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Massive Bleeding of Colonic Origin
Massive Bleeding of Colonic Origin EDWARD S. JUDD, M.D.
Melena as a cause of hospitalization is not particularly unusual, but massive bleeding from the colon is rare enough that not all surgeons have a great deal of experience with it. The patient and his relatives may be alarmed about the amount of bleeding or what they think is its amount, but observation in the hospital may show that only a little bleeding has been producing excessive fears. A definite mistake is to assume that all of the bleeding has its origin in hemorrhoids, as hemorrhoids are so common and the typical patient will recall having had hemorrhoids for some time. It is indeed possible that serious hemorrhage may have its source in these lesions, but the alert physician will press onward with his diagnostic measures before acceptjng them as the only source. Bleeding of significant degree arising from within the colon formerly meant cancer in every case until definite proof of another lesion was obtained. In recent years, we have learned that this may not be justified to nearly the degree we formerly thought. The physician dealing with such cases will often notice that anemia can be a rather chronic problem, and the detection of the source of the bleeding may test his ingenuity. The majority of patients harboring colon lesions do not experience massive hemorrhage at any time. Frequently direct questioning will elicit the fact that the stools have been streaked with blood or occasionally maroon stools have been passed. Even today it is most discouraging to note how many patients will procrastinate, hoping the bleeding will stop and trusting that no serious lesion is present. Finally the severe anemia, probably coupled with advanced obstruction, will force them to report to the hospital, but by this time nothing more than palliative surgery may be possible. Massive bleeding, of course, would force the issue much sooner and might serve as a blessing in disguise by forcing the initiation of curative attempts long before metastasis develops. In isolated instances, exsanguinating hemorrhage may be witnessed. This can be most alarming, not only to the patient and his family, but also to even the most experienced physician. The nature of the blood being passed can suggest the colon as the source of the bleeding. Yet the diagnosis may remain in great doubt, even though the patient appears to be in desperate circumstances. Time is of the utmost imporSurgical Clinics of North America- VoL 49, No.5, October, 1969
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tance here, and an ordinary diagnostic routine may be quite out of the question. Such circumstances will continue to pose acute problems in the selection of proper diagnosis, proper preparation, and proper timing of surgical interventionJf indeed a surgical lesion is proved.
POSSIBLE CAUSES OF THE MASSIVE BLEEDING Gastrojejunal Colic Fistula In an earlier day, the gastrojejunal colic fistula (Fig. 1) was all too common. Fortunately, it is now becoming rare, since surgery for peptic ulcer has taken a different form. But when present, it poses great difficulty in diagnosis, preparation, and management. In some cases the symptoms are surprisingly few and mild until massive hemorrhage develops. One would expect hematemesis as well as massive colonic hemorrhage, but this does not always occur. In the majority of instances, peptic ulcer is the original offender and the gastrojejunal colic fistula develops as a complication of surgical attempts to control the ulcer. During the years when gastroenterostomy was considered the acceptable procedure for surgical management of duodenal ulcer, gastrojejunal colic fistula was not at all rare. The fistula may not have developed for a surprising number of years after the gastroenterostomy, and the surgeons may have relaxed in their vigil and may well have reported excellent results of their original surgical management. But gastric resection, even of an extensive nature, was not without its difficulties in regard to ultimate formation of a gastrojejunal colic fistula. Although massive colonic hemorrhage was not common with these fistulas, diagnosis could be difficult because the customary approach to
Figure 1. Gastrocolic fistula, the source of massive bleeding. Gastric mucosa may be seen through fistulous opening in transverse colon.
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these problems would be the administration of barium by mouth to outline the stomach or gastric remnant. In the experience at this clinic, failure to demonstrate the fistula was frequent. My colleagues and I have found that a colon x-ray demonstrates the fistula in a much higher percentage of cases. Fortunately, surgeons are alert to the development of adjuncts to surgical care; so more recently a one-stage operation has been employed with surprisingly low mortality. Other less common causes of gastrojejunal colic fistula must include carcinoma of the stomach with erosion into the transverse colon and· ulcerative colitis with its inevitable tendency to form fistulas into adjacent organs. Most often other symptoms and signs disclose the offending mechanism before massive bleeding from the colon is evident, but our files contain the records of a few cases of each of these entities which illustrate the confusion that has resulted.
Polypoid Disease Polyps of the colon are very common indeed and usually do not present great difficulty of the kind under discussion. Many of them can be reached by the sigmoidoscope and fulgurated thus. Isolated pedunculated polyps higher in the colon, if of significant size, can be dealt with at very low risk through operative maneuvers. It is true that the bleeding from polyps is rarely massive, but occasionally surprisingly large polyps (4 cm or more in diameter) are witnessed and these can ulcerate and bleed to an alarming degree. The patient and the surgeon are ·fortunate indeed if this is the only problem involved, because its solu.tion is obvious and relatively easy. Multiple polyposis presents an entirely different problem. Usually there is a long history of disease and the patient is anemic, but with little history of frightening hemorrhage from the colon. At least 50% have family members with a similar problem. The tendency to development of carcinoma in all of these persons is so well known that I will not dwell on it (Fig. 2). We rarely have difficulty with these families now, since the proper treatment-namely colectomy-is being carried out with such a low risk that the younger members do not hesitate to report when any symptoms develop and, more importantly, they are being studied by colon x-ray and sigmoidoscope even when asymptomatic b€cause they are members of known "polyp families."
