Sigmoid Colon Haemrrhagic Colitis

- |T] 13.2 Bleeding from a Dieulafoy ulcer in the intestine -

Bleeding Dieulafoy Lesion

a, b Spurting blood from a Dieulafoy ulcer in the sigmoid colon (a). Bleeding stopped immediately after application of a hemoclip (Olympus) (b).

Bleeding Stopped Immediately After

c, d Adherent clot on a Dieulafoy ulcer (c). After washing off the clot the visible vessel underneath is clipped (Olympus) (d).

Sindrome Dieulafoy

e, f Dieulafoy ulcer in the small bowel (ileum) with visible vessel and slight hemorrhagic oozing (e). The lesion was reached endoscopically through an ileostomy and bleeding was stopped mechanically with a hemoclip (Olympus) (f).

a, b Spurting blood from a Dieulafoy ulcer in the sigmoid colon (a). Bleeding stopped immediately after application of a hemoclip (Olympus) (b).

c, d Adherent clot on a Dieulafoy ulcer (c). After washing off the clot the visible vessel underneath is clipped (Olympus) (d).

e, f Dieulafoy ulcer in the small bowel (ileum) with visible vessel and slight hemorrhagic oozing (e). The lesion was reached endoscopically through an ileostomy and bleeding was stopped mechanically with a hemoclip (Olympus) (f).

Dieulafoy Ulcer

Bleeding from a Dieulafoy ulcer in the stomach is not an unusual finding for the endoscopist, but it is an unexpected cause of colonic bleeding.

Dieulafoy lesions are caused by unusually large, tortuous vessels (arterioles) that are located at the affected area in the mucosa or submucosa. Small mucosal lesions can lead to massive spurting hemorrhage (0 13.2 a, b). Viewed endoscopically, one sees an adherent clot on a small lesion (0 13.2 c, d) or a visible vessel protruding from the mucosa (0 13.2e, f), which is not due to arteriovenous malformation. It has been postulated that the ruptured vessel is caused by fibrosis of the intima and loss of elastic fibers in the vessel wall.

Endoscopic therapy

► Endoscopic therapy of Dieulafoy lesions in the colon is based on experience with these lesions in the stomach.

► Successful achievement of endoscopic hemostasis using injection of sclerosing agents, band ligation, thermocoagulation, and hemoclips has been (casuistically) reported (0 13.2).

► A comparative study demonstrated that mechanical methods of hemostasis (hemoclip and band ligation) were clearly more effective in treating Dieulafoy ulcers (8% vs. 33%) than injection therapy (15).

Ischemia (see also Chapter 12)

Hematochezia is not infrequently caused by colonic ischemia (Tabs. 13.3, 13.4). The resulting lower gastrointestinal bleeding does not usually cause hemodynamic compromise. The patient complains of cramplike abdominal pain and usually diarrhea. In most cases, clinical picture is self-limiting and does not require any special treatment. Thus, one also speaks of transient ischemic colitis. However, there are also chronic forms and these can be difficult to differentiate from chronic inflammatory bowel syndrome (Tab. 13.6).

Endoscopic appearances vary in the course of disease. Submucosal hemorrhage and mucosal nodularity are typical endoscopic findings in early stages (0 13.3 a-c). Alternatively, the mucosa may not be edematous, but livid (0 13.3 d) or pale (0 13.3e). In later stages, when blood and edema have been resorbed, appearances are less characteristic. The mucosa may be red (0 13.3f, g), vessel pattern may be obscured, and ulcerations (0 13.3h, i) can appear. Changes are sometimes only segmental. In more serious forms the colon wall is covered by gray-white membranes (similar to pseudomembranous colitis) (0 13.3i) or gray-black membranes. After the membrane is sloughed off, ulcers appear. Endoscopic therapy options are limited unless a circumscribed bleeding source can be identified and treated.

Ischemic colitis lesions may also occur in association with vasculitis (Fig. 13.21). These are relatively rare and are usually only found in advanced forms of systemic vasculitis.

Table 13.6 Characteristics of colon ischemia (based on reference 35) Age

Cause

Clinical picture Localization

> 60 years old

< 60 years old

Idiopathic

Vasculitis

Aortic surgery

Oral contraceptives

Distal obstruction

Medication

Hypotension

Drugs

Thrombophilia

Infection

Pseudo-obstruction

Marathon running

Pheochromocytoma

Acute

Acute/recurrent

Splenic flexure

Ascending colon

Sigmoid colon

Cecum

Rectum

Sigmoid Colon

Fig. 13.21 Colon ulcer in vasculitis due to chronic polyarthritis.

Fig. 13.21 Colon ulcer in vasculitis due to chronic polyarthritis.

- [F| 13.3 Ischemic colitis: various appearances

- [F| 13.3 Ischemic colitis: various appearances

Sigmoid Flexure

a a, b Ischemic, nontransmural colitis, limited to the hepatic flexure in a 50-year-old female patient. a Endoscopy: swollen, bloodsoaked mucosa. b Histology: "damming" crypts and hemorrhagic inflammatory infiltrate, a typical finding for ischemic colitis (provided courtesy of Dr. Th. Wagner, Institute for Pathology, Augsburg Clinic). The patient recovered with conservative therapy.

Ischemia of the sigmoid mucosa in an 88-year-old female patient. The mucosa was reddened, swollen, vulnerable, and demonstrated sub-mucosal bleeding at multiple locations; histology showed this also to be ischemic colitis.

c a a, b Ischemic, nontransmural colitis, limited to the hepatic flexure in a 50-year-old female patient. a Endoscopy: swollen, bloodsoaked mucosa. b Histology: "damming" crypts and hemorrhagic inflammatory infiltrate, a typical finding for ischemic colitis (provided courtesy of Dr. Th. Wagner, Institute for Pathology, Augsburg Clinic). The patient recovered with conservative therapy.

Ischemia of the sigmoid mucosa in an 88-year-old female patient. The mucosa was reddened, swollen, vulnerable, and demonstrated sub-mucosal bleeding at multiple locations; histology showed this also to be ischemic colitis.

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Responses

  • athos
    Is haemrrhage a chronic or acute disease?
    2 years ago

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