Lower GI Bleeding

Dr. M. Ghanem

• A less common reason for hospitalization

• 95% from the colon

• Etiology usually age related

Presentation

• Hematochezia (bright red blood, clots)

• May present with melena

• Usually less severe than UGI

Etiology

Diagnosis

Diagnosis

Colonoscopy

• Major bleeding interferes significantly with visualisation

• Successful in identifying the source of bleeding in up to 95% of cases

Radionuclide Scanning

• Most sensitive study• Least accurate for localization of bleeding• RBCs from the ptn r labeled with Tc99 and

reinjected, images are collected• Detect bleeding at a rate of 0.1cc/min• Lack spatial resolution• As a guide to the utility of angio

Angiography

• Detect hemorrhage at a rate of 0.5-1 cc/min• Therapeutic advantage (vasopressin inj.,

embolization)• Invasive• Complications include:– Hematoma– Areterial thrombosis– Contrast rxns– ARF

Video Capsule

• A video camera is swallowed

• Identifies the source of bleeding is 90% of cases

• Good in stable ptns

• Doesn’t have a treatment option

Push enteroscopy

• Can reach 70 cms from the ligament of treitz

• Successful in 40% of cases

• Video capsule is usually preferred

Diveticulosis

• The most common cause of LGIB (55%)• >75% stop bleeding spontanously• 10% rebleed within 1 year• 50% rebleed within 10 years• >50% of bleeds from Rt colon

Diveticulosis

• Diagnosis by colonscopy

• Tx by injecting epinephrine, cautery of clip with colonscopy

• Angio carries risk of ischemia

Angiodysplasia

• About 40% of LGIB• Acquired degenerative lesions secondary to

progressive dilation of normal blood vessels within the submucosa of the intestine

• Can occur anywhere in the bowel, cecum most common site

• Diagnosis by colonoscopy, angio • Appear as red stellate lesions with a rim of pale

mucosa

Angiodysplasia

• Tx with sclerotherapy or cautery (colonscopy), embolization by angio

• Rebleeding consider surgery

Neoplasia

• Uncommon cause of significant LGIB

• The first to rule out!!!

• Polyps

• Diagnosis by colonscopy

• Tx depends whether it’s a tumor or polyp, pathology, etc…

Anorectal Disease

• Include internal hemorrhoids, fissures and colorectal neoplasia

• 5-10% of LGIB• Bright-red blood per rectum that is seen in the

toilet bowl and on the toilet paper• Internal hemorrhoids: painless, a lump that

reduces spontanously or by ptn• Fissures: painful

Anorectal Disease

• Malignancy needs to be ruled out before assuming that the bleeding is due to hemorrhoids

• Tx of hemorrhoids: rubber band ligation, sclerotherapy, coagulatiom, surgery

• Tx of fissures: stool softeners, NG, Ca channel blockers

Meckels Diverticulum

• A true diverticulum

• Remnant of the omphalomesentric duct

• Caused by acid production by ectopic musocsa

• Diagnosis by nuclear imaging, angio

• Tx is surgical