Carcinoma When colonic hemorrhage appears, carcinoma is the lesion uppermost in the minds of not only the patients but also the doctors responsible for their welfare. Massive hemorrhage is not the presenting symptom in most cases, though it may be encountered sometimes. More often, progressive anemia brings the patient to the doctor and direct questioning leads to the admission that there may have been short episodes of very significant hemorrhage. When the carcinoma is in the right colon, we find it much more difficult to detect unless there are other symptoms to accompany it. Obstruction is a very rare feature of right-colon carcinoma. Anemia may lead to some investigation, includ-
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Figure 2.
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Hemorrhagic polyposis of colon with carcinomatous transformation (arrow).
ing a colon x-ray. A single so-called negative colon x-ray can lead to serious mistakes. In such a situation, a second and occasionally even a third x-ray may be necessary before a small carcinoma may be detected in the right colon (Fig. 3). This is quite unusual in the present context, as such a lesion rarely causes massive bleeding, but it must be included in our differential diagnosis. Vascular Occlusion With Ulceration Although occasional instances of vascular occlusion with ulceration have been witnessed in the past, we are hearing more about these lesions because of the current widespread interest in vascular diseases. Such changes are being recognized much more commonly and documented in a more impressive manner. Venous occlusion has led to alarming hemorrhage in isolated instances (Fig. 4). Many times this was simply a part of the generalized vascular change throughout the venous system, but an isolated change within the colon probably would never be thought of except on very thorough consideration. Arterial changes now are detected much more commonly because of the phenomenal strides that have been made in arteriography. Certainly an arterial lesion within the colon could be accompanied by exsanguinating hemorrhage. If the patient is seen during such an episode, prompt angiography not only will prove the source of the bleeding hut also will point with great accuracy to its site. In this regard, since a fund of experience in surgery for aneurysm
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Figure 3.
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Bleeding carcinoma of ascending colon, not detected on first x-ray study.
has now been accumulated, we are all alert to the possibility of an aneurysm (or, more often, an aneurysm graft) leaking into the intestine. If such a graft is known to have been inserted and the patient later presents with massive intestinal bleeding, the presumptive evidence is strong enough for immediate surgical intervention. Those aneurysms which have not been detected previously or not dealt with by graft surgery may produce exsanguination before the diagnosis is established. Most often the type of bleeding suggests the small intestine rather than the colon, but the bleeding is so furious and voluminous that httle time is available for differential diagnostic studies. Diverticular Disease The term "diverticular disease" is employed since, although diverticulosis is a common development after middle life (it is said that perhaps 10% of the people beyond their fortieth year have diverticula), we have always considered problems arising from these changes as being due directly to the inflammation of the sacs. Probably 5 to 10% of
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Figure 4. Venous occlusion with ulceration near hepatic flexure.
the people who harbor the diverticula suffer at some time from diverticulitis. However, I have witnessed massive colonic bleeding arising apparently from simple diverticulosis without certain evidence of true diverticulitis (Fig. 5). This has led all of us to realize in more recent years that bleeding from the colon need not mean carcinoma in every single case. In fact, the massive nature of the bleeding may favor a presumption that the source of the bleeding is diverticulosis without inflammation or tumor formation. Rigg and Ewing have presented a summary of current attitudes toward this likelihood. Considerable emphasis is now being placed on diverticular disease, which to me seems by far the most important possibility when there is massive bleeding of colonic origin. Unfortunately, even today we have no really effective method of determining the exact site in the colon where the bleeding originates, and this may present not only a problem but a most serious danger. We have all seen the frequent well-documented localization of diverticulitis in the sigmoid only, even though the entire colon shows obvious diverticulosis. It is tempting to assume
I
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Figure 5.
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Hemorrhagic diverticular disease of sigmoid colon.
that the bleeding in such a case comes only from the sigmoid. The Mayo Clinic files contain a number of resected specimens which, on very close microscopic study, have finally revealed the offending diverticulum with the open vessel in its base (Fig. 6). Perhaps if pathologists had the time and inclination to examine serial sections of all such specimens, this change would be found much more frequently and we then would be more reluctant to accept the statement that no diverticulitis need be present before hemorrhage. Healey and Pfeffer reported that massive bleeding was the chief
Figure 6.
Diverticulum with fresh thrombus in artery at its base (x85).
