Lower GI bleed

Dr nawin kumar

• as any bleed that occurs distal to the ligament of Treitz and superior to the anus

• 20-33% of episodes of gastrointestinal (GI) hemorrhage– 85% from colon– 10% from UGI– 5% from SB

• The mortality rate for LGIB is between 2–4%

• marginal artery of Drummond -Connects the inferior mesenteric artery (IMA) with the superior mesenteric artery (SMA)

• The Arc of Riolan (Riolan's arcade, Haller's anastomosis or'meandering mesenteric artery) -connect the proximal middle colic artery with a branch of the left colic artery. This artery is found low in the mesentery, near the root. It is a poor anastomosis.

Aetiology

angiodysplasia

carcinoma

Meckel’s diverticulum intussusception enteritis Crohn’s disease

carcinoma proctitis

colitis

carcinoma

polyps

Diverticular disease

solitary ulcerhaemorrhoidsfissurecarcinomawartsPerianal Crohn’s disease

Rule out- Coagulopathy 1. SB2. Colon3. Benign anorectal

DANI

Differential Diagnosis of Lower Gastrointestinal Hemorrhage

% SMALL BOWEL BLEEDING (5%)

30-40 Angiodysplasias

5-10 Erosions or ulcers (potassium, NSAIDs)

5-15 Crohn's disease

5-10 Radiation

3-8 Meckel's diverticulum

3-7 Neoplasia

3-4 Aortoenteric fistula

3

1-3

1-5

10-25

• infectious colitis– E. coli O157:H7– Shigella– Salmonella– Campylobacter

jejuni• Pseudomembranous

colitis

DANI

• Rectal polyps• Haemorrhoids• Anal fissures• Anal fistulas• Proctitis• Gonorrheal or mycoplasmal

infections• Rectal trauma• Foreign objects

BENIGN ANORECTAL CAUSES

Lower Gastrointestinal Bleeding in Children and Adolescents• Intussusception

• Polyps and polyposis syndromes Juvenile polyps and polyposis Peutz-Jeghers syndrome Familial adenomatous polyposis (FAP)

• Inflammatory Crohn disease Ulcerative colitis Indeterminate colitis

• Meckel diverticulum

Clinical Approach

• History• Physical Examination• Investigation• Diagnosis• Management

History

• Presenting complaint(s)• History of presenting illness • Systemic review• Past medical and surgical history• Medication history (iatrogenic factors)• Family history• Social history

Information about bleeding

• Volume and frequency (amount)of bleeding• Colour of blood?• Relationship of bleeding to defecation? [before, during (mixed into faeces or coating surface?) or after]

• Associatiated symptoms eg, Painful defecation?, abdominal pain?

amount

• trivial hematochezia to massive hemorrhage with shock.

BLEEDING

FRANK OCCULT

ANAEMIASMALL BLEED

MASSIVE BLEED (rare)

3 groups

Stools may appear red in some patients after ingestion of beers

Colour- indicate the site

• occult, microscopic bleeding • Black tarry -melena - usually indicates blood

that has been in the GI tract for at least 8 hours. likely to come UGI

• Maroon color suggests rt. Sided lesion• Bright red stool- called hematochezia- sign of

a fast moving active GI bleed

Relationship of bleeding to defecation?

• minor blood on toilet paper • streaks of bright red blood• Blood mixed stools• Slash in pan• Mixed with mucus

Associated symptoms

• Bloody diarrhoea: – acute inflammation of the colon;

amoebic colitis; ulcerative colitis; ischaemic colitis; rectal and colonic carcinoma; shigellosis

•Abdominal pain?–Carcinoma of the colon; ischaemic colitis (in elderly(; ulcerative colitis; amoebic colitis

•No abdominal pain?–Painless bleeding from colonic diverticula, colonic angiodysplastic lesion; malignant lesion arising in the rectal ampulla

• anal pain?– External haemorrhoids; anal fissure, anal ulcer

• Fever?– Infectious colitis (amoebiasis, shigellosis); ulcerative

colitis

• Vomiting of blood– Bleeding above ligament of Treitz

•A change in your bowel habits?•A change in the caliber of the stools?

• colo-rectal Carcinoma

• Hypovolaemia – due to haemorrhage (e.g. pallor, dizziness

hypotension, tachycardia, angina, syncope, weakness, confusion, stroke, myocardial infarction/heart attack, and shock)

• Nonspecific complaints • may include dyspnoea, abdominal pain, chest

pain, fatigue

• past medical history– constipation or diarrhea- (hemorrhoids, colitis), – the presence of diverticulosis (diverticular

bleeding), – receipt of radiation therapy (radiation enteritis), – recent polypectomy (postpolypectomy bleeding),

and – vascular disease/hypotension (ischemic colitis).– anticoagulant – A family history of colon cancer - colorectal

neoplasm

Investigations &Management

• Resuscitation for major bleeds• Find site• Treat the cause

Initial steps in the management of upper gastrointestinal bleeding

Airway protection

Airway monitoring

Endotracheal intubation (if indicated)

Hemodynamic stabilization

Large bore intravenous access

Intravenous fluids

Red cell transfusion (for symptomatic anemia)

Fresh-frozen plasma, platelets (if indicated)

