1169

Obscure gastrointestinal bleeding

Rule out upper and lower GI

bleeding;
EGD and colonoscopy

Minor bleeding Major bleeding

CHAPTER 28 Small Intestine

(intermittent) (persistent)

Small bowel Stable Unstable

series Negative
Enteroclysis and
Enteroscopy patient stable
Capsule Tagged Operating
endoscopy RBC scan room
Positive Negative Positive

Repeat EGD/
Initiate appropriate Angiography Source Source of
Colonoscopy if
therapy and treatment uncertain bleeding identified
rebleeds

Localize bleeding: Treat source eg.

Serial clamping or intraoperative small bowel
enteroscopy followed by resection resection

Figure 28-29.  Diagnostic and management algorithm for obscure gastrointestinal (GI) bleeding. EGD = esophagogastroduodenoscopy;
RBC = red blood cell.

injury, Meckel’s and acquired diverticula, neoplasms (especially fever and tachycardia. Plain abdominal radiographs may reveal
lymphoma, adenocarcinoma, and melanoma), and foreign bodies. free intraperitoneal air if intraperitoneal perforation has occurred.
Among iatrogenic injuries, duodenal perforation dur- If perforation is suspected but not clinically obvious, CT scan-
ing ERCP with endoscopic sphincterotomy (ES) is the most ning should be performed. Jejunal and ileal perforations require
common. This complication occurs in 0.3% to 2.1% of cases. surgical repair or segmental resection.
Patients who have undergone Billroth II gastrectomy are at
increased risk of duodenal perforations as well as free jejunal Chylous Ascites
perforations during ERCP. Although ERCP-related duodenal Chylous ascites refers to the accumulation of triglyceride-rich
perforations can result in a free perforation, most are retroperi- peritoneal fluid with a milky or creamy appearance, caused
toneal. Manifestations of such contained duodenal perforations by the presence of intestinal lymph in the peritoneal cavity.
following ERCP can resemble those of ERCP-induced pancre- ­Chylomicrons, produced by the intestine and secreted into lymph
atitis, including hyperamylasemia. during the absorption of long-chain fatty acids, account for the
CT scanning is the most sensitive test for diagnosing duo- characteristic appearance and triglyceride content of chyle.
denal perforations; positive findings include pneumoperitoneum The most common etiologies of chylous ascites in Western
for free perforations, but more commonly retroperitoneal air, countries are abdominal malignancies and cirrhosis. In Eastern
contrast extravasation, and paraduodenal fluid collections. If all and developing countries, infectious etiologies, such as tuber-
patients undergoing a therapeutic ERCP are imaged with a CT culosis and filariasis, account for most cases. Chylous ascites
scan following the procedure, up to 30% will have evidence of can also develop as a complication of abdominal and thoracic
air in the retroperitoneum, but the majority are asymptomatic. operations and trauma. Operations particularly associated with
These patients do not require any specific therapy.70 this complication include abdominal aortic aneurysm repair,
True cases of retroperitoneal perforations of the duode- retroperitoneal lymph node dissection, inferior vena cava resec-
num can be managed nonoperatively, in the absence of progres- tion, and liver transplantation. Other etiologies of chylous asci-
sion and sepsis. However, intraperitoneal duodenal perforations tes include congenital lymphatic abnormalities (e.g., primary
require surgical repair with pyloric exclusion and gastrojejunos- lymphatic hypoplasia), radiation, pancreatitis, and right-sided
tomy or tube duodenostomy. Iatrogenic small bowel perfora- heart failure.
tion incurred during endoscopy, if immediately recognized, can Three mechanisms have been postulated to cause chylous
sometimes be repaired using endoscopic techniques. ascites: (a) exudation of chyle from dilated lymphatics on the
Perforation of the jejunum and ileum occurs into the peri- wall of the bowel and in the mesentery caused by obstruction
toneal cavity and usually causes overt symptoms and signs, such of lymphatic vessels at the base of the mesentery or the cisterna
as abdominal pain, tenderness, and distention accompanied by chili (e.g., by malignancies); (b) direct leakage of chyle through
1184
Acute colonic bleeding