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indication for surgical treatment in 5% of 160 patients requiring surgical management of diverticulitis. Noer, an outstanding authority on diverticulitis and its surgical management, has stated that some degree of very obvious bleeding from the colon may be noted in perhaps 30% of diverticulitis cases. From the standpoint of the surgical pathologist, Dockerty admitted that, although there had been a great deal of discussion about this problem, no real correlation between the bleeding and certain pathologic changes in the diverticula had been established. Therefore Mobley, Dockerty, and Waugh attempted to do that. The basis of their study was the 2000 patients presenting at the Mayo Clinic from 1940 to 1954 with diverticulitis that was producing symptoms. Of this group, a total of 145 patients (7%) had passed significant quantities of blood by rectum and, after effective surgery, no cause for their bleeding except diverticulitis could be located. Thirty-two of the surgical specimens had been preserved in such a manner that detailed pathologic survey could be carried out. Here again, although bleeding was the chief symptom which differentiated this group of patients, in only one case had the hemorrhage been truly massive. In 18 of the specimens, however, a significant ulcer or inflammatory granulation tissue in and about the diverticula was demonstrated. In one, an inverted diverticulum bore an ulcer on its tip. This phenomenon has been witnessed with increasing frequency at the Mayo Clinic. Dockerty is willing to accept the conclusion that ulcerative processes are probably always responsible for the bleeding in colonic diverticulitis. He believes that the pathologist is truly fortunate to be able to demonstrate an eroded artery in the base of the diverticulum. In presenting to a conference such a case, where the diverticulum was actually in the right colon, he stated he was able to find only three welldocumented similar cases in the literature, one of which had been described by Healey and Pfeffer, another by Earley, and the third by Weingarten and coauthors. In attempting to record Mayo Clinic experiences with significant bleeding that accompanied diverticular disease of the colon, I am mindful that the coexisting disease may introduce considerable confusion. The suspected portion of the bowel may contain a polyp (Fig. 7), and it is not at all uncommon to find one within the resected specimen, but proof of the exact site of the bleeding will not be forthcoming postoperatively. In addition, radical colectomy sometimes has been completed before the surgeon remembered to check carefully for Meckel's diverticulum. The coexistence of bleeding Meckel's diverticulum with universal diverticulosis of the colon is not common but certainly could serve to cloud a statistical study. Most often the surgeon's problem will be massive bleeding from the colon which has stopped before surgical consultation was sought. Many times colon x-rays reveal diverticula only on the right side of the colon, and the surgeon who has decided for himself that diverticulitis almost never strikes in the right colon will be led astray unless he keeps in mind the discussion above. More often diverticula may be indicated at other points in the colon-and even throughout the colon-so that the
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Figure 7. bleeding?
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Diverticulosis with large polyp in sigmoid (arrow). Which lesion produced the
exact area to be treated surgically will be most difficult to identify before operation.
Ulcerative and Inflammatory Disease Chronic ulcerative colitis and Crohn's disease of the colon, now generally known as "granulomatous colitis," should not offer too much difficulty to differential diagnosis in cases of massive bleeding. The patient with chronic ulcerative colitis usually is anemic because of the long period of diarrhea and the inability to eat and derive proper nutrition from his food. Certainly he may recall passing blood in his stools, but ordinarily massive hemorrhage is not a problem. We have seen a few cases of fulminating ulcerative colitis and even one or two of so-called toxic megacolon, wherein hemorrhage was the factor which led us to emergency colectomy. Granulomatous colitis is mostly a change in the lymphatic system with secondary involvement of the serosa of the colon, but of course mucosal ulceration can be present also. These conditions are mentioned for the sake of completeness. DIAGNOSIS Diagnosis can be truly worrisome because time is short and the patient is most often in dire straits. Frequently he is a very elderly
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individual who has fallen heir to more than his share of degenerative diseases and senile changes. His history will be helpful, of course, if it is positive - especially if he knows that diverticula have been revealed previously by colon x-rays or if it is known that he has an aneurysm of the aorta or one of its main branches. One will always search the history for any complicating peptic ulcer problem and for any previous operations for disease of the gastrointestinal tract. To make the history thorough, the possibility of significant disease of the colon must be recorded. Although the patient typically is very sick and cannot tolerate extensive examination, one still would like to follow the routine digital rectal examination with proctosigmoidoscopic study if at all possible. At the Mayo Clinic, Smith was able to visualize arterial blood spurting from the ostium of a diverticulum in just such a case, and this, of course, was evidence of prime value. Since that time, there have been a few other situations wherein the surgeon has been able to proceed after just such an experience with full knowledge preoperatively that his diagnosis is correct. Unfortunately, in many cases the bleeding is so continuous that proper visualization is impossible. Whether to x-ray the colon may be a dilemma. There are authorities who feel that this should not be attempted and others who feel that, sick though the patient may be and difficult though it may be for the radiologist, every effort should be made to visualize the lesion. Our own experience has been limited in this regard and most often, in the acute stage, little help is expected. Modern adjuncts to diagnosis and management include angiography. Certainly if an angiogram can be made during the acute bleeding episode, it is possible to locate the exact source of the hemorrhage, and then the course is clear. Unfortunately, by the time the x-ray is taken, the bleeding may have stopped, and no definite help is gained.
