Lower Gastrointestinal Bleeding

Hussein Shamaly M.D. French Hospital, Nazareth

Normal Rectum & Colon

Level of bleeding

• Upper GI bleeding -

the source is above the Treitz ligament

• Lower GI bleeding – is below

Hematemesis

• Vomiting of blood • The source is upper GI tract • May be serious enough to cause GI bleeding

with shock

Melena – passage per rectum of black tarry stools – occurs from approximately 150 to 200 mL of blood

in the GI tract for a prolonged period – Is present in approximately 70% of patients with

UGIB and a 1/3 of patients with LGIB – Blood from the duodenum or jejunum must

remain in the GI tract for approximately 8 hours before turning black

– Stool may remain black and tarry for several days, even though bleeding has stopped

Hematochezia • Passage of bright red blood per rectum • May be isolate or mixed with stools • Usually indicated lower GI bleed, but can occur with massive

upper GI bleed

Obscure GI bleeding

• Intermittent GI bleeding for which no source has been determined, despite rigorous endoscopic (gastroscopy+colonoscopy) and radiologic investigation

• Almost all are from small bowel.

Lower GI Bleeding

• Accounts for up to 0.3% of visits to major urban ERs

• Provokes alarm and anxiety in parents and physicians

• Differential diagnosis is extensive and varies according to age

• Most etiologies are self-limited and benign

D.D : Neonate • Anorectal fissures • Swallowed maternal blood • Necrotizing enterocolitis • Allergic colitis

• Malrotation with midgut volvulus • Hirschsprung disease

D.D. : Infant

• Anorectal fissures • Infectious colitis • Allergic enterocolitis • Intussusception • Meckle’s diverticulum • Hemolytic uremic syndrome • Henoch-Schonlein purpura • Lymphonodular hyperplasia • Gastrointestinal duplication

D.D : Preschooler

• Juvenile Polyps • Infectious colitis • Intussusception • Meckle’s diverticulum • Hemolytic uremic syndrome • Henoch-Schonlein purpura • IBD

D.D. : School age and Adolescence

• Infectious colitis • Anal fissures

• Juvenile Polyps • IBD • Haemorrhoids • Vaginal bleeding

Don't forget!

In both upper & lower GI bleed • Coagulopathy • Trauma • False positives

False Positive Visible “Blood”

• Antibiotics (Ampicillin, Rifampin) • Bismuth preparations (Pepto-Bismol) • Beets • Chocolate • Iron • Flavored gelatin • Red licorice

Anal Fissure • Most common cause in the first 2 years of life • Blood is generally bright red and present on

the outside of the stool • Results from superficial tear of the squamous

lining of the anal canal • Usually caused by passage of large, constipated

stool • Painful, leads to with-holding

Infectious Enteritis

Bacterial: Shigella, Salmonella, Campylobacter, E. coli, Yersinia, C. diff

Viral: Rotavirus, Norwalk virus, , HSV • Parasitic: Entameoba histolytica • Sexual abuse: Gonorrhea, Chlamydia

Food Allergy • Can present with postprandial nausea, vomiting,

abdominal pain, and diarrhea, +/- iron deficiency anemia and rectal bleeding

• May exhibit malabsorption, protein-losing

enteropathy, and failure to thrive • May see infiltration of GI tract with eosinophils

and/or peripheral eosinophilia • The most common allergens are- cow’s milk and

soy proteins

Intussusception

• Most common in children under 2 years

• Colicky abdominal pain, vomiting, pallor, palpable sausage-shaped abdominal mass, passage of “currant jelly stool”

?

Meckle’s Diverticle • Is a small bulge in the small intestine present from birth • It is a remnant of the omphalomesenteric duct, and is the most frequent malformation of the gastrointestinal tract • It is present in approximately 2% of the population • found twice in males than females • It is named after Johann Friedrich Meckle, who first described in 1809

Meckel’s Diverticle

• Usually found within 60-100 cm of the ileo-cecal valve. • It is typically 3-5 cm long, and has its own blood supply • Can be present in an indirect hernia, where it is known as Hernia of Littre. • It can be attached to the umbilicus, with the possibility of local cysts, torsions of intestine around the intestinal stalk, leading to obstruction, ischemia, and necrosis

Symptoms of Meckel’s

• Approximately 98% are asymptomatic • It appear before the age of two years old • The most common presenting symptom are : • painless rectal bleeding • Intestinal obstruction • Volvulus • Intussusception. • May present with all the features of acute appendicitis

Meckle Diverticle

• Diagnosis : Meckle’s Scan • Treatment : surgical, consisting of a resection of the affected portion of the bowel.

