LOWER GI BLEEDING

Clinical Consideration

Ali Salah Alkhudair

Supervision by Dr. Atef Khan

OBJECTIVES By the end of this presentation,we are able

to: Defention of Lower GI Hemorrhage . Classification Deferential Diagnosis Workup and investigation Interventions and Treatments Case Senario

LOWER GI HEMORRHAGE

Defined as an abnormal intraluminal blood loss from a source distal to the Treitz ligamentum.

CLASSIFICATION

- Massive- Moderate - Mild

MASSIVE LOWER GI BLEEDING

Passage of a large volume of red or maroon blood through the rectum

Hemodynamic instability and shock (Systolic blood pressure of less than 90 mm Hg )

Initial decrease in hematocrit level of 6 g/dL or less

Transfusion of at least 2 units of packed red blood cells

Bleeding that continues for 3 days Significant rebleeding in 1 week

DEFERENTIAL DIAGNOSIS

DIAGNOSIS OF ANAL CONDITIONS WHICH PRESENT WITH:  

PAIN AND BLEEDING: Fissures PAIN, LUMP AND BLEEDING: Prolapsed haemorrhoids Carcinoma of the anal canal Prolapsed rectal polyp or carcinoma Prolapsed rectum  

DEFERENTIAL DIAGNOSIS

DIAGNOSIS OF CONDITIONS PRESENTING WITH RECTAL BLEEDING BUT NO PAIN: Blood mixed with stool colon carcinoma Blood streak on stool rectal carcinoma Blood after defaecation haemorrhoids Blood and mucus colitis Blood alone diverticular disease Melaena peptic ulcer  

DEFERENTIAL DIAGNOSIS IN ADULT

DEFERENTIAL DIAGNOSIS IN CHILDREN

HEMORRHOIDS (PILES)

* it is one of the commonest cause of rectal bleeding

Causes: carcinoma of the rectum pregnancy: Chronic constipation Also, heart failure, excessive use of laxatives

and portal HTN are causes.

HEMORRHOIDS (PILES) TYPES INTERNAL HAEMORRHOIDS: -develops above the dentate line. -covered by anal mucosa. -lacks sensory innervation (painless) -bright red or purple in color.    EXTERNAL HAEMORRHOIDS: -arise below the dentate line. -covered by St. sq. epith. -innervated by the inferior rectal nerve.   Internal H. drains into sup. Rectal veins portal

system External H. drains into inf. Rectal veins I.V.C.

HEMORRHOIDS (PILES) GRADING FOR INTERNAL TYPE Internal H. are classified by the degree of tissue

prolapse into the anal canal.   GRADE 1: they are confined to the anal canal with

minimal bleeding or maybe asymptomatic but do not prolapse.

  GRADE 2: they prolapse on defecating or straining

then reduce spontaneously.   GRADE 3: prolapse with or without straining and

require manual reduction.   GRADE 4: chronically prolapsed and if reducible fall

out again. Others fall out of the anus and are irreducible (strangulated) surgical emergency.

HEMORRHOIDS (PILES) SYMPTOMS

Grade 1 usually are asymptomatic or with minimal bright red bleeding on defecation.  

1-bleeding:

-the main and earliest symptom

-starts as bright red bleeding on the surface of the stool or on the toilet paper.

2-prolapse:

-a much later symptom

-starts transiently on defecation, but occurs with increasing frequency

until 3rd degree H. develop.

3-discharge:

-a mucous discharge accompanies a prolapsed pile.

4-pruritis

5-pain

HEMORRHOIDS (PILES) SIGNS

the pt. should be in the left lateral position.   INSPECTION:

-1st degree H. show no outward abnormality

-2nd degree H. may show the skin covered components when the buttocks are separated or piles may prolapse when the pt. strains.

-3rd degree H. shows the red anal mucosa in their position (3,7,11)

  DIGITAL EXAMINATION: internal H. can’t be felt unless

they are thrombosed or in the long standing thickened piles. And should not apply PR

HEMORRHOIDS (PILES)

INVESTIGATION

1-sigmoidscopy: essential to exclude co-exclude rectal pathology as carcinoma or polyps.

