Kolon Kanamaları
Özet
Alt gastrointestinal sistem kanamaları, özellikle artan antitrombotik ilaç kullanımı ve yaşlanan nüfusa bağlı olarak dünya genelinde artış göstermektedir. Genellikle kalın bağırsak ve rektum kaynaklı olan bu kanamalar, minör epizodlardan hayatı tehdit eden masif kanamalara kadar geniş bir klinik yelpazede ortaya çıkar. Erişkinlerde en sık karşılaşılan etiyolojik nedenler arasında divertiküler hastalık, anjiyodisplazi, kolon kanseri, inflamatuar bağırsak hastalıkları, kolitler ve polipektomi sonrası komplikasyonlar yer almaktadır. Hastaların ilk değerlendirmesinde hemodinamik stabilizasyonun sağlanması ve üst gastrointestinal kanama olasılığının dışlanması kritik önem taşır. Tanı ve tedavide ilk tercih edilen yöntem, kanama odağını lokalize etme ve terapötik müdahale yeteneği sunan kolonoskopidir. Kolonoskopinin yetersiz kaldığı veya hastanın stabil olmadığı durumlarda BT anjiyografi, sintigrafi ve katater anjiyografisi gibi radyolojik yöntemlerden yararlanılır. Tedavi yaklaşımları medikal resüsitasyon, koagülopatinin düzeltilmesi, endoskopik hemostaz teknikleri, anjiyografik embolizasyon ve dirençli vakalarda cerrahi rezeksiyonu kapsar. Çoğu vaka spontan olarak dursa da mortalite riski yaşlı ve yandaş hastalığı olan bireylerde daha yüksektir.
Lower gastrointestinal bleeding is globally increasing, particularly driven by the growing use of antithrombotic medications and an aging population. Originating mostly from the colon and rectum, these hemorrhages exhibit a broad clinical spectrum ranging from minor episodes to life-threatening massive bleeding. The most common etiologies in adults include diverticular disease, angiodysplasia, colon cancer, inflammatory bowel diseases, colitis, and post-polypectomy complications. Initial management critically requires hemodynamic stabilization and ruling out potential upper gastrointestinal sources. Colonoscopy remains the primary preference for both diagnosis and management due to its capability to localize bleeding sources and perform therapeutic interventions. When colonoscopy is insufficient or patients are unstable, radiological methods such as CT angiography, scintigraphy, and catheter angiography are utilized. Treatment strategies encompass medical resuscitation, correction of coagulopathy, endoscopic hemostasis, angiographic embolization, and surgical resection for refractory cases. Although most cases resolve spontaneously, mortality rates remain significantly higher among elderly patients with substantial comorbidities.
Referanslar
Hreinsson JP, Gumundsson S, Kalaitzakis E, et al. Lower gastrointestinal bleeding: incidence, etiology, and outcomes in a population-based setting. European journal of gastroenterology & hepatology. 2013;25(1):37-43. doi: 10.1097/MEG.0b013e32835948e3
Oakland K, Guy R, Uberoi R, et al. Acute lower GI bleeding in the UK: patient characteristics, interventions and outcomes in the first nationwide audit. Gut. 2018;67(4): 654-662. doi:10.1136/gutjnl-2016-313428
El-Tawil AM. Trends on gastrointestinal bleeding and mortality: where are we standing?. World journal of gastroenterology: WJG. 2012;18(11): 1154. doi:10.3748/wjg.v18.i11.1154
Strate LL. Lower GI bleeding: epidemiology and diagnosis. Gastroenterology Clinics. 2005;34(4): 643-664. doi:10.1016/j.gtc.2005.08.007
Gralnek IM, Neeman Z, Strate LL. Acute lower gastrointestinal bleeding. New England Journal of Medicine. 2017;376(11): 1054-1063. doi:10.1056/NEJMcp1603455
Lanas A, Garcia-Rodriguez LA, Polo-Tomas M, et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Official journal of the American College of Gastroenterology| ACG. 2009;104(7): 1633-1641.
