Lower gastrointestinal bleeding surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Surgery

Emergency surgery may be needed to control bleeding in about 10% to 25% of patients in whom nonoperative management is unsuccessful or unavailable.

Indications

Indications for emergent surgery include:

• Hemodynamic instability with active bleeding
• Recurrent bleeding
• Transfusion requirement of greater than 6 units of packed red blood cells (PRBCs) in 24 hours with active bleeding.
  • Patients requiring ten or more units of PRBCs in 24 hours have a significantly greater mortality than patients who receive less than 10 units of blood (45% vs 7%).

Surgical Options

• Surgical options include segmental resection and subtotal colectomy.
• If emergency surgery is required, definitive localization of the bleeding site is ideal, because segmental colonic resection is preferred.
• However, segmental resection should be avoided unless the source is definitely identified because this operation is associated with high rebleeding, morbidity, and mortality rates.
• If the bleed cannot be localized, a subtotal colectomy is the recommended procedure.
• Bleeding caused by tumors should be resected with the appropriate oncologic procedure to ensure adequate margins and lymph nodes in the specimen.
• Intraoperative proctoscopy may help to exclude bleeding from a rectal source in patients undergoing subtotal colectomy

Compliations

• Both emergency segmental resection and subtotal colectomy are associated with high morbidity and mortality and should, therefore, be considered as a final treatment option
• Subtotal colectomy is associated with the highest complication rates, with morbidity rates of 20% to 60% and mortality rates of 15% 17%.