 2-barium enema: indicated when sigmoidscopy

and protoscopy can’t explain the symptoms.

3-CBC: anemia, rarely happen in longstanding piles.

HEMORRHOIDS (PILES)

D.D .

Anal or rectal cancer. Redunculated polyps. Rectal prolapse. Anal fissures or fistula or

hematoma – if painful-

HEMORRHOIDS (PILES)

COMPLICATION Anemia Strangulation: when a prolapsing pile become

gripped by the external anal sphincter. Thrombosis Ulceration: superficial ulceration of the exposed

mucous membrane. Gangrene Suppuration: uncommon Fibrosis

HEMORRHOIDS (PILES)

TREATMENT 1-first degree H.: bulk laxatives and high dietary fibers maybe enough to decrease the

constipation

2-injection therapy (sclerotherapy): -for the 1st degree and early 2nd degree H.

3- 5 ml of 5% phenol in almond oil is injected through a special syring to the base of the pile or just above the anorectal ring.

4- Rubber band ligation: -effective with 1st and 2nd degree H.

-a small o-ring rubber band applied to constrict the mucosa at the base. This will lead to strangulation of the pile and subsequent sloughing of the pile over a period of 10 days or so.

5-infra-red photocoagulation.

6-cryotherapy: a cryoprope is applied to the overlying mucosa.

7-stretching of the anal sphincter: it improves venous drainage and decrease the need for straining. Overstretching may lead to anal incontinence.

8-haemorrhoidectomy: Necessary for the 3rd degree H. or in prolapsed thrombosis.

Complications of the procedure: Anal stenosis, acute urinary retention, post-operative haemorrhage.

 

CARCINOMA OF THE RECTUM

75% occur in the lower part of the rectal ampulla papilliferous or a simple ulcer with everted edges.

25% in the upper part of the rectum annular in shape.

90% or rectal cancers can be felt with a finger during PR.

MACROSCOPIC APPEARANCE: It may be as follows: papilliferous ulcerating commonest stenosing at rectosigmoid colloid

CARCINOMA OF THE RECTUM

MICROSCOPIC APPEARANCE: *90% are adenocarcinoma *9% are colloid – adenocarcinoma with mucous

production- *1% highly anaplastic carcinoma simplex *at the anus, sq. cc occur but, a malignant tumour

protruding through the anal canal is more likely to be an adenocarcinoma of the rectum invading the anal skin.

Rectal ca is common in middle and old age (50-70 yrs) but can occur in young adults.

It is equally common in both sexes.

Rectal bleeding: small dark red streak on the stool. If a lot of blood accumulates it can pass as such but this is uncommon.

The surface of the tumour produces mucous which is expressed in a more liquid motion – diarrhea like- but if it pools it can be passed as liquid faeces.

There may be change in bowel habit usually towards constipation.

High annular cancers at the rectosigmoid junction may cause partial obstruction presenting as alternating constipation and diarrhoea.

Tenesmus tumour in the lower part of the rectum is large to fool the sensory mechanisims into thinking it is faeces.

Wight loss: this is common even if there isn’t any metastasis. Small primary lesions maybe symptom less but associated with

multiple metastasis especially to the liver. Here the pt. has upper abdominal pain, malaise and a palpable mass.

Pain is an uncommon symptom.

CARCINOMA OF THE RECTUM Symptoms

on Rectal Examination: More commonly, only the lower edge of a malignant ulcer can be felt. It

feels hard and bulges into the lumen of the rectum, the edges are everted and the base is irregular and friable.

Upon withdrawal of the finger, you will have blood and mucous on the gloved finger.

If the tumour is in the upper part of the rectum, only the lower edge is felt.

This position of the lesion makes it hard to decide if the tumour is in the rectum or out of it sigmoidscopy is the answer.

PR is not reliable in fat people. On general examination: the liver is the most common site for

metastasis. Other sites for metastasis are: supraclavicular lymph glands, the

lungs and the skin. Lung metastasis is uncommon, a chest x-ray is mandatory. The inguinal LN are involved only if the tumour is below the Hiltons line to

involve the skin. If the pt. has palpable inguinal LN, the tumour is most likely to be sq. cc.

of the anal skin.

