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Lower gastrointestinal bleeding remains an important medical emergency. Most lower gastrointestinal bleeding is now known to come from angiodysplasia or diverticular disease. Accurate angiographic and colonoscopic diagnosis may lead to a better focus for treatment and improved survival.
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To determine the effectiveness of abdominal imaging with RBCs labeled in vivo with Tc-99m, for the detection of gastrointestinal (GI) bleeding, 28 control subjects and ten patients with suspected bleeding underwent scintigraphy at 0-24 hr after tracer injection. Colonic activity was noted in one of the controls within 3 hr of injection, and in five of ten controls at 24 hr, all of whom had initial gastric activity. Of the ten patients with suspected GI bleeding, eight had documented active bleeding; seven of these had positive scintigrams. Nasogastric (NG) suction markedly decreased the presence of initial gastric activity in the patients with active bleeding. With this blood-pool radiopharmaceutical, frequent imaging of the abdomen over 24 hr can be done to test active bleeding. Continuous NG suction is recommended to reduce accumulation of gastric activity. These results suggest that red blood cells labeled in vivo with Tc-99m provide a sensitive method of detecting active GI bleeding.
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In order to clarify characteristics of diverticular disease in Japan, 625 patients with diverticular disease were studied. The frequency was 13.3% and increasing with years. The right-sided type was seen in 68.8% and was common in the younger patients. 77 patients were complicated with diverticulitis; 61 presented right sided diverticulitis and 16 left-sided diverticulitis. Most of those with right-sided diverticulitis recovered with medical treatment successfully. Drainage and supplemental appendectomy were recommended procedure for emergency operation. Patients with recurring inflammation should receive elective right hemicolectomy. Intraluminal pressure studies disclosed abnormal motility with high intraluminal pressure of the ascending colon in the patients with right-sided diverticular disease. This abnormal motility might play an important role in the pathogenesis of right-sided diverticular disease.
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In the elderly population bleeding from the colon is not unusual. In evaluating a patient with colonic bleeding, the rate of bleeding should be assessed, and the possibility of upper gastrointestinal and anorectal bleeding should be excluded. The most common cause of massive bleeding from the colon in the elderly patient is diverticulosis, and the next most common cause is angiodysplasia. A number of other less common causes of bleeding should be excluded when making the diagnosis. If angiography is employed and the bleeding site is identified, initial therapy can be started concurrently by either injecting a vasopressor drug intraarterially or by embolization. Failure to stop the bleeding leads to surgery as the next step. If the bleeding stops spontaneously, one can expect recurrence later; therefore an interval work-up is stressed to identify the anatomic area of suspected bleeding. Preoperative identification of the bleeding site is imperative so that a "blind resection" can be avoided.
The implication of intraluminal hyperpressure in the pathogenesis of colonic diverticulosis was investigated. Since colonic motricity depends on the anatomical integrity of the myenteric plexuses, we looked for morphological abnormalities of these plexuses in diverticulosis of the sigmoid, using the silver impregnation technique devised by Smith. Fifteen sigmoidectomy specimens (including the rectosigmoid junction) were studied in patients afflicted with diverticulosis. Operations were not performed during the acute phases of the illness. The results were compared to those obtained in 5 colectomy specimens in patients with cancer of the rectum, without colonic diverticulosis (control series). Conventional histology as well as the silver impregnation did not reveal any morphological abnormalities of the myenteric plexuses in the rectosigmoid junction or in the remaining sigmoid. The count of argyrophilic ganglion cells (10 to 15 per plexus) was identical in the colons affected with diverticulosis and in the control specimens. These results show that impairment of motricity in sigmoid diverticulosis is not a consequence of morphological abnormalities of the myenteric plexuses. They do not, however, exclude chemical or functional modifications in these plexuses.
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