Strate LL, Ayanian JZ, Kotler G, et al. Risk factors for mortality in lower intestinal bleeding. Clinical Gastroenterology and Hepatology. 2008;6(9): 1004-1010. doi:10.1016/j.cgh.2008.03.021
FARRELL, J. J.; FRIEDMAN, L. S. The management of lower gastrointestinal bleeding. Alimentary pharmacology & therapeutics. 2005;21(11): 1281-1298. doi: 10.1111/j.1365-2036.2005.02485.x
Gunjan D, Sharma V, Rana SS, et al. Small bowel bleeding: a comprehensive review. Gastroenterology report. 2014;2(4): 262-275. doi:10.1093/gastro/gou025
Oakland K. Changing epidemiology and etiology of upper and lower gastrointestinal bleeding. Best Practice & Research Clinical Gastroenterology. 2019;42: 101610. doi: 10.1016/j.bpg.2019.04.003
Aoki T, Hirata Y, Yamada A, et al. Initial management for acute lower gastrointestinal bleeding. World Journal of Gastroenterology. 2019;25(1): 69. doi: 10.3748/wjg.v25.i1.69
Sittichanbuncha Y, Senasu S, Thongkrau T, et al. How to differentiate sites of gastrointestinal bleeding in patients with hematochezia by using clinical factors?. Gastroenterology Research and Practice. 2013;2013: 214-218-032. doi:10.1155/2013/265076
Ishii N, Omata F, Nagata N, et al. Effectiveness of endoscopic treatments for colonic diverticular bleeding. Gastrointestinal endoscopy. 2018;87(1): 58-66. doi:10.1016/j.gie.2017.08.013
Marion Y, Lebreton G, Le Pennec, V, et al. The management of lower gastrointestinal bleeding. Journal of visceral surgery. 2014;151(3): 191-201. doi:10.1016/j.jviscsurg.2014.03.008
Sami SS, Al‐Araji SA, Ragunath K. gastrointestinal angiodysplasia–pathogenesis, diagnosis and management. Alimentary pharmacology & therapeutics. 2014;39(1): 15-34. doi:10.1111/apt.12527
Boley SJ, Sammartano R, Adams A, et al. On the nature and etiology of vascular ectasias of the colon: degenerative lesions of aging. Gastroenterology. 1977;72(4): 650-660. doi:10.1016/S0016-5085(77)80149-2
Ghassemi KA, Jensen DM. Lower GI bleeding: epidemiology and management. Current gastroenterology reports. 2013;15(7): 1-6. doi:10.1007/s11894-013-0333-5
Macrae FA, John DJBS. Relationship between patterns of bleeding and Hemoccult sensitivity in patients with colorectal cancers or adenomas. Gastroenterology. 1982;82(5): 891-898. doi:10.1016/S0016-5085(82)80252-7
Soulellis CA, Carpentier S, Chen YI, et al. Lower GI hemorrhage controlled with endoscopically applied TC-325 (with videos). Gastrointestinal Endoscopy. 2013;77(3): 504-507. doi:10.1016/j.gie.2012.10.014
Shah AR, Jala V, Arshad H, et al. Evaluation and management of lower gastrointestinal bleeding. Disease-a-Month. 2018;64(7): 321-332. doi:10.1016/j.disamonth.2018.02.002
Chavalitdhamrong D, Jensen DM, Kovacs TO, et al. Ischemic colitis as a cause of severe hematochezia: risk factors and outcomes compared with other colon diagnoses. Gastrointestinal endoscopy. 2011;74(4): 852-857. doi:10.1016/j.gie.2011.05.039
Lew JF, Glass RI, Gangarosa RE, et al. Diarrheal deaths in the United States, 1979 through 1987: a special problem for the elderly. Jama. 1991;265(24): 3280-3284. doi:10.1001/jama.1991.03460240076031
Jensen DM, Machicado GA, Jutabha R, et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. New England Journal of Medicine. 2000;342(2): 78-82. doi:10.1056/NEJM200001133420202
Feagins LA, Smith AD, Kim D, et al. Efficacy of prophylactic hemoclips in prevention of delayed post-polypectomy bleeding in patients with large colonic polyps. Gastroenterology. 2019;157(4): 967-976. e1. doi:10.1053/j.gastro.2019.05.003
Tagawa T, Yamada M, Minagawa T, et al. Endoscopic characteristics influencing postpolypectomy bleeding in 1147 consecutive pedunculated colonic polyps: a multicenter retrospective study. Gastrointestinal Endoscopy. 2021;94(4): 803-811. e6. doi:10.1016/j.gie.2021.03.996
Feagins LA, Smith AD, Kim D, et al. Efficacy of prophylactic hemoclips in prevention of delayed post-polypectomy bleeding in patients with large colonic polyps. Gastroenterology. 2019;157(4): 967-976. e1. doi:10.1053/j.gastro.2019.05.003
Hawks MK, Svarverud JE. Acute lower gastrointestinal bleeding: evaluation and management. American Family Physician. 2020;101(4): 206-212.