Consider erythropoeitin

Nasogastric oral administration

Large bore orogastric tube/lavage

Clinical and laboratory monitoring

Serial vital signs

Serial hemograms, coagulation profiles, and chemistries (as clinically indicated)

Electrocardiographic monitoring

Hemodynamic monitoring (if indicated in high-risk patients)

Endoscopic examination and therapy

localization

Colour- indicate the site

• occult, microscopic bleeding • Black tarry -melena - usually indicates blood

that has been in the GI tract for at least 8 hours. likely to come UGI

• Maroon color suggests rt. Sided lesion• Bright red stool- called hematochezia- sign of

a fast moving active GI bleed

LOCALIZATION

• past medical history– constipation or diarrhea- (hemorrhoids, colitis), – the presence of diverticulosis (diverticular

bleeding), – receipt of radiation therapy (radiation enteritis), – recent polypectomy (postpolypectomy bleeding),

and – vascular disease/hypotension (ischemic colitis).– anticoagulant – A family history of colon cancer - colorectal

neoplasm

localization

nasogastric tube

Blood

UGI bleed

bile

UGI bleed- unlikely

nondiagnostic (no blood or bile

LGI bleed

COLONOSCOPY

• Identifies lesion in 75 % or more

• Can provide endoscopic therapyAdvantages and disadvantages of common diagnostic procedures used in the evaluation of lower

gastrointestinal bleeding

Advantages Disadvantages

• Therapeutic possibilities • Bowel preparation required

• Diagnostic for all sources of bleeding

• Can be difficult to orchestrate without on-call endoscopy facilities or staff

• Needed to confirm diagnosis in most patients regardless of initial testing

• Invasive

• Efficient/cost-effective

• No bowel preparation needed • Requires active bleeding at the time of the exam

• Therapeutic possibilities • Less sensitive to venous bleeding

• May be superior for patients with severe bleeding

• Diagnosis must be confirmed with endoscopy/surgery

• Serious complications are possible

• Noninvasive • Variable accuracy (false positives)

• Sensitive to low rates of bleeding • Not therapeutic

• No bowel preparation • May delay therapeutic intervention

• Easily repeated if bleeding recurs • Diagnosis must be confirmed with endoscopy/surgery

• Diagnostic and therapeutic • Visualizes only the left colon

• Minimal bowel preparation • Colonoscopy or other test usually necessary to rule out right-sided lesions

• Easy to perform

MESENTERIC ANGIOGRAM

• Selective embolization initially controls hemorrhage in up to 100% of patients, but rebleeding rates are 15% to 40%

Advantages and disadvantages of common diagnostic procedures used in the evaluation of lower gastrointestinal bleeding

Procedure Advantages Disadvantages

Colonoscopy • Therapeutic possibilities • Bowel preparation required

• Diagnostic for all sources of bleeding

• Can be difficult to orchestrate without on-call endoscopy facilities or staff

• Needed to confirm diagnosis in most patients regardless of initial testing

• Invasive

• Efficient/cost-effective

Angiography • No bowel preparation needed • Requires active bleeding at the time of the exam

• Therapeutic possibilities • Less sensitive to venous bleeding

• May be superior for patients with severe bleeding

• Diagnosis must be confirmed with endoscopy/surgery

• Serious complications are possible

Radionuclide scintigraphy

• Noninvasive • Variable accuracy (false positives)

• Sensitive to low rates of bleeding • Not therapeutic

• No bowel preparation • May delay therapeutic intervention

• Easily repeated if bleeding recurs • Diagnosis must be confirmed with endoscopy/surgery

Flexible sigmoidoscopy

• Diagnostic and therapeutic • Visualizes only the left colon

• Minimal bowel preparation • Colonoscopy or other test usually necessary to rule out right-sided lesions

• Easy to perform

RADIONUCLIDE SCAN

Advantages and disadvantages of common diagnostic procedures used in the evaluation of lower gastrointestinal bleeding

Procedure Advantages Disadvantages

Colonoscopy • Therapeutic possibilities • Bowel preparation required

• Diagnostic for all sources of bleeding

• Can be difficult to orchestrate without on-call endoscopy facilities or staff

• Needed to confirm diagnosis in most patients regardless of initial testing

• Invasive

• Efficient/cost-effective

Angiography • No bowel preparation needed • Requires active bleeding at the time of the exam

• Therapeutic possibilities • Less sensitive to venous bleeding

• May be superior for patients with severe bleeding

• Diagnosis must be confirmed with endoscopy/surgery

• Serious complications are possible

Radionuclide scintigraphy

• Noninvasive • Variable accuracy (false positives)

• Sensitive to low rates of bleeding • Not therapeutic

• No bowel preparation • May delay therapeutic intervention

• Easily repeated if bleeding recurs • Diagnosis must be confirmed with endoscopy/surgery

Flexible sigmoidoscopy

• Diagnostic and therapeutic • Visualizes only the left colon

• Minimal bowel preparation • Colonoscopy or other test usually necessary to rule out right-sided lesions

• Easy to perform

Treatment

Lower GI bleed

Small volume Large volume

Investigate cause

Manage cause

Resuscitate

Bleeding stops

Bleeding persists

? Surgical intervention

SURGERY

• two settings: massive or recurrent bleeding.• Try to localize– Localisation- segmental rather – Not localise- blind subtotal colectomy.