CARCINOMA OF THE RECTUM SIGNS ON EXAMINATION

1-Sigmoidscopy: to inspect and take a biopsy. 2-Barium Enema: the indications for this procedure

are: * The growth isn’t visualized by sigmoidscopy *if a second tumour is suspected *ulcerative colitis *familial polyposis3-ultrasound of the abdomen to check liver

metastasis and ascites.

CARCINOMA OF THE RECTUM SPECIAL INVESTIGATIONS

Benign growth Carcinoma of the sigmoid prolapsing into the pouch of

Douglas. Ovarian or uterine tumours Extension of a carcinoma in the prostate or cervix Diverticular disease Endometriosis Lymphogranuloma inguinale Faeces – known by indentation on examination-

CARCINOMA OF THE RECTUM DDx OF RECTAL TUMOUR

Curative: Surgery depends on the distance of the tumour from the

anal verge. Upper third tumours resection with anastomosis

between the sigmoid and lower rectum (anterior resection)

Lower third tumours less than 5 cm from the anal verge are ttt by abdominoperineal excision of the rectum + terminal colostomy + adjunctive radiotherapy to reduce recurrence.

Mid third tumours anterior resection if distal clearance can be obtained. This easier in women due to the wide pelvic

CARCINOMA OF THE RECTUM TREATMENT

Palliative procedure: Even if secondary tumours are present, palliation is

best achieved when the primary is resected. Colostomy is necessary for intestinal obstruction. But

this doesn’t relieve the bleeding, discharge and sacral pain.

In inoperable cases, deep x-ray therapy, diathermy, or laser of the tumour may give temporary relief as may cytotoxic drugs.

CARCINOMA OF THE RECTUM TREATMENT

This disease may present in one of the following manners:

1-chronic left sided abdominal pain + change in bowel habits

2-acute abdominal symptoms 3- Rectal bleeding: acute, massive and fresh blood

Elderly pt. with this disease present with a little faint, lower abdominal pain, and a desire to defecate that when emptied pass large volume of fresh blood and clots.

The patients are rarely shocked and don’t require transfusion.

It is diagnosed via barium enema or colonscopy

DIVERTICULAR DISEASE

Causes of bleeding are: Eroded artery in the mouth of the diverticulum The disease is incidental and the bleeding is due to

angiodysplasia of the chronic mucosa

Surgery is very rarely needed

DIVERTICULAR DISEASE

It is not a true hematoma but a thrombosis of a vein in the subcutaneous plexus.

SYMPTOMS:

1-Pain: usually due to the tension

*it begins gradually increasing in severity over a few hours and subsiding gradually over few days

*it is continuous. *made worse by sitting, moving and defecating *localized to the lump2-Swelling: *appears at the same time as the lump*First it is small and spherical * Then it may enlarge and become more painful  

PERI-ANAL HEMATOMA

SYMPTOMS: 3-Bleeding: this happens only if: *the lump bursts *the skin over the lump ulcerates  4- The skin around the lump is itchy and moist

due to the leakage of the mucous because the lump doesn’t allow the anus to close properly.

 

PERI-ANAL HEMATOMA

SIGNS ON EXAMINATION: *Colour: if it is close to the overlying skin which is not

edematous, it is deep red-purple. But if the skin is edematous then its colour can’t be seen.

*The lump is tender especially if it ulcerates. *Shape and size: initially the lump is spherical and

up to 1cm in diameter. If the skin is lax or edematous then the lump is polypoid.

*Surface: covered by skin and the surface beneath it is smooth

*Composition: solid, hard hemispherical mass*Relations: the lump is superficial to the external

sphincter. Not fixed to the skin or other structures. Cannot be reduced to the anal canal.

PERI-ANAL HEMATOMA

TREATMENT: The symptoms may subside spontaneously after 2-

3 days during which analgesia is given. If it is in the acute phase and the patient doesn’t want to wait, incision under local anaesthesia is the way to go.

PERI-ANAL HEMATOMA

Anal fissure is a longitudinal split in the skin of the anal canal

Acute fissures are common in children who pass bulky stool quickly

Chronic fissures are most common in the age group 20 and 40 years.

