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Cecal Carcinoma Presenting as Bleeding

 

 

Related narrative: Lower GI Bleed from Cecal Carcinoma

Colonic neoplasms present with bleeding in from 2-26% of cases and about half of such lesions are malignant. Such lesions are responsible for 20% of minor bleeds and 10% of major bleeds in the elderly. Minor bleeding is most commonly due to anorectal disease or inflammatory bowel disease. Major bleeding is most commonly due to diverticular disease (see lower GI bleed ) or vascular malformations and less commonly to inflammatory bowel disease or aortoduodenal fistula.

Right-sided colon lesions most often cause occult blood loss due to surface oozing, and the drop in hematocrit may manifest as increasing angina in elderly patients with coronary artery occlusive disease. Such lesions present later and reach larger size than left colon lesions due to the larger diameter of the right colon and the liquid nature of the stool in the right colon. Left sided lesions more often produce obstructive symptoms. Once the diagnosis of a colonic tumor is made, the treatment is surgical resection.

Seventy percent of colonic polyps and neoplasms are within reach of the flexible sigmoidoscope. In a patient presenting with rectal bleeding, initial rectal exam and sigmoioscopic examination are done to rule out an obvious lesion. Inflammatory bowel disease, especially ulcerative colitis, which always involves the rectum, can also be detected.

Colonoscopy is becoming the first-choice diagnostic and therapeutic modality for patients with lower GI bleed. Major bleeding often clears the colon of solid stool and bowel prep may not be necessary. In a stable patient, bowel prep enhances the effectiveness of the exam. Angiodysplasias can be treated with injection of sclerosing agents and/or vasoconstrictors, or coagulated with cautery or laser. Recent innovation has allowed intraluminal clipping of bleeding perforating vessels adjacent to a diverticulum. If a colon tumor is identified, early resection is facilitated by the bowel prep done for colonoscopy.

Bleeding scan with technetium labeled sulfur colloid or tagged red blood cells can detect active bleeding at a rate of 0.5 cc/min. Bleeding is often intermittent, depending on the etiology. The patient can be rescanned up to 12 hours following injection. The study is often negative, but is non-invasive and provides valuable information both for follow-up angiogram and should emergency surgery become necessary.

If the bleeding is localized to the right side, the angiographer can skip the inferior mesenteric injection, which must normally be done first because of the obscuring effect of renal contrast excretion into the bladder. Angiography requires a slightly higher rate of bleeding for detection, and can be used to embolize a vascular malformation or diverticular vessel by selective catheterization. Infusion of vasopressin over a 12-24 hour period has a high rate of success (90%), but also a high recurrence rate. If such therapy is unsuccessful, it is at least diagnostic and temporizing to allow optimization of the patient's general condition for undergoing surgery.

References:

Farrell JJ, Friedman LS, Gastrointestinal bleeding in older people, Gastroenterology Clinics Volume 29 o Number 1 o March 2000; Copyright 2000 W. B. Saunders Company

Schnitzler M, McLeod RS, in Scientific American Surgery, vol. 2, elective care of the surgical patient, Chapter 8.

Yahanda AM, Chang AE, in Greenfield LJ, Surgery (3rd ed), Lippincott, Williams & Wilkins, 2001, p. 1110.


This page was last modified on 13-Aug-2002.