LOWER GASTROINTESTINAL BLEEDING IN THE … club_grand round... · Lower GI bleeding (LGIB) Account...

LOWER GASTROINTESTINAL

BLEEDING IN THE ELDERLY

Attapol Manatsathit, M.D.

Outline

Incidence

Definition

Causes

Management

Prognosis

Conclusion

Lower GI bleeding (LGIB)

Account for 15-20% of GI bleeding

Much less frequent than UGIB

Increase with age acquired lesion in the colon

15% of UGIB may present with haematochezia

Unidentified source of bleeding in approximately 5 % of

patients.

Am J Gastroenterol. 1997 Mar;92(3):419-24.

Langenbecks Arch Surg. 2001 Feb;386(1):8-16.

Incidence

Causes Incidence (%)

Diverticulosis 30-60

Angiodysplasia 4-15

Haemorrhoids 4-12

Ischaemic colitis 4-11

Other colitis 3-15

Tumour and malignancy 2-11

Post-polypectomy 2-7

Solitary rectal ulcer syndrome 0-6

Dieulafoy’s lesion Rare

Rectal varices Rare

ต ำรำเลือดออกในทำงเดินอำหำร, 2553.

Clin Gastroenterol Hepatol. 2004 Jun;2(6):485-90.


> 200 fold increase in the incidence f of LGIB from 3rd to

9th decade of life

64% of patients: > 70 years of age

Men and women equally affected

Elderly people with LGIB incur longer hospital stays and

greater health care costs.


Dis Colon Rectum. 1975 Jan-Feb;18(1):37-41.

Can J Gastroenterol. 2002 Oct;16(10):677-82.

Dig Dis Sci. 2005 May;50(5):898-904.

MORTALITY

Can J Gastroenterol. 2002 Oct;16(10):677-82.

Definition

Upper GI bleeding (UGIB)

มีต ำแหน่งเลือดออกตั้งแต่หลอดอำหำร กระเพำะอำหำร จนถึงล ำไส้เล็กส่วนท่ีอยู่เหนือต่อ ligament of Treitz


มีต ำแหน่งเลือดออกตั้งแต่ล ำไส้เล็กส่วนท่ีอยู่ต่ ำกว่ำ ligament of Treitz ล ำไส้ใหญ่ rectum จนถึงปำกทวำรหนัก

Obscure GI bleeding (OGIB)

ภำวะเลือดออกในทำงเดินอำหำรที่ไม่สำมำรถหำต ำแหน่งของเลือดออกได้ชัดเจนทั้งจำกกำรส่องกล้องหรือภำพถ่ำยรังสีของล ำไส้เล็ก


Gastroenterology. 2007 Nov;133(5):1697-717.

New definition

Upper GI bleeding

Oesophagus to ampulla of

Vater

Mid GI bleeding

Ampulla of Vater to

terminal ileum

Lower GI bleeding

Colonic bleeding

Gastroenterology. 2007 Nov;133(5):1697-717., Endoscopy. 2006 Jan;38(1):73-5.

Clinical presentation

• Overt GI bleeding

Passing of blood per rectum

Red blood

Maroon stool

Melaena

Occult GI bleeding

Positive faecal occult blood test (FOBT)

Iron deficiency anaemia


Causes

World J Gastrointest Endosc. 2010 May 16;2(5):147-54.

Diverticulosis

A sac-like protrusion that herniates through the colonic

wall through the spaces weakened by the vasa recta.

Incidence increases with age.

5% at age 40 65% at age 85

Can be found in small intestine obscure GI bleeding

Lancet. 2004 Feb 21;363(9409):631-9.


Diverticulosis

90% of colonic diverticula are in the left colon.

50%-90% of diverticular LGIB occurs from right-sided

colonic diverticula.

Most patients are asymptomatic.

LGIB occurs in 3-5% of patients with diverticular disease.

Lancet. 2004 Feb 21;363(9409):631-9.