Polyps • Most common source of lower GI bleeding

beyond infancy • Occur between 2 and 8 years

– Peak at 3 to 4 years • Benign hamartomas (arise from normal

tissue) • Painless rectal bleeding • Majority located in the rectosigmoid region • Bleed after autoamputation or injury by fecal

passage • Bright red blood on the outside of the stool

Polyps

Peutz–Jeghers syndrome

• Autosomal Dominant • 50 % risk of malignancy • STK11/LKB1 gene (chr. 19)

Cowden Syndrome

Breast, kidny,endometrium, colorectal and Thyroid cancer Mutation in PTEN gene Autosomal dominant

Gardner syndrome

• Familial Colorectal polyposis • Osteoma • Thyroid Cancer • Epidermoid Cancer • Sebaceous Cyst • 100% Malignancy • Autosomal Dominant • APC Gene, chromosome 5q21

Familial Polyposis Syndrome • Familial Adenomatous polyposis( FAP) • Autosomal Dominant ( APC Gene) • Autosomal Recessive (Muthy Gene) • 100% Malignancy

Rectal Prolapse

Idiopatic C.F. Constipation

Angiodysplasia=AVM • Small ectatic vessels in the

submucosa, arteriovenous malformation.

• 5-20% of LGIB. • The most common cause

of hemorrhage from SB. • The most common cause

of massive LGIB from rt colon.

AVM • Occur primarily in cecum and ascending colon of

elderly patients> 50% • Recurrent intermittent bleeding • Colonoscopy-most sensitive tool. - diagnostic and therapeutic.

Rendu- Osler Weber

• Also known as hereditary hemorrhagic telangiectasia (HHT)

• May be asymtomatic to multiorgan

involvement • typically identified by the triad of

telangiectasia, recurrent epistaxis, and a positive family history

Rendu- Osler Weber

• Telengiectasis : Involve the mucous membranes, skin, conjunctiva, retina, GI tract and lungs

• CNS complications : Cerebral absceses,Stroke • AVM – • Aneurism • High – Cardiac Output Failure • Genetic : Autosomal dominant • two genes: ENG or ALK-1

Rectal Hemangioma

Inflammatory Bowel Disease

• Approximately 25% of patients present before age 20 years

• Rectal bleeding is seen in almost all of UC patients and 25% of CD patients

• UC : Minor and insignificant bleeding =Conservative TRT

• Significant bleeding surgery

• Crohn’s : Conservative Treatmend • Surgery for complications

UC CD

Radiation colitis

Rectal Varices

History

• Duration of bleeding • Amount of bleeding • Color of blood • Relationship to stool • Consistency of accompanying stool • Presence of blood on toilet paper • Associated symptoms • Past episodes of GI bleeding • Recent use of medications, including NSAIDs

Physical Exam

• Vitals: Febrile, tachycardia, hypotension • General: Pallor, distress, nutritional status • ENT: Posterior nose (to r/o epistaxis) • Skin: Ecchymoses, jaundice, eczema • Abdomen: Caput medusa, ascites, bowel

sounds, masses, tenderness • Rectal: Fissures, hemorrhoids, skin tags • GU: Vaginal bleeding

Laboratory Evaluation

• CBC • Coags • LFTs • General chemistry • Stool cultures (bacterial, viral) • Confirmatory occult blood test

– False +: red meat, iron supplements, turnips,broccoi, medications

Anatomy of hemorrhoids

What are hemorrhoids? Engorgement of venous plexi of rectum/anus with protrusion of mucosa

Internal hemorrhoids are dilated blood vessels and the surrounding tissue above the dentate line. Covered by mucosa.

Symptoms come from dilation of the blood vessels and increased friability, weakening of the surrounding tissue and attachment to rectal wall, injury from passing stool, and prolapse

External hemorrhoids are below the dentate line and are covered with modified squamous epithelium and richly innervated with somatic nerves

Hemorrhoids tend to enlarge over time and prolapse.

What causes hemorrhoids?

Lack of soluble fiber and enough water in the diet, straining, and sitting longer than 2 minutes on the toilet which promotes prolapse of the anal cushions

Increase in abdominal pressure e.g. pregnancy, obesity, pelvic tumors, sitting, coughing, constipation, diarrhea, anal intercourse, aging.

Hemorrhoids can be exacerbated by excessive cleaning, steroids, and hemorrhoid creams.

Hemorrhoids

• Rare in infants and children • If present, portal HTN should be suspected • Common in constipated adolescents • Usually present with bleeding upon defecation • Blood may be on the surface of the stool, on the

toilet paper, or in the toilet bowl