Massive Haemorrhage

Massive haemorrhage is rarely an indication for emergency colectomy. Severe, life-treating haemorrhage occurs in 0-4.5% of patients with ulcerative colitis and it accounts for approximately 10% of all emergency colectomies performed due to ulcerative colitis [2]. The clinician should recognise potentially severe, massive bleeding and undertake appropriate measures in a timely fashion because a haemorrhage is one of the indications of the disease and can be easily underestimated. It is of paramount importance to distinguish a slow but persistent haemorrhage from severe bleeding with rapidly circulating volume loss. Haemorrhage with anaemia <6 g/dl, requiring 4-6 units of packed red cells, or haemorrhage with shock resistant to resuscitation should prompt emergency colectomy.

Since the bleeding is a marker of the severity of the disease, the clinician should be aware that the patient's life is not jeopardised only by the bleeding itself but by the severe underlying disease. Massive haemorrhage is often associated with concomitant toxic megacolon [2]. Many of these patients are or were using an immunosuppressive therapy that could further increase the risk. Sometimes paramedical reasons like reserves of blood in the blood bank, surgical facilities, etc., can also influence the decision for operative treatment. In any case, the clinician, erroneously believing that the bleeding will spontaneously cease, should not prolong medical treatment indefinitely. There are some reports of successfully managed severe bleeding in ulcerative colitis using a highly selective transcatheter embolisation [3]. This procedure is suggested as an alternative therapeutic approach in selected cases. Despite this successful but sporadic attempt, emergency proctocolectomy is currently advocated as the only reliable treatment. The alternative approach could be emergency colec-tomy without proctectomy. This alternative has the advantages of being a more simple procedure that can be performed in emergency settings by a less experienced surgeon and is less traumatic for the patient. It should be remembered, however, that total colectomy without proctectomy may not succeed in arresting the bleeding and, due to continued haemorrhage from the preserved rectum, subsequent proctectomy may be warranted in as much as 12% of cases [2]. Severe haemorrhage is a result of intense vascular congestion, erosion and ulceration through mucosa and submucosa. During an operation, it is necessary to resect the area of ulcerated bowel. The surgeon should make the decision, taking into account his experience with colorectal procedures, the condition of the patient and the endoscopic appearance of rectal mucosa. If he has a lack of experience, or the patient is in a poor condition, he should probably choose total colectomy without proctectomy as a first-line treatment. Probably the risk of continued bleeding from the rectal stump can be minimised by ligation of the superior haemor-rhoidal artery and vein during colectomy. If the bleeding persists from the rectal stump, it could be managed with rectal washouts with adrenaline chloride in saline solution [4] at 4-6 °C or with rectal packings. In case of continued bleeding despite rectal washouts and packings, proctectomy should be performed without hesitation. In this circumstance, the anal canal and pelvic floor should always be preserved. Specific procedures and management of acute severe bleeding in ulcerative colitis are presented in Figura 1.

Proctectomy
Fig. 1. Management of severe bleeding in ulcera-tive colitis

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