1.Dealing with LGIB:Overview LGIB Algorhythm Causes Endoscopic interventions Recommend ations

2. Lower GIB: Overview F Introduction A Aetiologies S Management algorythms T Endoscopic hemostasis 3. Introduction: LGIB is diagnosed in 20-30% of all patients presenting with major GI bleeding. The annual incidence is 0.03%. increases * 200 from 2nd- 8th decades of life. The mean age at presentation is 63 - 77 years. A full-time gastroenterologist manages >10 cases/ year. Blood loss can be trivial or massive & life-threatening, but the majority have self-limited& uncomplicated hospitalization. LGIB tend to present with a higher Hb &less likely to develop hypotensive shock or require blood transfusions. Mortality is 2- 4%, usually from comorbidities& noscom infs. Reported decreased incidence of LGIB & lower age/gender- adjusted fatality rate over the past decade. 4. Definitions: Before deep enteroscopy: Bleeding from a source distal to the ligament of Treitz Now: bleeding from a source distal to ICV. Now small-bowel sources called midgut bleeding. Acute LGIB: of recent duration (50 ys, to 60% >80 ys. Accounts for 20- 65% of acute LGIB episodes. Clinically significant bleeding occurs in 3-15% with colon diverticula, usually as a result of trauma to the vasa recta at the neck or dome of the diverticulum. NSAIDs increase the risk for diverticular bleeding. Hypertension&anticoagulation also may contribute to severe bleeding. 6. Diverticular bleeding: The clinical presentation: Painless hematochezia, resolves spontaneously in 75-80% but recurs in 25-40% within 4 years. Early rebleeding is uncommon after endoscopic treatment. Using epinephrine/or thermal coagulation early (2/3 of these lesions are seen in > 70 years. Angioectasias are caused by degenerative changes& chronic intermittent low-grade obstruction in the submucosal vessels. They are located predominantly in the cecum & the ascending colon. Multiple angioectasias may be seen on colonoscopy appear as red, flat lesions, 2 mm- several cms, with ectatic blood vessels radiating from a central feeding vessel 12. Angioectasias(angiodysplasias): Risk factors include: Advanced age, comorbidities, the presence of multiple angioectasias & the use of anticoagulants or antiplatelet agents. Patients can present with occult bleeding, melena, or painless intermittent hematochezia. Colonoscopy has a sensitivity of 80% for detection of angioectasias. Narcotics for sedation may reduce mucosal blood flow and impair the detection of these lesions at colonoscopy. Bleeding from angioectasias in AS( Heyde syndrome) explained that severe AS may result in type 2 VWD, which precipitates bleeding in patients with underlying angioectasias. There is a high rebleeding rate despite endoscopic treatment& defi nitive management may involve AV replacement. 13. Hemorrhoids: Aplexus of dilated AV vessels that arise from the superior & inferior hemorrhoidal veins,located in the submucosa of the distal rectum classified as internal or external, based on their location relative to the dentate line. Although may be present in up to 75% with LGIB, the majority are considered incidental findings. Hemorrhoidal bleeding accounts for only 2- 10- 24- 64.4% of acute LGIB or hematochezia. Patients typically present with painless, intermittent, scant hematochezia characterized by bright red blood on the toilet paper, coating the stool, or dripping into the toilet bowl. 14. CR neoplasias: Bowel habit changes&weight loss should raise suspicion for a colorectal neoplasia&prompt colonoscopy in patients with LGIB. Accounts for up to 17% of GIB & presents more commonly with occult bleeding. Acute LGIB associated with colorectal neoplasia usually results from surface ulcerations of an advanced tumor. Patients with tumors in the right side of the colon are more likely to present with occult blood loss &IDA whereas those with left-sided tumors more commonly present with hematochezia. Endoscopic hemostasis is rarely required because bleeding is slow in the majority. 15. Postpolypectomy bleeding: Account for 2- 8% of acute LGIB, 8.7/1000 procedures. 16. NSAID use : Associated with increased risk of LGIB, including DD. NSAID users had a significantly higher incidence of lower GI adverse events, including bleeding The prevalence of NSAID use is up to 86% LGIB. Mechanisms not well understood: local mucosal trauma &platelet inhibition in susceptible individuals & concomitant use of warfarin&other antiplatelets. Use of NSAIDs is associated with exacerbations of IBD. NSAIDs can induce NSAID colopathy, which may be misdiagnosed as IBD, characterized by colon ulcerations and diaphragm-like strictures, predominantly located in the terminal ileum& right side of the colon. NSAID colopathy may be associated with LGIB &perforation. 