Management of massive lower gastrointestinal bleeding: should there be surgical intervention without initial endoscopy and radiological evidence of the source of bleeding?

Abstract

We report two case histories of patients with massive rectal blood loss. Endoscopic and radiological investigations could not identify the source of bleeding at admission. Initially, both patients recovered without surgical intervention, receiving a large number of blood transfusions only. Extensive subsequent radiological analysis showed that the bleeding was due to a pathological part of the proximal jejunum in one case and of the colon transversum in the other. Although immediate surgical intervention was not needed at presentation, both patients underwent resection of a part of the bowel some time thereafter. Surgery was performed after hemodynamic stabilization in the first case. However, in the second case, emergency surgical intervention was needed due to persistent bleeding 4 days after admission. Both patients are still doing well half a year after this massive gastrointestinal (GI) hemorrhage. Aside from a small area of chronic inflammation and fibrosis of the jejunum in one patient, histopathological evaluation of the surgical resection specimens revealed no specific cause for these massive gastrointestinal bleedings. We discuss the general approach of gastrointestinal hemorrhage and the several (dis)advantages of the various imaging techniques and the order in which they should be used.