WHAT IS TO BE DONE FOR THE PATIENT? The decision concerning proper management will be most difficult; one may feel occasionally that no matter what course he pursues, he will have taken the wrong turn. The prime decision to be made is whether one is going to continue a conservative course with repeated transfusions and supportive measures and hope for the best or whether he is going to be surgically aggressive, proceeding with operative interference as soon as the vital signs are stable. The neophyte in surgery may take some small measure of satisfaction in knowing that his elders are still poised on the horns of that same dilemma and must still make an individual question out of every case of this type. Suffice it to say that there is no dogmatic statement which will always cover this most perplexing problem. Surgical Management Our own current tendency is to be much more aggressive than we were in an earlier day and to proceed with surgical management if the bleeding has continued and more than three or four blood transfusions
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have been required to keep the patient's condition stable. The acceptable number of transfusions cannot be stated with finality. The individual decision must be made jointly by the gastroenterologist and the surgeon. In some instances, time will not permit anything but emergency preparation. In other cases, the bleeding is intermittent enough that several days of observation can be used to help one arrive at the right decision. After a decision to operate, the next question is the placement of the incision. My personal preference is to use a long vertical left rectus incision which can be extended to any degree necessary. I have thought that the left colon would most often be the site of the difficulty and that diverticular disease would probably be the ultimate diagnosis. However, as noted above, more and more cases of hemorrhage from right-sided diverticular disease are being recorded; and so one might prefer to make a long midline incision such as the vascular surgeons employ in attacking an aneurysm of the abdominal aorta. Most often the surgeon will encounter a colon filled with blood. If he can detect a lesion which feels significant, he probably will elect to resect that portion of the colon, being reasonably sure that the bleeding is coming from the lesion which he has noted. But all too often he will find no lesion, except for scattered diverticula without apparent diverticQlitis. At this point, I would strongly urge that he make a quick check of the duodenum and entire small intestine. A large Meckel's diverticulum with considerable thickening and obvious ulceration at its tip will make his decision even harder, but he would be acutely embarrassed to overlook such a lesion. When Meckel's diverticulum coexists with diverticulosis of the colon and hemorrhage is the indication for surgery, it seems that both lesions demand immediate attention. One would expect the small bowel to contain very obvious blood if the diverticulum were the only offending mechanism. However, active bleeding from the colon itself can probably result in regurgitation of blood through the ileocecal valve and make the problem more complex. The surgeon has a choice of methods to try for determining just where the bleeding arises. Theoretically, it seems that the introduction of a sterile sigmoidoscope into colotomy incisions might permit visualization of the bleeding point; but experience with this method has led us to a great deal of frustration. Even a small amount of stool within the colon fills the end of the proctoscope and closes off the vision. Repeated attempts at clearing this away may lead to serious contamination. If one is working in a darkened operating room he must be unusually cautious in manipulating the instrument so as not to spread fecal material throughout the region. Personally, I have abandoned this method. The surgeon may place intestinal clamps across segments of the colon, and after watching for a time he may be rewarded by the filling of the segment between a pair of clamps, whereupon he can assume rather logically that he has located the source of bleeding. From a practical standpoint, however, the colon may be so filled with feces, clots, and fresh blood that, having attempted this, he will still not have unequivocal evidence and so remain confused.
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If none of the above seems appropriate and effective, the surgeon may employ multiple colotomy with direct inspection of the lumen of the colon at many points. He would want to wait a considerable length of time before undertaking this action, for here again blood clots and feces may well up into the individual wounds so that not only will the field be clouded but a real threat of serious contamination will exist. A different expedient, which might well be lifesaving if the surgeon has been unable to locate the site of the bleeding, is transverse colostomy. By the time this is done, the bleeding may well have stopped. The condition of the patient may be such that the wound may be closed and the colostomy opened a few hours later. The management then changes to watchful waiting to see which limb of the colostomy will produce the active bleeding. If the blood comes only from the proximal limb, the surgeon will be inclined to reopen the abdomen and resect the right half of the colon. If it comes only from the distal limb and rectum, he will be more secure in his decision to attack the left colon. From practical experience with this maneuver, we have noted rather equivocal results. Often no further bleeding has occurred in 2 or 3 weeks of careful observation. By this time, the patient is feeling well again and is demanding closure of the stoma. This simply adds to the frustration, as interval studies with barium x-rays may not locate a significant lesion either. Perhaps the more modern approach to this problem is arbitrary resection of long segments of the colon or-what may be preferable even to that - colectomy with ileorectosigmoidostomy. The latter operation has seemed rather radical to many of us, but undeniably, since using it in a small series of cases, we have been quite gratified. At least the patients have not bled again, and although the surgical specimens have revealed only universal diverticulosis, perhaps serial sections (which seem an insurmountable task) might reveal the sort of changes that Dockerty had noted in the right colon, as mentioned above. We have reached this conclusion by having dealt with patients who have come to us after radical hemicolectomy for presumed diverticular disease and then have bled again. There have been enough of these that we have come to feel more secure with the more radical approach.
SUMMARY Massive bleeding of colonic origin is quite uncommon. Differential diagnosis may be complex, but the most important cause appears to be diverticular disease. The diagnosis may be based on exclusion of other lesions and presumptive evidence only. A decision must be made between conservative management without operation (relying mostly upon multiple transfusions) and aggressive, early surgical intervention. The chief problem at operation is to determine the source of the bleeding. In a limited series, colectomy with ileorectosigmoidostomy has yielded satisfactory results.
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REFERENCES 1. Dockerty, M. B.: Personal communication to the author. 2. Earley, C. M., Jr.: The management of massive hemorrhage from diverticular disease of the colon. Surg Gynec Obstet 108:49-60 (Jan.) 1959. 3. Healey, S. J., and Pfeffer, R I.: Exsanguinating hemorrhage from diverticulosis of the ascending colon: Report of a case. New Eng J Med 273:1480-1481 (Dec. 30) 1965. 4. Mobley, J. E., Dockerty, M. B., and Waugh, J. M.: Bleeding in colonic diverticulitis. Amer J Surg 94:44-51 (July) 1957. 5. Noer, R J.: Hemorrhage as a complication of diverticulitis. Ann Surg 141 :674-683 (May) 1955. 6. Rigg, B. M., and Ewing, M. R: Current attitudes on diverticulitis with particular reference to colonic bleeding. Arch Surg (Chicago) 92:321-332 (March) 1966. 7. Smith, N. D.: Diverticulosis and diverticulitis: General consideration and sigmoidoscopic diagnosis. Amer J Surg 82:583-586 (Nov.) 1951. 8. Weingarten, M., Venet, L., and Victor, M. B.: Direct observation of massive arterial hemorrhage from a diverticulum of the hepatic flexure. Gastroenterology 36:642-644 (May) 1959.