Chronic fissures are common in women after childbirth.

Anal fissures are more common in men than in women.

Multiple fissures may complicate Crohn’s disease.

FISSURE-IN-ANO

SYMPTOMS:  

1-Pain: fissures are the commonest cause of pain in the anal verge both acute and chronic fissures are very painful it begins at defecation and is described as tearing it persists for minutes to hours after defecation it is throbbing or aching in nature  

2- Bleeding: acute fissures may streak the stool with blood and stain the

toilet paper Chronic fissures bleed less and may produce little blood stain of

the toilet paper if any.  

3-a small skin tag called sentinel tag or sentinel pile may form at the lower end of a chronic fissure. This tag may be felt by the pt.

FISSURE-IN-ANO

4- Because of the pain, the pt. is usually constipated.

5-the fibrosis around the chronic fissure prevents a good seal around the anus leading to small amounts of mucous leak on the peri-anal skin pruritus –could be the presenting symptom of a chronic fissure-

6-the symptoms are slow to develop and become long standing, there may be periods of remission

DDx: Crohn’s disease, Trauma (abuse of children), Carcinoma, TB, Syphilis and Psoriasis.

FISSURE-IN-ANO

TREATMENT: Acute fissures: *if early and small may heal spontaneously. *local anaesthetic ointment + lubricant laxative relief *application of GTN cream relaxes the anal sphincter healing

of the epithelium. *more intractable cases respond to dividing the internal

sphincter submucosally under general anaesthetic. *chemical sphincterotomy using an injection of botox into the

internal sphincter *advantages of the chemical method are: 1-sphincter paralysis is short lived 2-gives a more sustained effect than GTN cream  

Chronic fissures: require excision  

FISSURE-IN-ANO

TREATMENT: Acute fissures: *if early and small may heal spontaneously. *local anaesthetic ointment + lubricant laxative relief *application of GTN cream relaxes the anal sphincter healing

of the epithelium. *more intractable cases respond to dividing the internal

sphincter submucosally under general anaesthetic. *chemical sphincterotomy using an injection of botox into the

internal sphincter *advantages of the chemical method are: 1-sphincter paralysis is short lived 2-gives a more sustained effect than GTN cream  

Chronic fissures: require excision  

FISSURE-IN-ANO

DEFENITION:

A fistula is a track lined with epith. Or granulation tissue, connecting two epithelial surfaces. It may connect two body cavities or one cavity and the body’s external surface.

A fistula-in-ano connects the lumen of the rectum or anal canal with the external surface. It is usually lined by granulation tissue.

FISTULA-IN-ANO

LOW LEVEL FISTULAS: The internal opening is below the anorectal ring.

They could be of the following:

1-trans sphincteric

2-inter sphinteric

3-subcutaneous or submucous

 

HIGH LEVEL FISTULAS: The internal opening is above the anorectal ring.

They could be of the following:

1-extra sphincteric (pelvirectal supralevator)

2-trans sphincteric

3-inter sphincteric

FISTULA-IN-ANO

SYMPTOMS: Watery or purulent discharge from the external

opening of the fistula Pain is episodic as the fistula fills with pus. If the

pus doesn’t discharge pain is more intense and throbbing

The discharge causes pruritus ani. There may be minor bleeding from the external

opening The symptoms in general are episodic but the

condition hardly ever cures itself

FISTULA-IN-ANO

GOODSALL’S RULE: The internal opening of an anterior fistula lies along

a radial line drawn from the external opening to the anus, whereas the internal opening of a posterior fistula lies in the mid line posteriorly.

FISTULA-IN-ANO

ON PR EXAMINATION: The external opening is visible anywhere around the anus usually

close to the anal margin but sometimes a few centimetres away. The opening is not tender but the thickened tissue around it may

be. The serous or purulent discharge may be visible. Rectal examination is not painful. The internal opening may be felt. 2/3 are posterior, 1/3 are anterior. Sigmoidscopy and protoscopy are essential to exclude underlying

disease as chron’s or carcinoma or TB. The inguinal LN are not enlarged except if there is inflammation or

secondary infiltration by carcinoma. Don’t forget general examination if there is a suspected systemic

underlying cause.

