Although we had no patients with massive bleeding in our hospital in the last 7 years to treat, this issue is worth mentioning. Severe bleeding occurs in 0-6% of patients with inflammatory bowel disease with most series quoting a 2-3% incidence [42-44]. As compared with ulcerative colitis, where bleeding may diffuse from large areas of ulcerated mucosa, in Crohn's disease the bleeding is often from a localised source. It is important to rule out a gastroduodenal source prior to bowel resection. Robert et al. [43] found that nearly 30% of patients with Crohn's disease treated for significant gastrointestinal bleeding had a bleeding duodenal ulcer as its source. In Crohn's disease, it is important to localise the source of bleeding pre-operatively. If gastroscopy and colonoscopy are not successful, the use of angiography may be considered, but only if patient stability is obtained. Other methods include the use of a nuclear medicine known as red cell scan.

Life-threatening haemorrhage and exsanguination from Crohn's disease in four patients were described in 1995, when 34 cases similar to the medical literature were reviewed [45]. Five patients died, in 30 (90%) surgery was necessary to cease haemorrhage and ileocolectomy was the most frequently performed procedure. Mesenteric arteriography was positive in 17 patients, providing precise preopera-tive localisation, resulting in no mortality in this group [45]. A retrospective study of 34 patients with acute lower gastrointestinal bleeding in Crohn's disease, the largest to date, shows a more favourable result [46]. Acute haemorrhage was defined as acute rectal bleeding originating in diseased bowel, requiring a transfusion of at least 2 units of red blood cells within 24 h. Upper gastrointestinal tract haemorrhage or anal lesions and postoperative bleeding were excluded. Recently, several promising studies have been published that describe transcatheter embolization for the treatment of massive lower gastrointestinal bleeding in cases of bleeding colonic diverticular disease and angiodysplasia. This approach may be useful for bleeding in Crohn's disease as well.

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