Gastrointestinal bleeding is defined as bleeding from any part of the esophagus, stomach, with the small intestine and colon, divided into the upper and lower GI tract with the flexor ligament of the duodenojejunal migration as the boundary point. Bleeding from the lower GI tract as a symptom is clinically common and may be one of the manifestations of systemic diseases in the lower GI tract. Therefore, in addition to stopping bleeding and replenishing blood volume, it is most important to find the site of lower gastrointestinal bleeding and the nature of the disease for treatment of the original cause. There are many different causes of bleeding, and the clinical manifestations vary according to the amount of bleeding, speed and duration of stagnation in the intestinal cavity. Common causes are polyps, inflammatory bowel disease, tumors (benign or malignant), colonic diverticula, vascular malformations, internal hemorrhoids, and perianal diseases. There are very significant differences in the prognosis of the various etiologies. It is more important to identify the site and cause of bleeding as soon as possible. Finding the cause and site of lower gastrointestinal bleeding is sometimes difficult and requires repeated examinations, especially when the bleeding has not stopped (e.g., endoscopy, nuclear scan, angiography, etc.) Treatment should also be etiologically based to completely eliminate the root cause of the problem. The following is my deepest experience in treating this case, and I would like to share it with you: Du Xiangyang, Department of General Surgery, Siping Central Hospital
Patient Ye, male, 43 years old, was admitted to the hospital with recurrent bloody stools for 20 days, 1 year after hepatoportal bile duct cancer surgery. He was diagnosed with hepatoportal cholangiocarcinoma (type 1) one year ago and underwent two bile duct anastomoses on both sides, after which he was given 8 times of systemic chemotherapy. The condition was stable. 20 days ago, he had recurrent tarry stools, and the gastroscopy in the local hospital did not show any bleeding point.
On admission, blood pressure was low (80/50mmHg), heart rate was normal, and the patient was unwell. PTCD drainage was performed in the left liver. One week after the last bleeding, 2 hours before and after, dark red blood stool with a volume of about 800 ml appeared again. Before the bleeding, he had chills, high fever (temperature 41 degrees), abdominal pain and cold sweat. There was no blood in the PTCD duct, and the analysis was that of biliary bleeding at the site of the anastomosis. The only thing that could not be done was to embolize the hemorrhage because of the disorganized vascular mass in the hilar region. After conservative treatment with blood transfusion and hemostasis, the amount of bloody stool gradually decreased, and the color of stool turned yellow, and the bleeding had stopped. The symptoms were still high fever (temperature 40 degrees) and abdominal pain with cold sweats. The last gastroscopy pathology suggested that heterotypic cells were seen, and metastatic cancer was considered, and tumor markers were elevated, which also supported metastatic cancer.
After combining the above information, we considered to look for the bleeding point, and the suspicion of the hepatoportal vascular mass was the greatest. We decided to perform arteriography again, and if the bleeding point was still not seen, we would embolize the intrinsic hepatic artery. In fact, no spillage of contrast agent was seen after the angiogram, and then the hepatic artery was embolized with gelatin sponge. On the postoperative day, there was no further blood in the stool, but on the afternoon of the second day, there was a dark red blood stool with a volume of about 1000 ml, and after intraoperative discussion, an emergency caesarean section was performed. The recurrent mass was found to be located in the descending duodenum, infiltrated with the lower posterior wall of the anastomosis, hard and fixed, with blood remaining in the output intestinal canal. At the end of the operation, the patient recovered well and did not show any further symptoms of blood loss.
Now, let’s go back and analyze the treatment process: Gastrointestinal bleeding is divided into upper and lower gastrointestinal bleeding, first determine whether it is upper or lower gastrointestinal bleeding, gastroscopy is very clear, denying that it is upper gastrointestinal bleeding. That is the lower gastrointestinal bleeding, first paragraph by paragraph to exclude: colonoscopy did not see bleeding points, can exclude colorectal lesions bleeding, and 2 abdominal arteriography also confirmed the above point. There is also small intestine bleeding, and the possibility of small intestine bleeding is very, very small; there is not enough evidence to disregard first; then the rest is very reasonable biliary bleeding (with periodicity, chills, high fever, abdominal pain, cold sweat when blood in the stool), and there is no blood in the PTCD duct, the analysis of intrahepatic biliary bleeding is also unlikely; the most evidence is anastomotic bleeding: gastroscopic pathology, CT, elevated tumor markers . At that time, angiography suggested that bleeding from the disordered vascular mass in the hepatic portal was the culprit, although no contrast spillage was seen, it was also best to embolize the intrinsic hepatic artery to stop the bleeding, and it was minimally invasive, with small blows and good results. But why did it still bleed again? There are two reasons: 1. the liver is a dual system blood supply, in addition to the hepatic artery there is a portal vein blood supply, therefore, if the portal vein bleeding embolization of the hepatic artery is useless. 2. the gelatin sponge can be recanalized, theoretically 14 days can be recanalized, but the patient preoperative ultrasound has seen the liver arterial blood flow, so it can also be considered that there is no embolization, when the steel ring is better.