FISTULA-IN-ANO

INVESTIGATIONS: fistulogram, endoanal ultrasound, MRI

DDx: pilonidal sinus, hidradenitis, suppurative,

incontinence, chron’s, trauma.

FISTULA-IN-ANO

TRAETMENT: Superficial and low level fistulas are laid open and allowed

to heal by granulation. There is no loss of continence This is only done if the fistula lies below the anorectal ring High fistulas (suprasphincteric, trans-sphincteric) only

the lower part of the fistula is laid open a non-absorbable ligature (eg.: nylon) termed a seton is passed through the upper part of the fistula left for 2-3 weeks the sphincter is fixed by scar tissue subsequent division of the upper part of the track either by a second operation or by tightening of the ligature.

Lying open the whole track will completely divide the sphincter incontinence

FISTULA-IN-ANO

Symptoms Pain

Ulcerative Colitis Lower abdominal cramps Relieved with Bowel Movement

Crohn's Disease Constant pain often in right lower quadrant Not relieved with Bowel Movement

Stool Blood Grossly bloody stool in Ulcerative Colitis

Inflammatory Bowel Disease

Signs Abdominal Mass

Ulcerative Colitis: No abdominal mass Crohn's Disease: Mass often at Right lower quadrant

Gastrointestinal Tract Affected Ulcerative Colitis

Affects only colon Continuous from rectum

Crohn's Disease Mouth to anus potentially affected Discontinuous, "Skip" lesions

Bowel Tissue affected Ulcerative Colitis: Mucosal disease (no granuloma) Crohn's Disease: Transmural disease (granulomas)

Inflammatory Bowel Disease

LAB INVESTIGATION Appropriate blood tests include : CBC count Serum electrolytes Blood urea nitrogen, creatinine blood grouping and cross matching Coagulation profile including:- (aPTT) - (PT)- platelet count- bleeding time

INVESTIGATIONFECAL OCCULT BLOOD TESTING • Normally lose 0.5-1.5mL blood/day from GIT• Three types of test– Guaiac-based (Haemoccult II, Haemoccult II Sensa) • Good for detecting large, more distal lesions • Inconsistent – Need >10mL daily blood loss for +ve test 50% of the time – Can detect as little as 1mL of blood in stool • Affected by dietary factors – Foods which darken stool make it harder to read – False positives from dietary iron

– Immunochemical• Do not detect bleeding from upper GIT - localizes to the colon• Can detect as little as 0.3mL of blood in stool• Lab processing required

– Heme-porphyrin test• Very sensitive• High false positive rate• Lab processing required

INVESTIGATIONFECAL OCCULT BLOOD TESTING

• Sensitivity 60-80%

• False positive rate 5-13%

• If test is positive patients require a colonoscopy or double-contrast Barium Enema + sigmoidoscopy

• If test is positive and the colon has been “cleared”

unless iron deficiency is present no further Ix isnecessary

INVESTIGATION BARIUM ENEMA

• No role in diagnosis of active lower GIT bleeding

• If used will obscure any subsequent attempts tovisualize by arteriography or colonoscopy• Double contrast enema has 70% sensitivity inelective detection of nonbleeding colonic lesions

INVESTIGATION COLONOSCOPY • Diagnostic and therapeutic capabilities• Can be used even with ongoing massive bleeding• Characteristic endoscopic findings of recent upper

GITh’age are the same as for lower GIT h’age – Active bleeding - focal adherent clots – Nonbleeding visible vessels• Timing ideally 6-24 hours post presentation – Patient must be in stable condition – Allows bowel prep – This is the time when recurrent bleeding

usually occurs

INVESTIGATION COLONOSCOPY • Increased risk of bowel perforation

– Should not be attempted with ischaemia or severe mucosal inflammation

• Endoscopic coagulation tx of choice for bleeding AVMs

– 2% risk of perforation

• Diverticular bleeding usually not able to be endoscopically coagulated (technically challenging)

• CT Colonoscopy (Virtual colonoscopy)

– May have a role in assessment of pts with +ve FOB

BLEEDING DIVERTICULUM

INVESTIGATION NUCLEAR SCINTIGRAPHY • Detects bleeding ≥0.05-0.1mL/minute13• Two methods

