I think, yes, this is the best option for this condition.

 In this case and under the conditions described above, a midline laparotomy is mandatory. What group of disease is most possible to find in the abdominal cavity and what can we do?

However, we should to answer some questions, while performing the laparotomy (or early, if possible):

1) What kind of hematohezia it was:

1a. A frank arterial blood with clots  - seek its origin is the left colon, either a polyp or vascular malformation

1b. A frank venous blood - from the lower porto-systemic shunt at the rectosygmoid or lower/3 of the sygma (the portal history may be or may be not known); 

2) A blood mixted with intestinal contents:

2a. A source of the bleeding is high (the right colon including appendix or its fresh stump; even the small intestine), but localized or solid (a polyp, a tumor, and a vascular malformation, an atopic portal varix.

2b. IBD and acute bacterial and/or amoebial colitis and iliocolitis.

3) Characteric of the abdominal pain: If severe, seek for iliocae- etc - intussusception.

At surgery:

If all the colon from the ceacum till the sygma, but not the small intestine (as seen through its wall) is filled with blood, the ceacotomy should be performed so that to revise ab oculus its mucosa. The ceacum is the superior border of the bleeding and the most probable its location. When the finding is conformed to or suspicious for the ulcerative colitis/Crohn, a wedge biopsy from the ceacal wall should be taken, and complete the operation by forming 2 stomae, separate terminal ileo- and colostomae. The further treatment will be proceed by  intensivists in ICU.

In case that the ceacal mucosa seems unaltered, an intraoperative fibrocolonoscopy is indicated, or some improvised methods like transillumination may be of use.

So, IMHO, the total abdominal colectomy should not be considered as the single approach in this situation.

Provided the ongoing critical heamodynamical instability on operational table, the total colectomy is possible (but is not always savable in situations like this).

Good luck!

Your question needs modification. The whole colon is full of blood/ clot. But you do not know the bleeding site.  Mostly haematochezia  is due to upper GI bleed.  In fact any lower GI bleed Upper GI endoscopy must be done.

Now regarding the total colectomy

If no endoscopist is available, Emergency laparotomy is indicated after you rule out coagulation defect.  At laparotomy, please look, which part of the small bowel is containing blood. If need be use the laparoscope if available to locate the bleeder with a BP of above 90 mmHg. The enterotomy can be done at the stomach, proximal jejunum or the appendix base. IT is important to locate the bleeder. It it is in the colon, then only the situation of total colectomy.

ak pujahari

Dr.Pujahari,

Good point about a possible coagulopathy, aquired or even congenital, to rule out before surgery.

Bleeding requiring four units of blood in 24 hours or 10 units in total must be treated surgically. The laparotomy, in the absence of a reliable source of bleeding will most likely be a "blind colectomy". This still happens, though rarely, in western countries also. That for which I totally disagree with what has been done is the absolute lack of any attempt to diagnostics. An endoscopy service at Km 10 is not unattainable, plus 150 km there was a service of Angio CT. If the patient had been kept in hemodynamically stable conditions, a helicopter could transfer the patient to a center of high-volume where a diagnostic CT would be of great help. Then no one can say what would have happened, but doing so was not given any chanche the patient and the surgeon.

I think I would consider surgical option after rapid confirmation of absent coagulopathy (is he a hepatic, having any blood disease as hemophilia...etc) for u did not mention his PT, PTT or INR. Second thing is to exclude upper GIT bleeding...because a huge bleeding gastric ulcer eroding through the gastroduodenal artery for example can lead to massive bleeding and hematocazia mounting to death. So simply inserting a NG tube and doing gastric lavage would solve this in some way should u have no endoscopist available in hand.

Also as a part of initial parient stabilization, this patient of course requires massive blood transfusion, platelets, FFP and cryoprecipitate if possible plus hemostatic agents as vitamin K, dicynine and cyclokapron IV. Don't give SO much fluids to avoid diluting the coagulation factors in his blood turning him to DIC.  Also monitor his body temp, hypothermia promotes bleeding.

AFTER all these, I'll have full confidence that this patient is in need of emergency surgical laparotomy to SAVE his life as long as u have no CT or CT ANGIO to locate the bleeder and coil it.

This may be (if of colonic origin) due to one of 2 causes, diverticular disease (and in this case you should have asked for any previous attacks of chronic constipation with hard small pellet stools). The other option may be angiodysplasia of the colon.

Usually diverticular disease responds to blood transfusion and blood products...if not responding within the next few hours, total colectomy is the rule.

During laparotomy, I woukd gently clamp the terminal ileum, do th and do small after doing the colectomy, just make sure that the end colostomy

Dear Hastanesi,

A massive bleeding per rectum with hemodynamic instability is firstly due to an upper GI source, even in absence of a frank hematemesis. So, in absence of accessible upper GI endoscopy (in spite 10 Km distance is not an obstacle), firstly insert a nasogastric tube. If no diagnosis was confirmed non-invasively, of course you should operate, but firstly track the source of bleeding. Full colon is just a blood reservoir and not necessarily the source of bleeding. Hoping that your patient had been recovered. 

Sometimes surgeons are forced into situations and have to do what they don't want to do in order to save a patient's life.  If you really want to(this happened to one of the surgeons who trained me, the gastroenterologist forgot to tag a spot on the colon where a lesion had been excised, he only gave a distance length measurement from the anal verge to where the lesion had been).  The surgeon did a focal excision, then opened the specimen to look for the site of lesion excision, but couldn't want it.  He tried to feel the site, but couldn't so he called the gastroenterologist to come in and do an intra-op colonoscopy.  However, the gastroenterologist was attending grand rounds and couldn't get out to do the colonoscopy.  After several choice words, the surgeon had a rigid sigmoidoscope brought in and made skip incisions on the colon to look for the site.  It wasn't easy, but he eventually found the excised lesion site just as the gastroenterologist walked in with his scope.  The colonoscope confirmed the location.  It gave a very different location of the excised lesion relative to the distance measurement from the anal verge initially given by the gastroenterologist.  Ergo, if you want to, try a few skip colotomies and check out the colon with the rigid sig.

Dr.Lum,

I am afraid your suggestion - as it is useful without any doubt for certain unusual cases - could be hardly possible to perform in the situation described above due to short of time. There was needed something fast, precise, and simple to make, and, IMHO, the total colectomy would be too heavy procedure to survive for the critically bleeding patient and  too blind one to cure the disease successfully. However, I do hope that the case of Dr.Akkapulu has ended quite happily and might we become aware of what it really was.

Sincerely, Andrey Borodach