Volume resuscitation
plus blood transfusion

NG aspirate NG aspirate
negative positive

Proctoscopy Gastroduodenoscopy
Rule out anorectal bleeding + endoscopic treatment
PART II
UNIT II

Bleeding stopped or slowed down Massive life-threatening bleeding

Elective colonoscopy Mesenteric arteriography

Positive Negative Positive Negative

Endoscopic Observe Moderate bleeding Vasopressin Explore, intraoperative

treatment continued or emboli endoscopy
SPECIFIC CONSIDERATIONS

Rebleeding
Rebleeding Fail Positive Negative

Segmental See moderate bleeding Segmental Segmental Total

resection or massive bleeding resection resection colectomy

or
99MTc RBC scintigraphy Urgent colonoscopy
Positive Negative
Positive Negative

Mesenteric arteriography Explore, intraoperative Colonoscopic treatment Explore, intraoperative

endoscopy or explore, segmental endoscopy
Positive Negative resection
Positive Negative Positive Negative
Vasopressin Explore, intraoperative Segmental Total Segmental Total
or emboli endoscopy resection colectomy resection colectomy
Fail Positive Negative

Segmental Segmental Total

resection resection colectomy

Figure 29-7.  Algorithm for treatment of colorectal hemorrhage. NG = nasogastric; 99mTc = technetium-99; RBC = red blood cell.
(Reproduced with permission of Taylor & Francis, LLC from Gordon PH, Nivatvongs S, eds. Principles and Practice of Surgery for the
Colon, Rectum, and Anus. 2nd ed. New York: Marcel Dekker, Inc.; 1999:1279. Permission conveyed through Copyright Clearance Center,
Inc.)

movements, hard stools, or excessive straining. A careful his- (colonic inertia) refractory to maximal medical interventions.
tory of these symptoms often clarifies the nature of the problem. While this operation almost always increases bowel movement
Constipation has many causes. Underlying metabolic, frequency, complaints of diarrhea, incontinence, and abdominal
pharmacologic, endocrine, psychological, and neurologic pain are not infrequent, and patients should be carefully selected
causes often contribute to the problem. A stricture or mass and counseled.15
lesion should be excluded by colonoscopy, barium enema, or
CT colonography. After these causes have been excluded, eval- Diarrhea and Irritable Bowel Syndrome.  Diarrhea is also
uation focuses on differentiating slow-transit constipation from a common complaint and is usually a self-limited symptom of
outlet obstruction. Transit studies, in which radiopaque markers infectious gastroenteritis. If diarrhea is chronic or is accompa-
are swallowed and then followed radiographically, are useful for nied by bleeding or abdominal pain, further investigation is
diagnosing slow-transit constipation. Anorectal manometry and warranted. Bloody diarrhea and pain are characteristic of colitis;
EMG can detect nonrelaxation of the puborectalis, which con- etiology can be an infection (invasive E. coli, Shigella, Salmo-
tributes to outlet obstruction. The absence of an anorectal inhibi- nella, Campylobacter, Entamoeba histolytica, or C. difficile),
tory reflex suggests Hirschsprung’s disease and may prompt a inflammatory bowel disease (ulcerative colitis or Crohn’s coli-
rectal mucosal biopsy. Defecography can identify rectal pro- tis), or ischemia. Stool wet-mount and culture can often diag-
lapse, intussusception, rectocele, or enterocele. nose infection. Sigmoidoscopy or colonoscopy can be helpful in
Medical management is the mainstay of therapy for consti- diagnosing inflammatory bowel disease or ischemia. However,
pation and includes fiber, increased fluid intake, and laxatives. if the patient has abdominal tenderness, particularly with peri-
Outlet obstruction from nonrelaxation of the puborectalis often toneal signs, or any other evidence of perforation, endoscopy is
responds to biofeedback.14 Surgery to correct rectocele and rec- contraindicated.
tal prolapse has a variable effect on symptoms of constipation Chronic diarrhea may present a more difficult diagnos-
but can be successful in selected patients. Subtotal colectomy is tic dilemma. Chronic ulcerative colitis, Crohn’s colitis, infec-
considered only for patients with severe slow-transit constipation tion, malabsorption, and short gut syndrome can cause chronic