17. Rectal ulcers : 8% of severe hematochezia&32% LGIB after ICU admissions for other critical illnesses. Patients often have major medical comorbidities: ESRD on HD Respiratory failure requiring mechanical ventilation, Decompensated cirrhosis Malignancy. Endoscopic findings:clean-based ulcers (82%),adherent clots (17%),nonbleeding visible vessels (33%),active bleeding (50%). Early rebleeding after endoscopic treatment is 44% -48% &mortality rate of 33-48% in high-risk stigmata who have multiple comorbidities. 18. Radiation proctopathy: LGIB occurs in 4-13% with rad colitis. This disorder is caused by radiation-induced endarteritis obliterans, which results in neovascularization& telangioectasias in the rectum. 19. IBD: Commonly present with LGIB. Acute LGIB requiring hospitalization is uncommon & reported to account for only 1.2-6% of all admissions in patients with Crohn s disease &0.1- 4.2% in patients with ulcerative colitis. Clinically significant bleeding in Crohn s disease is more common in patients with colon involvement than in those with isolated small-bowel disease. Bleeding resolves spontaneously in up to 50% of patients, but there is a recurrence rate of up to 35%. Medical management with biologics can be effective in the management. 20. HIV: LGIB occurs in 2.6% of patients with HIV, usually in the setting of AIDS-related thrombocytopenia&associated with an inpatient mortality rate of 28%. The most common etiologies of LGIB in these patients are opportunistic infections, including cytomegalovirus, herpes simplex virus, Kaposi s sarcoma& idiopathic proctocolitis. 21. U& SI source of LGIB : UGI source may be present in 11- 15% of patients with suspected LGIB Small-bowel sources constitute 2-15% of cases. 22. Management: Resuscitation/ evaluation Initial assessment: whether or not an urgent intervention is necessary. The majority, manifesting as occult fecal blood or scant hematochezia, can be managed electively in OP. Patients presenting with acute LGIB with melena or hematochezia usually require inpatient management, because the majority are elderly with significant comorbidities. Should undergo stabilization&resuscitation with crystalloids or blood products. Coagulation factors &platelets may be necessary in patients who are on antithrombotics or with underlying bleeding disorders. 23. Management: Resuscitation/ evaluation ICU admission: Clinical evidence of ongoing or severe bleeding. Transfusion > 2 units of packed RBCs Significant comorbidities. NGT lavage to exclude an upper GI bleeding source should be considered in patients presenting with hematochezia & hemodynamic instability. An actively bleeding upper GI source is unlikely if bile is seen in NG Lavage, but it cannot be ruled out with clear aspirate. A targeted history: NSAID use, prior bleeding episodes, recent polypectomy, radiation therapy for prostate or pelvic malignancies, IBD, CRC risk. 24. Management: Resuscitation/ evaluation Risk stratification: High risk of severe bleeding 80%: > 3 the following RFs. Moderate risk (45%) with 1-3 RFs. Low risk No Rfs (< 10%):. HR 100/minute, systolic blood pressure % 115 mm Hg, syncope, nontender abdominal exam, rectal bleeding during the first 4 hours of evaluation, aspirin use, multiple comorbid illnesses. 25. Management: Resuscitation/ evaluation Another model: independent predictors of severe LGIB. Initial hematocrit! 35%, presence of abnormal vital signs (SBP 100/minute) 1 hour after initial medical evaluation& gross blood on initial rectal exam. Kollef et al100 developed and validated another BLEED model; Outcome prediction tool for UGIB&LGIB: predict resource utilization& inpatient adverse events, including mortality. Ongoing bleeding, low SBP, elevated PT, erratic mental status, &unstable comorbid illness. 26. Occult GI bleeding Colonoscopy for evaluation of underlying CR neoplasia. CT colonography may be an alternative if high risk for colonoscopy-related adverse events& for the detection of proximal lesions in those who have had an incomplete colonoscopy. An EGD should be considered if a bleeding source is not identifi ed in the colon, especially in those patients with upper GI symptoms, IDA, or NSAID use( overall yield 13- 41%, with PUD &esophagitis) Small-bowel evaluation if fecal occult blood&persistent anemia, after negative EGD &colonoscopy. 