– Technetium 99m (99mTc) sulfur-colloid • Requires no preparation → inject immediately • Short half life • Enhances liver and spleen → can obscure bleeding

sites • Able to detect slower rates of bleeding

– 99mTc-labeled red blood cells • Preferred method • Good for intermittent bleeds • Able to visualize bleeds near liver/spleen• 73-98% sensitive

INVESTIGATION NUCLEAR SCINTIGRAPHY False localization rate ~20%1 (3-59%)

– Blood does not remain stationary within bowel lumen

• Reflux into small bowel

• Rapid transit through bowel with pooling in other areas

• Institution dependent

– Not available in all hospitals

– Variability in quality

• ?plan surgery on results

• Useful as a prelude to angiography to confirm active

haemorrhage +/- localization

– Increased diagnostic accuracy of angiograms in patients with +ve scans

• Not recommended for massive haemorrhage (delays treatment)

ACTIVE BLEEDING FROM ASCENDING COLON

INVESTIGATION ANGIOGRAPHY • Selective mesenteric angiography – Femoral artery punctured – Evaluates SMA then IMA then coeliac axis – Positive test if extravasation of contrast into

bowel lumen• Can detect haemorrhage rates ≥0.5mL/min14• Diagnostic and potentially therapeutic – Adrenaline infusion – Embolization

• Sensitivity 40-86%• Complication rate ~ 2%

NORMAL SELECTIVE IMA ANGIOGRAM

INVESTIGATION CT ANGIOGRAPHY • New and evolving technology• Requires modern CT scanner• Fast - < 15mins• Non-invasive• Identifies large and small bowel haemorrhage• Sensitivity and specificity 72-80%17• ? Ix of choice in the future

INVESTIGATION CAPSULE ENDOSCOPY (CE)

OBSCURE GIT BLEEDING

• ~5% of patients have bleeding which remains

unlocalized despite extensive Ix• Investigative options – “Push” enteroscopy / Sonde enteroscopy – Capsule enteroscopy – Small bowel follow-through – Meckel’s Scan – Diagnostic laparoscopy – Exploratory laparotomy +/- enteroscopy

INVESTIGATION ENTEROSCOPY

• Requires special instruments – “push” Enteroscope • 2.7m long thin scope – Sonde Enteroscope • scope with balloon attached to peristalses

through the bowel – Paediatric colonoscope use has been reported

• Permits inspection of SB – to proximal jejunum with push enteroscopy – entire SB with Sonde scope

• ~25% diagnostic yield in reported series15

INVESTIGATION MECKEL’S SCAN

• Meckel’s diverticulum = remnant of vitellointestinalduct• Disease of 2’s• only picks up Meckel’s containing gastric mucosa

50%• 99m-Tc-pertechnetate radioisotope used – concentrated mainly by the mucous

secretory cells of the stomach

•85% sensitive• 95% specific• Useful in Ix of young patients with GIT bleeding

CASE SENARIO A 67 year-old man presented to the emargency department

with a 6 –hour history of bleeding per rectum . The patient’s symptoms began after he developed an urge

to defecate that was followed by several voluminous bowel movements containing maroon-colored stool mixed with blood clots.

The patient complains of feeling light headed just prior to arriving at the hospital but denies any abdmoinal pain his past medical history is significant for borderline hypertension managed with diet control.His surgical history is significant for a right inguinal hernia repair 2 years ago.

His blood pressure is 100/80, pulse rate 100/min , and respiratory rate 20/min.

The results of an examination of his abdomen are unremrkable. The rectal exmination revealed no masses and a large amount of maroon colored stool in rectal vault

Q

What should be our next step ? What is the most likely Diagnosis ? How would we confirm this Diagnosis?

REFERENCE

BROWSE’S book Last Chapter Churchill’s pocket book of surgery pp 299-

314. Vernava A. Lower Gastrointestinal bleeding.

Dis Colon Rectum 1997;40:846-858 Emedicene

http://emedicine.medscape.com/article/195246-overview

Lecture about Investigation of Lower GI Bleeding by Dr.Dean Trotter