Lower GIT Bleeding

Acute Lower Gastrointestinal Acute Lower Gastrointestinal BleedingBleeding

Essentials of Diagnosis:Essentials of Diagnosis: Hematochezia usually present. Hematochezia usually present. Ten percent of cases of Ten percent of cases of

hematochezia due to upper hematochezia due to upper gastrointestinal source. gastrointestinal source.

Evaluation with colonoscopy in Evaluation with colonoscopy in stable patients. stable patients.

Massive active bleeding calls for Massive active bleeding calls for evaluation with sigmoidoscopy, evaluation with sigmoidoscopy, upper endoscopy, angiography, or upper endoscopy, angiography, or nuclear bleeding scan. nuclear bleeding scan.

LGI hemorrhageLGI hemorrhage

Sites:Sites: Colon – 95-97%.Colon – 95-97%. Small bowel – 3-5%.Small bowel – 3-5%.

Only 15% of massive GI bleeding.Only 15% of massive GI bleeding. Finding the site:Finding the site:

Intermittent bleeding common.Intermittent bleeding common. Up to 42% have multiple sites.Up to 42% have multiple sites.

AetiologyAetiology

Causes of lower G.I. bleeding:Causes of lower G.I. bleeding:

1. Auto-Immune1. Auto-Immune Inflammatory bowel disease Inflammatory bowel disease

(I.B.D) eg. UC & CD(I.B.D) eg. UC & CD

2. Inflammatory2. Inflammatory Bacterial Bacterial Dysentry Dysentry Parasitic Parasitic Bilharzial Bilharzial ViralViral Solitary ulcer of the rectumSolitary ulcer of the rectum

3. Tumours3. Tumours Polyps Polyps Cancer caecumCancer caecum Cancer sigmoid Cancer sigmoid

4. Vascular4. Vascular AngiodysplasiaAngiodysplasia Ischaemic colitisIschaemic colitis PilesPiles

5.5. Meckel’s diverticulum and Meckel’s diverticulum and

Diverticular disease. Diverticular disease.

6. Anal Fissures.6. Anal Fissures.

NB:NB: Massive bleeding from lower Massive bleeding from lower G.I.T is rare.G.I.T is rare.

Lower Gastrointestinal BleedingLower Gastrointestinal Bleeding

Etiology:Etiology: Hemorrhoids and anal fissures:Hemorrhoids and anal fissures: Bleeding is typically small volume and Bleeding is typically small volume and

intermittent, with bright red blood on intermittent, with bright red blood on the surface of the stool. Occasionally the surface of the stool. Occasionally bleeding is severe. The diagnosis can bleeding is severe. The diagnosis can be confirmed on anoscopy and/or be confirmed on anoscopy and/or flexible sigmoidoscopy. Severe or flexible sigmoidoscopy. Severe or recurrent bleeding are indications for recurrent bleeding are indications for hemorrhoidal band ligation or hemorrhoidectomy. .

Anal fissures: may also bleed, but : may also bleed, but bleeding is usually minimal and is bleeding is usually minimal and is associated with anal discomfort. Fiber associated with anal discomfort. Fiber supplementation and laxatives are supplementation and laxatives are advised. advised.

http://www.uwgi.org/guidelines/ch_10/blist/frames/fs11.htm



HemmorrhoidsHemmorrhoids


Etiology:Etiology:

Colonic diverticula: Colonic diverticula:

Local erosion into one of the Local erosion into one of the

arteries leads to brisk but usually arteries leads to brisk but usually

self-limited bleeding. Rarely self-limited bleeding. Rarely

bleeding is massive on bleeding is massive on

presentation, requiring emergent presentation, requiring emergent

diagnostic angiography followed diagnostic angiography followed

by intra-arterial infusion of by intra-arterial infusion of

vasopressin or segmental vasopressin or segmental

resection.resection.

DiverticulosisDiverticulosis


Etiology:Etiology:

Vascular anomalies:Vascular anomalies:

Sporadic and secondary Sporadic and secondary

angiodysplasia are a common angiodysplasia are a common

cause of bleeding from the small cause of bleeding from the small

bowel and colon. Vascular bowel and colon. Vascular

ectasias (or angiodysplasias) ectasias (or angiodysplasias)

occur throughout the upper and occur throughout the upper and

lower intestinal tracts and cause lower intestinal tracts and cause

painless bleeding ranging from painless bleeding ranging from

melena or hematochezia to occult melena or hematochezia to occult

blood loss.blood loss.


Etiology:Etiology:

Colorectal neoplasm: Colorectal neoplasm:

Benign polyps and carcinoma are Benign polyps and carcinoma are

associated with chronic occult blood loss associated with chronic occult blood loss

or intermittent anorectal hematochezia. or intermittent anorectal hematochezia.

