HEMORRAGIA DIGESTIVA BAJA

Lisandro Pereyra Servicio de Gastroenterologa y Endoscopa Hospital Alemn

Objetivos

Lo terico

Definicin Causas Abordaje Tratamiento

Lo prctico

Algoritmo

Definicin

Es originada por lesiones ubicadas por debajo del ngulo de Treitz

Epidemiologa

Es originada por lesiones ubicadas por debajo del ngulo de Treitz Es menos frecuente que la HDA Es mas frecuente en > 65 aos El 80% de los casos cesa espontneamente En un 25% de los casos se observa recidiva

Manifestaciones clnicas

Proctorragia, enterorragia
Hematoquezia Melena

Etiologa
Colon (85%)
Intestino delgado (5%) HDA (10%)

Etiologas mas frecuentes

Hemorroides Enfermedad diverticular: es la causa mas frecuente en edad avanzada. En gral autolimitada y recidivante. Mas frecuente es la localizacin de divertculos sangrantes en colon derecho, aunque los divertculos son mas frecuentes en colon izquierdo. Angiodisplasia: constituye la 2 causa en pacientes mayores. Se caracterizan por ser mltiples, > en colon derecho. Suelen generar sangrado recurrente y autolimitado.

Colitis isqumica

ABORDAJE....

Importante interrogar

Antecedentes personales y familiares de patologa del aparato digestivo Realizacin de colonoscopa previa (polipectoma) Episodios previos de sangrado
Cambios en el ritmo evacuatorio, perdida de peso, anemia (neoplasia) Diarrea inflamatoria, tenesmo rectal, dolor abdominal tipo clico (enfermedad inflamatoria intestinal) Sangre roja rutilante que aparece en el agua del inodoro o en el papel higinico (hemorroides)

Examen fisico

Primero SIGNOS VITALES: TA, FC, FR y T. Ortostatismo, ritmo diurtico, sensorio

Piel: palidez, cianosis Abdomen: dolor a la palpacin, masa palpable, signos de irritacin peritoneal Tacto rectal: para objetivar sangrado y evaluar lesiones anorrectales

Laboratorio

Hemograma: Hto, Hb, Plaquetas Coagulograma Urea (muy elevada) Creatinina normal

Saturacin de O2
Grupo sanguneo y factor Rh

Importante establecer pronstico.......

Factores de riesgo de mayor mortalidad

Edad > de 60 aos Hemorragia digestiva masiva con descompensacion hemodinamica Enfermedades asociadas: insuficiencia hepatica, renal, o respiratoria, IAM reciente, hepatopatia previa Antecedentes de hemorragia digestiva previa Recidiva precoz del sangrado

Validation of a clinical prediction rule for severe acute lower intestinal bleeding. Strate LL, Saltzman JR, Ookubo R, Mutinga ML, Syngal S.

FC >100 TAS < 115mmhg Sincope Sangre por el recto en las cuatro primeras hora de evaluacin AINES >2 comorbilidades

Riesgo de sangrado severo: Bajo riesgo: ninguna variable clnica (9%) Riesgo moderado: entre 1 y 3 variables (43%) Alto riesgo: mas de 3 variables (84%)

Am J Gastroenterol. 2005 Aug;100(8):1821-7.

Abordaje medico

Colocacin de 1 o 2 vas perifricas, eventual colocacin de va central para medir PVC Reposicin de lquidos (SF o coloides) Colocacin de sonda vesical para cuantificar diuresis (si esta oligrico) Eventual transfusin de Globulos Rojos Administracin de O2

DIAGNSTICO

Diagnstico y tratamiento especficos

Anoscopia-rectosigmoidoscopia Colonoscopia: visualiza todo el colon, permite obtener biopsia de lesiones sospechosas, realizar polipectomias, usar tecnicas de coagulacin para controlar hemorragias. Centellografia con GR marcados con Tc 99: localiza el sitio de sangrado, pero no la etiologia, necesario salida de sangre < 0,5 ml/min Arteriografia selectiva celiaco-bimesenterica: permite ver el sitio de sangrado, la posible etiologa y realizar hemostasia transitoria con vasopresina o embolizacion arterial. Es necesario salida de sangre > 0,5 ml/min y no requiere preparacin intestinal.

Colonoscopa
Preparar o no preparar antes de VCC? Preparar con que? En que momento la hacemos?

Preparar con que ?

Preparacin para colonoscopa

Evitar fosfatos....(pacientes hipovolmicos) PEG Enemas

Hepatogastroenterology. 2009 Sep-Oct;56(94-95):1331-4.

Management of acute lower intestinal bleeding: what bowel preparation should be required for urgent colonoscopy?

Saito K, Inamori M, Sekino Y, Akimoto K, Suzuki K, Tomimoto A, Fujisawa N, Kubota K, Saito S, Koyama S, Nakajima A. Source Department of Gastroenterology, Tokyo Metropolitan Hiroo Hospital, 2-34-10 Ebisu, Shibuya-ku, Tokyo, 150-0013, Japan. Abstract BACKGROUND/AIMS: The management of acute intestinal bleeding is not standardized. The aim of this study was to determine the most suitable method of bowel preparation for urgent colonoscopy. METHODOLOGY: One hundred and forty patients admitted with acute lower intestinal bleeding (ALIB) to our Hospital (April 1998 to March 2004) were studied. The preparation for colonoscopy consisted, usually, of oral administration of polyethylene glycol (PEG)-salt solution. For elderly patients or for those suspected of bleeding from a sigmoid colon lesion, colonoscopy was performed following glycerin enemas or water enemas. For patients with a suspected rectal lesion or soon after undergoing a polypectomy, colonoscopy was performed without any of the above procedures. RESULTS: Ischemic colitis was the most common cause of bleeding. The overall cecal completion ratio was 41%, compared with 74% in the PEG group. The percentage of those in whom colonoscopy was impossible (poor preparation) was 16% overall, compared with 5% in the PEG group. Endoscopic hematemesis were performed successfully for 26 patients who were mainly postpolypectomy cases or had rectal ulcers. CONCLUSIONS: In urgent colonoscopy, the preparation with PEG-salt solution may improve the patient's outcome. In postpolypectomy patients and those with rectal ulcers preparation was not always needed.

