Asso. Prof. Utham Murali. M.S ; M.B.A.IMS / MSU / Malaysia.

Lower GI - Bleed

Definition

Lower GI - bleeding is defined as abnormal hemorrhage into the lumen of the bowel from a source distal to the ligament of Treitz.

Normal faecal blood loss – 1.2 ml / day

Significant - > 10 ml / day

Presentation

Lower GI bleeding typically presents with

1. Hematochezia (which can range from bright-red blood to old clots)

2. Melena (If the bleeding is slower or from a more proximal source)

Massive Bleeding

Presents as a large volume of bright red blood PR

Bleeding > 1.5 l / day Hemodynamic instability & shock ↓ in hematocrit level of 6 g / dL Common causes – D / A Transfusion of at least 2 units of

packed red blood cells Bleeding that continues for 3 days

Moderate Bleeding

Presents as haematochezia or malena

Hemodynamically stable Causes – Ano-rectal / Cong./

Infla.& Neoplastic diseases Initial ↓ in hematocrit level

of 8 g / dL or less

Occult Blood

Detected by routine chemical

tests of the stool, with or

without systemic evidence of

chronic blood loss.

10 ml. of blood loss / day is

necessary to have stool

occult blood positive.

Types

Aetiology

Site of Bleeding

Pain + / -

Classification

Aetiology – General causes

1. Congenital -Polyp’s / Meckel’s diverticulum / HHT 2. Infammatory - Ulcerative colitis / Infective /Amoebic / Crohn’s disease3. Neoplastic – Adenomas / Carcinomas / Polyps4. Vascular –Angiodysplasia / Ischaemic colitis / Vasculitis / Hamangioma5. Clotting disorders - Haemophilia / Leukaemia / Warfarin therapy / DIC 6. Miscellaneous – Piles / Anal fissure / Injury to rectum

Site – Local causes

1. Small Intestine -Polyp’s / Meckel’s diverticulum / Ulcers / Tumours / Intussusception2. Large intestine - Angiodysplasia / Carcinomas / Colitis / Diverticulitis 3. Perianal –Injury / Rupture(Haematoma /Anorectal abscess)/ Carcinoma / Condyloma 4. Anal - Piles / Anal fissure / Carcinoma / Fistula-in-ano

With Pain

Fissure in Ano

Fistula in Ano

Ca. Anal Canal

Rup. perianal haematoma

Rup. Ano Rectal abscess

Endometriosis

Injury

Without Pain

1. Blood Alone a. Polypb. Villous Adenomac. Diverticular diseases

2. Blood After Defecationa. Hemorrhoids

3. Blood with mucusa. Ulcerative colitisb. Intussusceptionc. Ischaemic Colon

4. Blood Streaked on stoola. Ca. Rectum

Common Causes

Acute Sub-acute / Chronic

Diverticular disease Anal disease

Mesenteric ischaemia Inflammatory bowel disease

Angiodysplasia Large polyps

Ischaemic colitis Carcinoma

Meckel’s diverticulum Solitary rectal ulcer

Intussusception Radiation enteritis

Differential Diagnosis

Clinical Presentations Bleeding Per rectum –

- Bright red blood Piles / Polyps / Fissure- Altered blood Ca / Ulcer / IBD / Dysentery- Maroon colour Meckel’s diverticulum- Streaks of blood Anal fissure- Splash in pan Piles- Red currant jelly Intussusception- Blood with mucus Colitis / Ca / Dysentery

Note : Ask & Look for bleeding tendency

Relation to Defecation

Streak of fresh blood – FIA At the time of passing stool –

Bright red & Splashes over the pan

- Piles Other than during defecation -

Polyps / PP / RP / Ca / UC Bleeding per anum in child –

Polyp

OTHERS

Pain

Altered bowel habits

Anaemia / Malnutrition / LOW / LOA

Mass palpable PA – Rt /Lt / MOI

Per-rectal exam – Very important

Investigations

1. Blood Tests –a. Hb% / PCV / LFT

b. Coag. Profile / RFT

2. Stool examination - a. Ova / cyst / worms

b. Occult blood – FOBT

Investigations - Contd

Small Bowel Enema

Barium Enema

Investigations - Contd

Proctoscopy

Sigmoidoscopy

Investigations - Contd

Colonoscopy – Gold Standard

Investigations - Contd

Colonoscopy – Gold Standard

Investigations - Contd

Colonoscopy – Gold Standard

Investigations - Contd

Colonoscopy – Gold Standard

Investigations - Contd

5. U/S abdomen –

6. Angiography – Identifies bleeding rate of 0.5ml/mtAll 3 vessels – are usedAngiodysplasia / Tumours/ Vasculitis – diagnosed

7. Radionuclear scanning –Identifies 0.1ml / mtTc labelled sulphur colloid / tagged RBC scan

Investigations - Contd

Capsule Endoscopy

CT / MRI - Angiography

Treatment

Cause is treatedProper exploration – lengthy midline incision – essentialEndoscopic polypectomy for polypsMassive resection – small bowel – mesenteric ischemiaSurgical resection – colonic carcinomaSigmoid colectomy – sigmoid diverticulaEndoscopic fulguration / therapeutic embolization / Rt.hemicolectomy for angiodysplasiaDrugs / Mesacol enema / Total proctocolectomy i IA anastomosis for ulcerative colitisExcision & ligation – piles

References