Melena as a cause of hospitalization is not particularly unusual, but massive bleeding from the colon is rare enough that not all surgeons have a great deal of experience with it. The patient and his relatives may be alarmed about the amount of bleeding or what they think is its amount, but observation in the hospital may show that only a little bleeding has been producing excessive fears. A definite mistake is to assume that all of the bleeding has its origin in hemorrhoids, as hemorrhoids are so common and the typical patient will recall having had hemorrhoids for some time. It is indeed possible that serious hemorrhage may have its source in these lesions, but the alert physician will press onward with his diagnostic measures before acceptjng them as the only source. Bleeding of significant degree arising from within the colon formerly meant cancer in every case until definite proof of another lesion was obtained. In recent years, we have learned that this may not be justified to nearly the degree we formerly thought. The physician dealing with such cases will often notice that anemia can be a rather chronic problem, and the detection of the source of the bleeding may test his ingenuity. The majority of patients harboring colon lesions do not experience massive hemorrhage at any time. Frequently direct questioning will elicit the fact that the stools have been streaked with blood or occasionally maroon stools have been passed. Even today it is most discouraging to note how many patients will procrastinate, hoping the bleeding will stop and trusting that no serious lesion is present. Finally the severe anemia, probably coupled with advanced obstruction, will force them to report to the hospital, but by this time nothing more than palliative surgery may be possible. Massive bleeding, of course, would force the issue much sooner and might serve as a blessing in disguise by forcing the initiation of curative attempts long before metastasis develops. In isolated instances, exsanguinating hemorrhage may be witnessed. This can be most alarming, not only to the patient and his family, but also to even the most experienced physician. The nature of the blood being passed can suggest the colon as the source of the bleeding. Yet the diagnosis may remain in great doubt, even though the patient appears to be in desperate circumstances. Time is of the utmost imporSurgical Clinics of North America- VoL 49, No.5, October, 1969
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tance here, and an ordinary diagnostic routine may be quite out of the question. Such circumstances will continue to pose acute problems in the selection of proper diagnosis, proper preparation, and proper timing of surgical interventionJf indeed a surgical lesion is proved.
POSSIBLE CAUSES OF THE MASSIVE BLEEDING Gastrojejunal Colic Fistula In an earlier day, the gastrojejunal colic fistula (Fig. 1) was all too common. Fortunately, it is now becoming rare, since surgery for peptic ulcer has taken a different form. But when present, it poses great difficulty in diagnosis, preparation, and management. In some cases the symptoms are surprisingly few and mild until massive hemorrhage develops. One would expect hematemesis as well as massive colonic hemorrhage, but this does not always occur. In the majority of instances, peptic ulcer is the original offender and the gastrojejunal colic fistula develops as a complication of surgical attempts to control the ulcer. During the years when gastroenterostomy was considered the acceptable procedure for surgical management of duodenal ulcer, gastrojejunal colic fistula was not at all rare. The fistula may not have developed for a surprising number of years after the gastroenterostomy, and the surgeons may have relaxed in their vigil and may well have reported excellent results of their original surgical management. But gastric resection, even of an extensive nature, was not without its difficulties in regard to ultimate formation of a gastrojejunal colic fistula. Although massive colonic hemorrhage was not common with these fistulas, diagnosis could be difficult because the customary approach to
Figure 1. Gastrocolic fistula, the source of massive bleeding. Gastric mucosa may be seen through fistulous opening in transverse colon.
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these problems would be the administration of barium by mouth to outline the stomach or gastric remnant. In the experience at this clinic, failure to demonstrate the fistula was frequent. My colleagues and I have found that a colon x-ray demonstrates the fistula in a much higher percentage of cases. Fortunately, surgeons are alert to the development of adjuncts to surgical care; so more recently a one-stage operation has been employed with surprisingly low mortality. Other less common causes of gastrojejunal colic fistula must include carcinoma of the stomach with erosion into the transverse colon and· ulcerative colitis with its inevitable tendency to form fistulas into adjacent organs. Most often other symptoms and signs disclose the offending mechanism before massive bleeding from the colon is evident, but our files contain the records of a few cases of each of these entities which illustrate the confusion that has resulted.
Polypoid Disease Polyps of the colon are very common indeed and usually do not present great difficulty of the kind under discussion. Many of them can be reached by the sigmoidoscope and fulgurated thus. Isolated pedunculated polyps higher in the colon, if of significant size, can be dealt with at very low risk through operative maneuvers. It is true that the bleeding from polyps is rarely massive, but occasionally surprisingly large polyps (4 cm or more in diameter) are witnessed and these can ulcerate and bleed to an alarming degree. The patient and the surgeon are ·fortunate indeed if this is the only problem involved, because its solu.tion is obvious and relatively easy. Multiple polyposis presents an entirely different problem. Usually there is a long history of disease and the patient is anemic, but with little history of frightening hemorrhage from the colon. At least 50% have family members with a similar problem. The tendency to development of carcinoma in all of these persons is so well known that I will not dwell on it (Fig. 2). We rarely have difficulty with these families now, since the proper treatment-namely colectomy-is being carried out with such a low risk that the younger members do not hesitate to report when any symptoms develop and, more importantly, they are being studied by colon x-ray and sigmoidoscope even when asymptomatic b€cause they are members of known "polyp families."