27. Melena: EGD is the initial test in the evaluation of melena Melena also may result from slow bleeding emanating from the colon or small-bowel. Colonoscopy should, be pursued after negative EGD. Persistent melena after negative results with bidirectional endoscopy warrant small-bowel endoscopy. 28. Intermitent scant hematochesia: Is the most common pattern of LGIB. Usually is caused by an anorectal or distal colon source A digital rectal exam&flexible sigmoidoscopy ( yield of 9-58%), with or without anoscopy, may be sufficient for the evaluation of healthy patients aged< 40 years. A colonoscopy should be pursued in the absence of a defi nitive source of bleeding on flexible sigmoidoscopy, patients aged> 50 years, IDA, CRC risk, or alarm symptoms of weight loss or bowel habit changes. 29. Severe hematochesia: An emergent EGD is the test of choice for patients presenting with severe hematochezia & hemodynamic instability, followed by a colonoscopy after if the later is normal. In hemodynamically stable patients with severe hematochezia, colonoscopy should be performed first, followed by an EGD, if the colonoscopy is negative. The main advantage of colonoscopy lies in the ability to perform a therapeutic intervention in conjunction with diagnosis of the underlying lesion. The diagnostic yield of colonoscopy is 45-100% in LGIB & significantly higher than radiologic evaluation with RBC scan & angiography. 30. Severe hematochesia: Urgent colonoscopy should be performed within 8-24 hours of admission. Early colonoscopy increases its diagnostic yield &likelihood of a therapeutic intervention. Endoscopic therapy is performed in 10-40%, with immediate hemostasis achieved in 50-100%. Earlier colonoscopy is associated with higher higher successful hemostasis,reduced duration of hospitalization&cost of care but no improvement rebleeding or surgery. 31. Severe hematochesia: Colon preparation is important to improve visualization, increase the diagnostic yield&reduce the risk of perforation. Polyethylene glycol based solutions can be administered orally (or via NGT in patients at increased risk of aspiration or who are unable to complete oral consumption) at 1 L/30-45 minutes until the effluent is free of fecal material. Colonoscopy is performed within 1- 2 hours of preparation. The reaccumulation of blood in the colon after preparation may be helpful in localizing the bleeding source. Endoscopic hemostatic interventions include epinephrine solution injection, thermal contact coagulation, argon plasma coagulation, hemostatic clips&band ligation. 32. Endoscopic hemostasis : Bleeding DD Thermal contact modalities:heater probe&bipolar coagulation alone or in combination with epinephrine injection. Epinephrine solution in a dilution of 1:10,000 or 1:20,000 is injected in aliquots of 1 mL-2 mL at the site of active bleeding or around a non-bleeding visible vessel. An adherent clot, may be guillotined by using a polypectomy snare. The visible vessel can be treated effectively by using a heater probe (10 J-15 J) or bipolar coagulation (10 W-16 W) with 2 to 3 second pulse&application of mild contact pressure. Perforation reported with contact thermal coag in thin-walled right side colon in up to 2.5%, so higher settings or repeated applications avoided to prevent transmural injury. 33. Endoscopic hemostasis: Bleeding DD Endoscopic clips is an alternative to thermal coagulation&has the advantage of quick&easy application. Clips can be deployed over a bleeding vessel at the neck of the diverticulum or to oppose the walls& close the diverticular orifice, thereby tamponading a vessel within the dome. The use of an endocap has been described to evert the diverticulum and facilitate clipping of bleeding vessels within the dome of a diverticulum. There are no reports of early rebleeding after endoscopic treatment with clips. 34. Endoscopic hemostasis : Bleeding DD Endoscopic band ligation described in some small series ,but limited by inadequate suction of diverticula with small orifi ces or large domes&high early rebleeding. A tattoo should be placed adjacent to the bleeding diverticulum, if identified at colonoscopy, for future identifi cation in recurrent bleeding &necessity for repeat endoscopic or surgical intervention. Placement of an endoscopic clip also may be useful to allow localization of the bleeding source at angiography. 