c l i n i c a l f o l i o s : n a r r a t i v e





A D V E R T I S E M E N T

 

Left Colon Bleed (Diagnostic/Therapeutic Algorithm): 1

A D V E R T I S E M E N T

   
 

An 83-year-old woman presented with rectal bleeding. There was bile present and no blood seen in the NG aspirate. Emergency colonoscopy (see lower GI bleed, frame 2) visualized blood in the left colon, none in transverse or right, and no blood in the terminal ileum. Because of the quantity of blood, no bleeding point could be visualized. If the typical single diverticulum (see lower GI bleed, frames 13-15) can be identified, colonoscopic epinephrine injection and/or clipping can often control the bleed. If not, as in this case, definitive localization is important in case the bleeding does not cease spontaneously as it most often does.    

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Left Colon Bleed (Diagnostic/Therapeutic Algorithm): 2

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The bleeding scan identified a bleeding source in the mid-left colon. Bleeding (tagged RBC) scan is more sensitive than angiogram (0.1cc/min v 1cc/min, see lower GI bleed, frame 4) and is done first for that reason, and because, if the bleed is on the right, it spares the need to inject the IMA first with the added contrast load that could endanger the kidneys. Without this localization, the inferior mesenteric artery (IMA) must be injected first because contrast accumulation in the bladder from proximal vessel injection obscures part of the left colon.     

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Left Colon Bleed (Diagnostic/Therapeutic Algorithm): 3

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The bleeding site in the left colon visualized rapidly indicating a significant ongoing bleed. Selective embolization (see lower GI bleed, frames 8-9) is the next therapeutic maneuver. If embolization is unsuccessful, the final option is surgical resection of the bleeding segment. If embolization is less selective than desired and the IMA is compromised, ischemia of the left colon is a risk, depending on collateral blood supply (see lower GI bleed, frame 21.)   

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This page was last modified on 2/11/2008.