Diverticulosis

Factors increased injury

NSAIDs

Hard stool stercoral ulcer

Usually presents as acute, painless haematochezia

Usually ceases spontaneously, but may be severe in elderly

Comorbid diseases

Use of anticoagulants or NSAIDs



Recurrent risk


Angiodysplasia

Intestinal vascular ectasia, angioectasia

A degenerative lesion of previously normal blood vessels

May occur anywhere in the colon

Profound at caecum and right colon (56-100%)

0.1- to 1-cm dilated submucosal veins, venules, or

capillaries

Tortuous, thin walled vessels lined mostly by endothelium

Rarely exhibit smooth muscle in the walls

Arch Intern Med. 1995 Apr 24;155(8):807-12.


Angiodysplasia

Patients are usually more than 60 years of age at

presentation.

Majority are in their 7th or 8th decade of life.

Low grade, painless bleeding with recurrence

Majority: spontaneously ceased

15% of patients can have massive bleeding.



Angiodysplasia

An important cause of haemorrhage in patients with

chronic renal failure

Platelet dysfunction in uraemia

Use of ASA

Use of heparin with haemodialysis



Angiodysplasia vs. diverticulosis

Angiodysplasia Diverticulosis

Nature of bleeding Venous Arterial

Recurrence Less massive at any 1 time;

more likely to recur; ≥ 3

episodes in 80%

Usually more severe; less

likely to recur; ≥ 3

episodes in 30%

Angiography Bleeding site seen in 6-20%;

vascular tuft and/or early

filling of large vein is seen

Bleeding site seen in 35-

75%; no vascular tuft or

early filling of vein is seen

Site of bleeding Almost always right colon

(97-100%)

Majority are in right colon

(45-65%)

Associated diseases Reported increased

association with

cardiovascular disease

No predominant

association


Ischaemic colitis

An acute, self-limited compromise in intestinal blood flow

accounts for 3% to 9% of LGIB in the elderly

Colonic atherosclerosis is almost universal in the elderly

and predisposes to ischemic colitis.

Mesenteric artery emboli, thrombosis, or trauma

Mesenteric Hypoperfusion e.g. CHF, shock

History of a hypotension supports the diagnosis.


World J Gastroenterol. 2008 Dec 28;14(48):7302-8.

Ischaemic colitis

Lower abdominal cramp followed by haematochezia or

bloody diarrhoea

Watershed areas of the colon

Right-sided colon

Splenic flexure

Recto-sigmoid junction

complicated by perforation or stricture


World J Gastroenterol. 2008 Dec 28;14(48):7302-8.

Inflammatory diseases of the colon

Infectious colitis

< 10% of patients with bloody stool

Campylobacter

Salmonella, Shigella

E. coli O157: H7 TTP

Clostridium difficile (long-term care facility, hospital, Hx of antibiotic

use)

Inflammatory bowel diseases

Bimodality with 2nd peak at 60-70 years of age

15% of patients develop symptoms at age > 65 years


Stercoral ulcer & solitary rectal ulcer

syndrome

Stercoral ulcer

Hard impacted stool in the rectum

Manipulation

Foreign body injury e.g. rectal tube placement

Solitary rectal ulcer syndrome

Rectal prolapse

Constipation

Straining

Gastroenterol Clin North Am. 2009 Sep;38(3):541-5.

Neoplasms

10% to 20% of cases of LGIB

Often present as a change in stool frequency, stool caliber

or weight loss

Initial presenting symptom in up to 26% of patients with

colorectal neoplasms


Rev Esp Enferm Dig. 2011 Aug;103(8):408-15.

Seminars in Oncology. 2004 Apr; 31(2):206-219.

Post-radiation colitis & proctitis

Higher incidence of malignancy requiring radiation

Prostate cancer

Gynaecologic malignancy

Genito-urinary cancer

Can be acute or develop years after treatment has ended

Treatment

Argon plasma coagulation

Formalin application

Sucralfate enema

Hyperbaric oxygen therapy


Clin Colon Rectal Surg. 2007 Feb;20(1):64-72.

Post-polypectomy bleeding

The incidence of colonic polyps and thus the necessity of

colonoscopic polypectomy rises with advancing age.