Zuccaro Jr G. Management of the adult patient with acute lower gastrointestinal bleeding. Official journal of the American College of Gastroenterology| ACG. 1998;93(8): 1202-1208.
Strate LL, Gralnek IM. Management of patients with acute lower gastrointestinal bleeding. The American journal of gastroenterology. 2016;111(4): 459. doi:10.1038/ajg.2016.41
Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clinical Gastroenterology and Hepatology. 2010;8(4): 333-343. doi: 10.1016/j.cgh.2009.12.017
Jensen DM, Machicado GA. (Diagnosis and treatment of severe hematochezia: the role of urgent colonoscopy after purge. Gastroenterology. 1988;95(6): 1569-1574. doi:10.1016/S0016-5085(88)80079-9
Lim DS, Kim HG, Jeon SR, et al. Comparison of clinical effectiveness of the emergent colonoscopy in patients with hematochezia according to the type of bowel preparation. Journal of Gastroenterology and Hepatology. 2013;28(11): 1733-1737. doi:10.1111/jgh.12264
Rossini FP, Ferrari A, Spandre M, et al. Emergency colonoscopy. World journal of surgery. 1989;13(2): 190-192. doi:10.1007/BF01658398
Zuckerman GR, Prakash C. Acute lower intestinal bleedingPart I: Clinical presentation and diagnosis. Gastrointestinal endoscopy. 1998;48(6): 606-616. doi: 10.1016/S0016-5107(98)70043-4. doi: 10.1016/S0016-5107(98)70043-4
Jackovides CL, Nadolski G, Allen SR. Arteriography for lower gastrointestinal haemorrhage: role of preceding abdominal computed tomographic angiogram in diagnosis and localization. JAMA Sure. 2015;150: 650-656. doi:10.1001/jamasurg.2015.97
Martí M, Artigas JM, Garzón G, et al. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012;262(1): 109-116. doi:10.1148/radiol.11110326
Feuerstein JD, Ketwaroo G, Tewani SK et al. Localizing acute lower gastrointestinal hemorrhage: CT angiography versus tagged RBC scintigraphy. American Journal of Roentgenology. 2016;207(3): 578-584.
Kennedy DW, Laing CJ, Tseng LH, et al. Detection of active gastrointestinal hemorrhage with CT angiography: a 4½-year retrospective review. Journal of Vascular and Interventional Radiology. 2010;21(6): 848-855. doi:10.1016/j.jvir.2010.01.039
Ren JZ, Zhang MF, Rong AM, et al. Lower gastrointestinal bleeding: role of 64-row computed tomographic angiography in diagnosis and therapeutic planning. World Journal of Gastroenterology: WJG. 2015;21(1)3: 4030. doi: 10.3748/wjg.v21.i13.4030
Dobritz M, Engels HP, Schneider A, et al. Evaluation of dual-phase multi-detector-row CT for detection of intestinal bleeding using an experimental bowel model. European radiology. 2009;19(4): 875-881. doi: 10.1007/s00330-008-1205-5
Ernst O, Bulois P, Saint-Drenant S et al. Helical CT in acute lower gastrointestinal bleeding. European radiology. 2003;13(1): 114-117. doi:10.1007/s00330-002-1442-y
Yoon W, Jeong YY, Shin SS, et al. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi–detector row helical CT. Radiology. 2006;239(1): 160-167. doi: 10.1148/radiol.2383050175
Zuccaro Jr G. Management of the adult patient with acute lower gastrointestinal bleeding. Official journal of the American College of Gastroenterology| ACG. 1998;93(8): 1202-1208.
