Lower intestinal bleeding in the elderly

Increasing recognition of bleeding vascular ectasias of the right colon prompted the present reevaluation of the importance classically attributed to diverticulosis as a cause of lower intestinal hemorrhage in the elderly. The records of all patients more than age sixty-five years admitted to Montefiore Hospital and Medical Center with lower intestinal bleeding from 1971 to 1976 were reviewed. Of 183 such patients, ninety-nine had major and eighty-four had minor bleeding. Of the ninety-nine patients with major bleeding, forty-three were discharged with a diagnosis of diverticular bleeding, and twenty were discharged with a diagnosis of vascular ectasias of the right colon. In most cases of diverticulosis, there was insufficient evidence to support this conclusion, and in only 18 per cent was the diagnosis based upon the angiographic demonstration of extravasation of contrast material into a diverticulum. In patients in whom a bleeding diverticulum was identified on angiography, segmental colectomy was not followed by recurrent hemorrhage. When no bleeding site was identified, colectomy was associated with a high incidence of rebleeding and subtotal colectomy with a high postoperative mortality. In all twenty patients with vascular ectasias, the lesion was identified on angiography, although extravasation was seen only twice. Eighteen patients were operated on: sixteen underwent right hemicolectomy and two subtotal colectomy; only two have rebled. Segmental colectomy will usually prevent recurrent hemorrhage when a site of diverticular bleeding or a vascular ectasia has been identified angiographically. Subtotal colectomy should be used only as a last resort. This study gives further support to the importance of vascular ectasias as a cause of bleeding in elderly patients and demonstrates the essential role of angiography in the diagnosis and management of this problem. Angiography is used to locate bleeding sites, to identify nonbleeding vascular ectasias, and for infusion of vasopressors into the mesenteric circulation to arrest bleeding.