Carcinoma When colonic hemorrhage appears, carcinoma is the lesion uppermost in the minds of not only the patients but also the doctors responsible for their welfare. Massive hemorrhage is not the presenting symptom in most cases, though it may be encountered sometimes. More often, progressive anemia brings the patient to the doctor and direct questioning leads to the admission that there may have been short episodes of very significant hemorrhage. When the carcinoma is in the right colon, we find it much more difficult to detect unless there are other symptoms to accompany it. Obstruction is a very rare feature of right-colon carcinoma. Anemia may lead to some investigation, includ-
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Figure 2.
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Hemorrhagic polyposis of colon with carcinomatous transformation (arrow).
ing a colon x-ray. A single so-called negative colon x-ray can lead to serious mistakes. In such a situation, a second and occasionally even a third x-ray may be necessary before a small carcinoma may be detected in the right colon (Fig. 3). This is quite unusual in the present context, as such a lesion rarely causes massive bleeding, but it must be included in our differential diagnosis. Vascular Occlusion With Ulceration Although occasional instances of vascular occlusion with ulceration have been witnessed in the past, we are hearing more about these lesions because of the current widespread interest in vascular diseases. Such changes are being recognized much more commonly and documented in a more impressive manner. Venous occlusion has led to alarming hemorrhage in isolated instances (Fig. 4). Many times this was simply a part of the generalized vascular change throughout the venous system, but an isolated change within the colon probably would never be thought of except on very thorough consideration. Arterial changes now are detected much more commonly because of the phenomenal strides that have been made in arteriography. Certainly an arterial lesion within the colon could be accompanied by exsanguinating hemorrhage. If the patient is seen during such an episode, prompt angiography not only will prove the source of the bleeding hut also will point with great accuracy to its site. In this regard, since a fund of experience in surgery for aneurysm
MASSIVE BLEEDING OF COLONIC ORIGIN
Figure 3.
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Bleeding carcinoma of ascending colon, not detected on first x-ray study.
has now been accumulated, we are all alert to the possibility of an aneurysm (or, more often, an aneurysm graft) leaking into the intestine. If such a graft is known to have been inserted and the patient later presents with massive intestinal bleeding, the presumptive evidence is strong enough for immediate surgical intervention. Those aneurysms which have not been detected previously or not dealt with by graft surgery may produce exsanguination before the diagnosis is established. Most often the type of bleeding suggests the small intestine rather than the colon, but the bleeding is so furious and voluminous that httle time is available for differential diagnostic studies. Diverticular Disease The term "diverticular disease" is employed since, although diverticulosis is a common development after middle life (it is said that perhaps 10% of the people beyond their fortieth year have diverticula), we have always considered problems arising from these changes as being due directly to the inflammation of the sacs. Probably 5 to 10% of
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Figure 4. Venous occlusion with ulceration near hepatic flexure.
the people who harbor the diverticula suffer at some time from diverticulitis. However, I have witnessed massive colonic bleeding arising apparently from simple diverticulosis without certain evidence of true diverticulitis (Fig. 5). This has led all of us to realize in more recent years that bleeding from the colon need not mean carcinoma in every single case. In fact, the massive nature of the bleeding may favor a presumption that the source of the bleeding is diverticulosis without inflammation or tumor formation. Rigg and Ewing have presented a summary of current attitudes toward this likelihood. Considerable emphasis is now being placed on diverticular disease, which to me seems by far the most important possibility when there is massive bleeding of colonic origin. Unfortunately, even today we have no really effective method of determining the exact site in the colon where the bleeding originates, and this may present not only a problem but a most serious danger. We have all seen the frequent well-documented localization of diverticulitis in the sigmoid only, even though the entire colon shows obvious diverticulosis. It is tempting to assume
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Figure 5.
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Hemorrhagic diverticular disease of sigmoid colon.
that the bleeding in such a case comes only from the sigmoid. The Mayo Clinic files contain a number of resected specimens which, on very close microscopic study, have finally revealed the offending diverticulum with the open vessel in its base (Fig. 6). Perhaps if pathologists had the time and inclination to examine serial sections of all such specimens, this change would be found much more frequently and we then would be more reluctant to accept the statement that no diverticulitis need be present before hemorrhage. Healey and Pfeffer reported that massive bleeding was the chief
Figure 6.
Diverticulum with fresh thrombus in artery at its base (x85).