Triantafyllou K, Gkolfakis P, Gralnek IM, et al. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2021;53(08): 850-868. doi:10.1055/a-1528-2092
Pham T, Tran BA, Ooi K, et al. Super-selective mesenteric embolization provides effective control of lower GI bleeding. Radiology Research and Practice. 2017;2017: 1074804-1074804. doi: 10.1155/2017/1074804
Browder W, Cerise EJ, Litwin MS. Impact of emergency angiography in massive lower gastrointestinal bleeding. Annals of surgery. 1986;204(5): 530. doi: 10.1097/00000658-198611000-00004
Sarode R, Milling Jr TJ, Refaai MA, et al. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation. 2013;128(11): 1234-1243. doi:10.1161/CIRCULATIONAHA.113.002283
Zakko L, Rustagi T, Douglas M, et al. No benefit from platelet transfusion for gastrointestinal bleeding in patients taking antiplatelet agents. Clinical Gastroenterology and Hepatology. 2017;15(1): 46-52. doi:10.1016/j.cgh.2016.07.017
Acosta RD, Abraham NS, Chandrasekhara V, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointestinal endoscopy. 2016;83(1): 3-16. doi:10.1016/j.gie.2015.09.035
Stollings JL, Landsperger JS, Semler MW, et al. Tranexamic acid for refractory gastrointestinal bleeds: a cohort study. Journal of critical care. 2018;43: 128. doi: doi:10.1016/j.jcrc.2017.08.035
Heidet M, Amathieu R, Audureau E, et al. Efficacy and tolerance of early administration of tranexamic acid in patients with cirrhosis presenting with acute upper gastrointestinal bleeding: a study protocol for a multicentre, randomised, double-blind, placebo-controlled trial (the EXARHOSE study). BMJ open. 2018;8(8): e021943. doi:10.1136/bmjopen-2018-021943
Dionne JC, Oczkowski SJ, Hunt BJ, et al. Tranexamic Acid in Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. Critical care medicine. 2022;50(3): e313-e319. doi:10.1097/CCM.0000000000005362
Kherad O, Restellini S, Almadi M, et al. Systematic review with meta‐analysis: limited benefits from early colonoscopy in acute lower gastrointestinal bleeding. Alimentary Pharmacology & Therapeutics. 2020;52(5): 774-788. doi: 10.1111/apt.15925
Oakland K, Chadwick G, East JE, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut. 2019;68(5): 776-789. doi:10.1136/gutjnl-2018-317807
Pasha SF, Shergill A, Acosta RD, et al. The role of endoscopy in the patient with lower GI bleeding. Gastrointestinal endoscopy. 2014;79(6): 875-885. doi:10.1016/j.gie.2013.10.039
Ananthakrishnan AN, McGinley EL, Saeian K. Outcomes of weekend admissions for upper gastrointestinal hemorrhage: a nationwide analysis. Clinical Gastroenterology and Hepatology. 2009;7(3): 296-302. e1. doi:10.1016/j.cgh.2008.08.013
Abougergi MS, Travis AC, Saltzman JR. Impact of day of admission on mortality and other outcomes in upper GI hemorrhage: a nationwide analysis. Gastrointestinal endoscopy. 2014;80(2): 228-235. e1. doi:10.1016/j.gie.2014.01.043
Navaneethan U, Njei B, Venkatesh PG. et al. Timing of colonoscopy and outcomes in patients with lower GI bleeding: a nationwide population-based study. Gastrointestinal endoscopy. 2014;79(2): 297-306. e12. doi:10.1016/j.gie.2013.08.001
Darcy M. Treatment of lower gastrointestinal bleeding: vasopressin infusion versus embolization. Journal of vascular and interventional radiology. 2003;14(5): 535-543. doi:10.1097/01.RVI.0000064862.65229.8A
Funaki B. Endovascular intervention for the treatment of acute arterial gastrointestinal hemorrhage. Gastroenterology Clinics. 2002;31(3): 701-713. doi:10.1016/S0889-8553(02)00025-0
Chan DKH, Soong J, Koh F, et al. Predictors for outcomes after super‐selective mesenteric embolization for lower gastrointestinal tract bleeding. ANZ journal of surgery. 2016;86(6): 459-463. doi:10.1111/ans.12762
McGuire Jr HH. Bleeding colonic diverticula. A reappraisal of natural history and management. Annals of surgery. 1994;220(5): 653. doi:10.1097/00000658-199411000-00008
Gianfrancisco JA, Abcarian H. Pitfalls in the treatment of massive lower gastrointestinal bleeding with “blind” subtotal colectomy. Diseases of the Colon & Rectum. 1982;25(5): 441-445. doi:10.1007/BF02553650