En que momento pedimos la VCC? Urgente o en forma electiva?

m J Gastroenterol. 2010 Dec;105(12):2636-41; quiz 2642. Epub 2010 Jul 20. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Laine L, Shah A. Source Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA. llaine@usc.edu Abstract OBJECTIVES: We sought to determine, in patients with serious hematochezia, the proportion who have an upper gastrointestinal (GI) source and whether urgent colonoscopy improves outcomes as compared with elective colonoscopy in those without an upper source. METHODS: Patients with hematochezia were eligible if they also had heart rate >100, systolic blood pressure <100, orthostatic change in heart rate or blood pressure >20, hemoglobin drop 1.5 g/dl, or blood transfusion. Patients had upper endoscopy within 6 h. Those without an upper source were randomized to urgent ( 12 h) or elective (36-60 h after presentation) colonoscopy. The primary end point was further bleeding. Patients were followed for the duration of hospitalization. RESULTS: Eighty-five eligible patients had urgent upper endoscopy; 13 (15%) had an upper source. The remaining 72 were randomized to urgent (N=36) or elective (N=36) colonoscopy. Further bleeding occurred in 8 (22%) vs. 5 (14%) of the urgent vs. elective groups (difference=8%, 95% confidence interval (CI)=-9 to 26%). Units of blood (1.5 vs. 0.7), hospital days (5.2 vs. 4.8), subsequent diagnostic or therapeutic interventions for bleeding (36% vs. 33%), and hospital charges ($27,590 vs. $26,633) also were not lower in the urgent group. A major limitation is that the study was terminated before reaching the prespecified sample size. CONCLUSIONS: Patients with clinically serious hematochezia should have upper endoscopy initially to rule out an upper GI source. Use of urgent colonoscopy in a population hospitalized with serious lower GI bleeding showed no evidence of improving clinical outcomes or lowering costs as compared with routine elective colonoscopy.

Resultados

Papel de la COLONOSCOPIA?

Oportunidad de deteccin de estigmas colonoscopia precoz

Rendimiento diagnstico: 80 % Detencin espontnea de la hemorragia (85-90%)

CUNDO LA COLONOSCOPIA?

En las primeras 24 horas tras primera atencin. Tras estabilizacin del paciente y aproximacin diagnstica (contraindicacin: SHOCK).
Ventajas*:

Permitir la limpieza colnica Posibilidad de detectar estigmas o recidiva hemorrgica. Manejo ms eficiente del paciente: Tratamiento de la lesin *Gostout CJ. NEJM 2000; 342: 125-7 Gostout CJ. Am J Gastroenterol 2003; 98: 1996 9 Disminuir la recurrencia^ Garca Snchez MV. Gastroenterol Hepatol 2001; 24: 327 32 ^Jensen DM et al. N Engl J Med 2000; 342: 78 - 82 Acortar la estancia hospitalaria** ** Strate LL. Am J Gastroenterol 2003; 98: 317-22

Tratamiento especifico

Endoscopico: electrocoagulacion, termocoagulacion o clips Arteriografia: perfusion de vasopresina intraarterial o embolizacion arterial

Angiografa
Pacientes con descompensacin hemodinmica Falla de colonoscopa Sospecha de sangrado masivo

Am Surg. 2005 Jul;71(7):539-44; discussion 544-5. Superselective catheterization and embolization as first-line therapy for lower gastrointestinal bleeding. Neuman HB, Zarzaur BL, Meyer AA, Cairns BA, Rich PB. Emergent operative intervention for lower gastrointestinal bleeding (LGIB) is associated with significant morbidity and mortality. Advances in endovascular techniques have made superselective catheterization and embolization (SSCE) of small visceral arterial branches possible. We hypothesized that SSCE for LGIB would be an effective firstline therapy and associated with low mortality. We identified all patients that underwent visceral angiography at our institution from 1997 to 2003. Records from all patients with documented LGIB and in whom SSCE was used as first line therapy were reviewed. Twenty-three patients (69 +/- 11 years) were treated with SSCE as an initial intervention for LGIB. A definitive bleeding site was identified in 95 per cent of cases (22/23). Eleven patients (48%) developed an early complication [recurrent bleeding (n=5; two required surgery), asymptomatic ischemic colonic mucosa (n=3), acute renal insufficiency (n=1; resolved), and femoral pseudo-aneurysm (n=2; one treated operatively)]. Long-term (mean 19 months) follow-up was available for 17 patients. Five patients (22%) experienced recurrent LGIB, and three patients had evidence of colonic ischemic. One patient required endoscopic dilation of a stricture, and three underwent surgical resection. There was no mortality in our series.

Tratamiento quirurgico

Con el uso de la endoscopia terapeutica y la radiologia intervencionista, se ha reducido la necesidad de intervencion quirurgica Se reserva ante fracaso del tratamiento endoscopico (escleroterapia) o en pacientes graves con sangrado incoercible Se realiza la reseccion intestinal

Lo prctico

Colonoscopa
Angiografa Enteroscopa, estudio del ID (video cpsula)

MUCHAS GRACIAS