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indication for surgical treatment in 5% of 160 patients requiring surgical management of diverticulitis. Noer, an outstanding authority on diverticulitis and its surgical management, has stated that some degree of very obvious bleeding from the colon may be noted in perhaps 30% of diverticulitis cases. From the standpoint of the surgical pathologist, Dockerty admitted that, although there had been a great deal of discussion about this problem, no real correlation between the bleeding and certain pathologic changes in the diverticula had been established. Therefore Mobley, Dockerty, and Waugh attempted to do that. The basis of their study was the 2000 patients presenting at the Mayo Clinic from 1940 to 1954 with diverticulitis that was producing symptoms. Of this group, a total of 145 patients (7%) had passed significant quantities of blood by rectum and, after effective surgery, no cause for their bleeding except diverticulitis could be located. Thirty-two of the surgical specimens had been preserved in such a manner that detailed pathologic survey could be carried out. Here again, although bleeding was the chief symptom which differentiated this group of patients, in only one case had the hemorrhage been truly massive. In 18 of the specimens, however, a significant ulcer or inflammatory granulation tissue in and about the diverticula was demonstrated. In one, an inverted diverticulum bore an ulcer on its tip. This phenomenon has been witnessed with increasing frequency at the Mayo Clinic. Dockerty is willing to accept the conclusion that ulcerative processes are probably always responsible for the bleeding in colonic diverticulitis. He believes that the pathologist is truly fortunate to be able to demonstrate an eroded artery in the base of the diverticulum. In presenting to a conference such a case, where the diverticulum was actually in the right colon, he stated he was able to find only three welldocumented similar cases in the literature, one of which had been described by Healey and Pfeffer, another by Earley, and the third by Weingarten and coauthors. In attempting to record Mayo Clinic experiences with significant bleeding that accompanied diverticular disease of the colon, I am mindful that the coexisting disease may introduce considerable confusion. The suspected portion of the bowel may contain a polyp (Fig. 7), and it is not at all uncommon to find one within the resected specimen, but proof of the exact site of the bleeding will not be forthcoming postoperatively. In addition, radical colectomy sometimes has been completed before the surgeon remembered to check carefully for Meckel's diverticulum. The coexistence of bleeding Meckel's diverticulum with universal diverticulosis of the colon is not common but certainly could serve to cloud a statistical study. Most often the surgeon's problem will be massive bleeding from the colon which has stopped before surgical consultation was sought. Many times colon x-rays reveal diverticula only on the right side of the colon, and the surgeon who has decided for himself that diverticulitis almost never strikes in the right colon will be led astray unless he keeps in mind the discussion above. More often diverticula may be indicated at other points in the colon-and even throughout the colon-so that the
r
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Figure 7. bleeding?
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Diverticulosis with large polyp in sigmoid (arrow). Which lesion produced the
exact area to be treated surgically will be most difficult to identify before operation.
Ulcerative and Inflammatory Disease Chronic ulcerative colitis and Crohn's disease of the colon, now generally known as "granulomatous colitis," should not offer too much difficulty to differential diagnosis in cases of massive bleeding. The patient with chronic ulcerative colitis usually is anemic because of the long period of diarrhea and the inability to eat and derive proper nutrition from his food. Certainly he may recall passing blood in his stools, but ordinarily massive hemorrhage is not a problem. We have seen a few cases of fulminating ulcerative colitis and even one or two of so-called toxic megacolon, wherein hemorrhage was the factor which led us to emergency colectomy. Granulomatous colitis is mostly a change in the lymphatic system with secondary involvement of the serosa of the colon, but of course mucosal ulceration can be present also. These conditions are mentioned for the sake of completeness. DIAGNOSIS Diagnosis can be truly worrisome because time is short and the patient is most often in dire straits. Frequently he is a very elderly
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individual who has fallen heir to more than his share of degenerative diseases and senile changes. His history will be helpful, of course, if it is positive - especially if he knows that diverticula have been revealed previously by colon x-rays or if it is known that he has an aneurysm of the aorta or one of its main branches. One will always search the history for any complicating peptic ulcer problem and for any previous operations for disease of the gastrointestinal tract. To make the history thorough, the possibility of significant disease of the colon must be recorded. Although the patient typically is very sick and cannot tolerate extensive examination, one still would like to follow the routine digital rectal examination with proctosigmoidoscopic study if at all possible. At the Mayo Clinic, Smith was able to visualize arterial blood spurting from the ostium of a diverticulum in just such a case, and this, of course, was evidence of prime value. Since that time, there have been a few other situations wherein the surgeon has been able to proceed after just such an experience with full knowledge preoperatively that his diagnosis is correct. Unfortunately, in many cases the bleeding is so continuous that proper visualization is impossible. Whether to x-ray the colon may be a dilemma. There are authorities who feel that this should not be attempted and others who feel that, sick though the patient may be and difficult though it may be for the radiologist, every effort should be made to visualize the lesion. Our own experience has been limited in this regard and most often, in the acute stage, little help is expected. Modern adjuncts to diagnosis and management include angiography. Certainly if an angiogram can be made during the acute bleeding episode, it is possible to locate the exact source of the hemorrhage, and then the course is clear. Unfortunately, by the time the x-ray is taken, the bleeding may have stopped, and no definite help is gained.