LGIB is a complication of colonoscopic polypectomy in

approximately 0.7% to 2.5% of cases

More commonly follows sessile polyp removal

Haematochezia soon after the procedure, but can develop

up to 1 week


Haemorrhoids

Prevalence decreases with age

Intermittent low-volume haematochezia, which often

coats the stool

Haemorrhoids

Colonic pseudo-obstruction

Constipation

LGIB

Stercoral ulcer &

solitary rectal

ulcer syndrome World J Gastrointest Endosc. 2010 May 16;2(5):147-54.

Evaluation

History

Complicated by the

presence of visual,

auditory and cognitive

impairment

May be necessary to call

the primary care provider,

caregiver and perhaps

even the pharmacist

Extent of bleeding

Duration of symptoms,

Presence of co-morbid

disease

Prior surgical history

Drug allergies

Recent and current use of

medication (clopidogrel,

warfarin and NSAIDS)


Evaluation

Physical examination

Orthostatic hypotension

20-40% of blood loss

Signs of cardiopulmonary

compromise

Chronic liver stigmata

Evidence of coagulopathy

Digital rectal examination

Proctoscopy

MMSE (optional)


Evaluation

CBC

Metabolic profile

Group match

Coagulogram

Electrocardiogram

CXR

Faecal occult blood test

Cardiac enzyme


Identification of bleeding site

Colonoscopy

Radionuclide scan

Abdominal angiography

Wireless capsule endoscopy

Push enteroscopy

Double-balloon enteroscopy


Colonoscopy

Urgent colonoscopy performed within 24 h of

hospitalization following a rapid purge is the best test for

evaluation of LGIB, once the patient has been resuscitated

and haemodynamically stabilised.

Accuracy 72-86%


Age Ageing. 2005 Sep;34(5):510-3.

225/247 patients with colonoscopy

Age > 80 years

Only 1 patients with complication (perforation)

Endoscopy. 2006; 38 (3): 226-230.

Complication rate = 0.2% in each group

Am J Gastroenterol. 2005;100:2395–2402.

RBC scan & abdominal angiography

Can be performed where colonoscopy is not feasible due

to massive bleeding

For visualising the bleeding source

RBC scan: bleeding rate 0.1 to 0.5 mL per minute

Abdominal angiography: bleeding rate > 1 mL per minute

Accuracy

RBC scan: 24-78%

Abdominal angiography: 27-77%

Am J Surg. 2007 Mar;193(3):404-7.


RBC scan & abdominal angiography

Bleeding cannot be ruled out when these tests are

negative.

Am J Surg. 2007 Mar;193(3):404-7.

Rebleeding rate 27%

Management

Adequate resuscitation and haemodynamic stabilisation

are cornerstones.

In the majority of cases, LGIB stops spontaneously with

appropriate resuscitation and supportive care.

The timing of tests and the type of intervention should be

custom tailored

Patient’s functional status

Impact on clinical outcome

Available diagnostic strategies


Issues to be concerned in the elderly

Intervention should not be withheld because of age alone.

Older patients are more likely to have cardiac pacemakers with or without defibrillators.

Consultation with cardiologist

Driven to automatic pacing by placing a magnet on the skin overlying the device whenever monopolar electrosurgical devices are used

Continuous ECG monitoring during the procedure

Initial dosage of sedative drugs should be lower and titration should be more gradual.


Treatment modalities

Colonoscopy

Thermal coagulation

Band ligation

Metallic clips

Epinephrine injection

Sclerosing agent injection

Fibrous glue

Abdominal angiography

Vasopressin infusion

Embolisation

Surgery


Algorithm


Poor prognostic factors

Unstable haemodynamics

Continuous

haematochezia

Older age

Comorbid diseases

LGIB in hospitalised

patients

On antiplatelet or

anticoagulant

No abdominal sign

Anaemia (Hct < 35%)

High serum Cr

leucocytosis



Conclusion

LGIB is a significant worldwide cause of increased

morbidity and mortality in the elderly.

The incidence of LGIB increases with age and

corresponds to the increased incidence of specific

gastrointestinal diseases.

Comorbid diseases

Polypharmacy

In the majority of elderly patients with LGIB appropriate

evaluation and management will lead to a successful

outcome.

THANK YOU!!!

LOWER GASTROINTESTINAL BLEEDING IN THE … club_grand round... · Lower GI bleeding (LGIB) Account...

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