35. Endoscopic hemostasis : Bleeding AD Both contact& noncontact thermal coagulation APC is useful in the endoscopic treatment of angioectasias. APC is the preferred technique because of its ease use, ability to treat large surface areas& predictable depth of penetration. Lower APC power settings of 30- 45 W & 1 L/minute, 1-3 mm away from the mucosal surface &at 1- 2 second pulses used to decrease the risk for perforation in the thin-walled right side of the colon. APC showed a significant improvement in Hb& reduction in transfusion requirements with no adverse events. The use of endoscopic clips with APC reported. 36. Non- endoscopic treatments: Mesenteric angiography with or without a preceding RBC scan is reserved for patients with: Severe bleeding who cannot be stabilized or prepped for a colonoscopy Failed endoscopic management. The multidetector row CT scan may be superior to the nuclear RBC scan for evaluation of LGIB& replaced RBC scan at several centers. It decreases scan time, allows accurate acquisition of arterial images&demonstrates contrast material extravasation into any portion of the GI tract. A mesenteric angiogram can detect bleeding at 0.5 mL/min. 37. Non - endoscopic treatments: Superselective embolization with microcoils, polyvinyl alcohol particles, or water-insoluble gelatin (gel foam) improved the success rate of this technique&decreased the occurrence of the adverse event of bowel infarction. Angiography & embolization as first-line therapy for LGIB found embolization to be an effective treatment for diverticular bleeding, with successful hemostasis in 85% compared with 50% of those with bleeding from other sources at 30-day follow-up with early re-bleeding after embolization in 22%. The technique is less successful in angiodysplasia & with more re-bleeding 40%. Major adverse events, including bowel infarction, nephrotoxicity,hematomas. 38. Non endoscopic treatments: Surgery Surgery is rarely required &reserved for minority of patients who have persistent or refractory diverticular bleeding. Indications for surgery: Hypotension&shock despite resuscitation. Persistent bleeding with transfusion of >units of Packed RBCs. Lack of a diagnosis despite a pan-intestinal evaluation for persistent bleeding in a surgical candidate. It is important to attempt localization of the bleeding site for a segmental colectomy opposed to a subtotal colectomy with significantly higher mortality rate. Surgery should be performed elective, because there is a high mortality with emergent one. 39. Recommendations: 1. We recommend colonoscopy in patients with occult GIB. 2. We recommend EGD in patients with occult GIB if a bleeding source is not identified in the colon, especially in those patients with UGI symptoms, IDA or NSAIDs use. 3. We suggest small-bowel evaluation after negative EGD& colonoscopy results in patients with occult GIB who have persistent anemia. 4. We recommend colonoscopy for the evaluation of chronic intermittent scant hematochezia in patients > 50 years& for patients who have IDA, risk factors for CR neoplasia, or the alarm symptoms of weight loss or bowel habit changes. 5. We suggest that in younger patients presenting with chronic intermittent scant hematochezia without alarm symptoms, a DRE &flexible sigmoidoscopy may be sufficient evaluation. 40. Recommendations: 6. We recommend EGD in the initial evaluation of patients with melena followed by colonoscopy if the EGD is negative. 7. We recommend an initial EGD in patients with severe hematochezia&hemodynamic instability to evaluate for a high-risk UGI lesion, followed by colonoscopy if EGD is VE. 8. We suggest colonoscopy within 24 hours of admission after a rapid bowel preparation in the evaluation of patients with severe hematochezia. 9. We recommend endoscopic treatment with epinephrine solution injection combined with thermal coagulation or endoscopic clip placement as the preferred management in patients presenting with diverticular bleeding. 41. Recommendations: 10. We recommend endoscopic clip or tattoo placement adjacent to a bleeding diverticulum if identifi ed at colonoscopy for future localization in the event of recurrent bleeding. 11. We recommend endoscopic treatment with APC as the preferred management in patients with bleeding angioectasias. 12. We recommend surgical &radiologic consultation in patients presenting with severe hematochezia who cannot be stabilized for endoscopy or in whom endoscopic evaluation has failed to reveal a bleeding source.