WHAT IS TO BE DONE FOR THE PATIENT? The decision concerning proper management will be most difficult; one may feel occasionally that no matter what course he pursues, he will have taken the wrong turn. The prime decision to be made is whether one is going to continue a conservative course with repeated transfusions and supportive measures and hope for the best or whether he is going to be surgically aggressive, proceeding with operative interference as soon as the vital signs are stable. The neophyte in surgery may take some small measure of satisfaction in knowing that his elders are still poised on the horns of that same dilemma and must still make an individual question out of every case of this type. Suffice it to say that there is no dogmatic statement which will always cover this most perplexing problem. Surgical Management Our own current tendency is to be much more aggressive than we were in an earlier day and to proceed with surgical management if the bleeding has continued and more than three or four blood transfusions
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have been required to keep the patient's condition stable. The acceptable number of transfusions cannot be stated with finality. The individual decision must be made jointly by the gastroenterologist and the surgeon. In some instances, time will not permit anything but emergency preparation. In other cases, the bleeding is intermittent enough that several days of observation can be used to help one arrive at the right decision. After a decision to operate, the next question is the placement of the incision. My personal preference is to use a long vertical left rectus incision which can be extended to any degree necessary. I have thought that the left colon would most often be the site of the difficulty and that diverticular disease would probably be the ultimate diagnosis. However, as noted above, more and more cases of hemorrhage from right-sided diverticular disease are being recorded; and so one might prefer to make a long midline incision such as the vascular surgeons employ in attacking an aneurysm of the abdominal aorta. Most often the surgeon will encounter a colon filled with blood. If he can detect a lesion which feels significant, he probably will elect to resect that portion of the colon, being reasonably sure that the bleeding is coming from the lesion which he has noted. But all too often he will find no lesion, except for scattered diverticula without apparent diverticQlitis. At this point, I would strongly urge that he make a quick check of the duodenum and entire small intestine. A large Meckel's diverticulum with considerable thickening and obvious ulceration at its tip will make his decision even harder, but he would be acutely embarrassed to overlook such a lesion. When Meckel's diverticulum coexists with diverticulosis of the colon and hemorrhage is the indication for surgery, it seems that both lesions demand immediate attention. One would expect the small bowel to contain very obvious blood if the diverticulum were the only offending mechanism. However, active bleeding from the colon itself can probably result in regurgitation of blood through the ileocecal valve and make the problem more complex. The surgeon has a choice of methods to try for determining just where the bleeding arises. Theoretically, it seems that the introduction of a sterile sigmoidoscope into colotomy incisions might permit visualization of the bleeding point; but experience with this method has led us to a great deal of frustration. Even a small amount of stool within the colon fills the end of the proctoscope and closes off the vision. Repeated attempts at clearing this away may lead to serious contamination. If one is working in a darkened operating room he must be unusually cautious in manipulating the instrument so as not to spread fecal material throughout the region. Personally, I have abandoned this method. The surgeon may place intestinal clamps across segments of the colon, and after watching for a time he may be rewarded by the filling of the segment between a pair of clamps, whereupon he can assume rather logically that he has located the source of bleeding. From a practical standpoint, however, the colon may be so filled with feces, clots, and fresh blood that, having attempted this, he will still not have unequivocal evidence and so remain confused.
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If none of the above seems appropriate and effective, the surgeon may employ multiple colotomy with direct inspection of the lumen of the colon at many points. He would want to wait a considerable length of time before undertaking this action, for here again blood clots and feces may well up into the individual wounds so that not only will the field be clouded but a real threat of serious contamination will exist. A different expedient, which might well be lifesaving if the surgeon has been unable to locate the site of the bleeding, is transverse colostomy. By the time this is done, the bleeding may well have stopped. The condition of the patient may be such that the wound may be closed and the colostomy opened a few hours later. The management then changes to watchful waiting to see which limb of the colostomy will produce the active bleeding. If the blood comes only from the proximal limb, the surgeon will be inclined to reopen the abdomen and resect the right half of the colon. If it comes only from the distal limb and rectum, he will be more secure in his decision to attack the left colon. From practical experience with this maneuver, we have noted rather equivocal results. Often no further bleeding has occurred in 2 or 3 weeks of careful observation. By this time, the patient is feeling well again and is demanding closure of the stoma. This simply adds to the frustration, as interval studies with barium x-rays may not locate a significant lesion either. Perhaps the more modern approach to this problem is arbitrary resection of long segments of the colon or-what may be preferable even to that - colectomy with ileorectosigmoidostomy. The latter operation has seemed rather radical to many of us, but undeniably, since using it in a small series of cases, we have been quite gratified. At least the patients have not bled again, and although the surgical specimens have revealed only universal diverticulosis, perhaps serial sections (which seem an insurmountable task) might reveal the sort of changes that Dockerty had noted in the right colon, as mentioned above. We have reached this conclusion by having dealt with patients who have come to us after radical hemicolectomy for presumed diverticular disease and then have bled again. There have been enough of these that we have come to feel more secure with the more radical approach.
SUMMARY Massive bleeding of colonic origin is quite uncommon. Differential diagnosis may be complex, but the most important cause appears to be diverticular disease. The diagnosis may be based on exclusion of other lesions and presumptive evidence only. A decision must be made between conservative management without operation (relying mostly upon multiple transfusions) and aggressive, early surgical intervention. The chief problem at operation is to determine the source of the bleeding. In a limited series, colectomy with ileorectosigmoidostomy has yielded satisfactory results.
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REFERENCES 1. Dockerty, M. B.: Personal communication to the author. 2. Earley, C. M., Jr.: The management of massive hemorrhage from diverticular disease of the colon. Surg Gynec Obstet 108:49-60 (Jan.) 1959. 3. Healey, S. J., and Pfeffer, R I.: Exsanguinating hemorrhage from diverticulosis of the ascending colon: Report of a case. New Eng J Med 273:1480-1481 (Dec. 30) 1965. 4. Mobley, J. E., Dockerty, M. B., and Waugh, J. M.: Bleeding in colonic diverticulitis. Amer J Surg 94:44-51 (July) 1957. 5. Noer, R J.: Hemorrhage as a complication of diverticulitis. Ann Surg 141 :674-683 (May) 1955. 6. Rigg, B. M., and Ewing, M. R: Current attitudes on diverticulitis with particular reference to colonic bleeding. Arch Surg (Chicago) 92:321-332 (March) 1966. 7. Smith, N. D.: Diverticulosis and diverticulitis: General consideration and sigmoidoscopic diagnosis. Amer J Surg 82:583-586 (Nov.) 1951. 8. Weingarten, M., Venet, L., and Victor, M. B.: Direct observation of massive arterial hemorrhage from a diverticulum of the hepatic flexure. Gastroenterology 36:642-644 (May) 1959.