gastrointestinal hemorrhage: role of artificial neural network. Eur J Gastroenterol Hepatol. 2007;19:1064–9.

In this review, the technical development and potential use of artificial neural network in patients presenting with acute LGI bleed are discussed.

6.Bounds BC, Kelsey PB. Lower gastrointestinal bleeding. Gastrointest Endosc Clin N Am. 2007;17:273–88.

Lower endoscopic evaluation is established as the diagnostic procedure of choice in the setting of acute lower GI hemorrhage. A comprehensive review of lower GIT bleed.

7.Bhasin DK, Goenka MK, Dhavan S, Dass K, Singh K. Diagnostic value of ileoscopy: a report from India. J Clin Gastroenterol. 2000;31:144–6.

The ileoscopy is a useful adjunct to colonoscopy that not only helps to modify the diagnosis but also establishes it.