However, colonic neoplasms may cause However, colonic neoplasms may cause

up to 10% of acute lower up to 10% of acute lower

gastrointestinal hemorrhage. Although gastrointestinal hemorrhage. Although

colorectal cancer is most commonly colorectal cancer is most commonly

associated withassociated with occult blood loss rather rather

than overt bleeding, patients with than overt bleeding, patients with

rectosigmoid lesions may present with rectosigmoid lesions may present with

hematochezia. The diagnosis is readily hematochezia. The diagnosis is readily

made on endoscopy.made on endoscopy.

http://www.uwgi.org/guidelines/ch_07/ch07txt.htm#ch07_50

Colonic PolypsColonic Polyps

MalignancyMalignancy

Colon CarcinomaColon Carcinoma


Etiology:Etiology: Infectious, inflammatory or ischemic Infectious, inflammatory or ischemic

colitis:colitis:

A variety of infectious, inflammatory and A variety of infectious, inflammatory and

ischemic colitides may present with ischemic colitides may present with

bloody diarrhea. The diagnosis of bloody diarrhea. The diagnosis of infectious colitis is usually confirmed by is usually confirmed by

stool culture or assay for Clostridium stool culture or assay for Clostridium

difficile toxin, but occasionally stool difficile toxin, but occasionally stool

studies are negative. Endoscopy is studies are negative. Endoscopy is

always indicated in the setting of always indicated in the setting of

possible inflammatory or ischemic possible inflammatory or ischemic

colitis, unless there is clinical evidence colitis, unless there is clinical evidence

for perforation. Again, mucosal biopsies for perforation. Again, mucosal biopsies

are usually diagnostic.are usually diagnostic.

http://www.uwgi.org/guidelines/ch_04/AlgA.htm


Etiology:Etiology:

-Inflammatory Bowel Disease:-Inflammatory Bowel Disease:

Patients with inflammatory bowel Patients with inflammatory bowel

disease (especially ulcerative colitis) disease (especially ulcerative colitis)

often have diarrhea with variable often have diarrhea with variable

amounts of hematochezia. Bleeding amounts of hematochezia. Bleeding

varies from occult blood loss to varies from occult blood loss to

recurrent hematochezia usually mixed recurrent hematochezia usually mixed

with stool. Symptoms of abdominal with stool. Symptoms of abdominal

pain, tenesmus, and urgency are often pain, tenesmus, and urgency are often

present.present.

Inflammatory Bowel DiseaseInflammatory Bowel Disease

Some distinguishing characteristics of ulcerative Some distinguishing characteristics of ulcerative colitis and Crohn’s diseasecolitis and Crohn’s disease::

CharacteristicsUlcerative ColitisCrohn's Disease

Rectal bleedingUsualSometimes

Abdominal massRareOften

Abdominal painSometimesOften

Perianal diseaseExtremely rare5-10%

Upper GI symptomsNeverOccasional

Cigarette smokingVery rareCommon

MalnutritionSometimesCommon

Low-grade feverSometimesOften

Rectal diseaseUsualSometimes

Continuous diseaseUsualRare

ContCont________________________.________________________.

CharacteristicsUlcerative ColitisCrohn's Disease

GranulomasNever10-30%

Crypt abscessesCommonRare

Discrete ulcersRareCommon

Aphthoid ulcersRareCommon

Cobblestone lesionsNeverCommon

Skip lesionsNo, except rarely in treated patients

Common

Ileal involvementRare, backwash ileitisUsual

FistulasNeverCommon

CancerRareVery rare

Microscopic skip lesionsNo, except rarely in treated patients

Common

Transmural inflammation

Only in fulminant diseaseCommon

Evaluation & Evaluation & ManagementManagement


Evaluation & Management:Evaluation & Management: Initial stabilization, blood replacement.Initial stabilization, blood replacement.

The color of the stool helps distinguish The color of the stool helps distinguish upper from lower gastrointestinal upper from lower gastrointestinal bleeding, especially when observed by bleeding, especially when observed by the physician. Brown stools mixed or the physician. Brown stools mixed or streaked with blood predict a source in streaked with blood predict a source in the rectosigmoid or anus. Painless the rectosigmoid or anus. Painless large-volume bleeding usually suggests large-volume bleeding usually suggests diverticular bleeding or vascular diverticular bleeding or vascular ectasias. Bloody diarrhea associated ectasias. Bloody diarrhea associated with cramping abdominal pain, urgency, with cramping abdominal pain, urgency, or tenesmus is characteristic of or tenesmus is characteristic of inflammatory bowel disease, infectious inflammatory bowel disease, infectious colitis, or ischemic colitis.colitis, or ischemic colitis.

RESUSCITATION

Indications for transfusion Profuse bleeding Persistent hemodynamic instability

despite crystalloid resuscitation Symptomatic anemia (CP, SOB,

orthostasis with Hgb < 10) AMI or unstable angina with Hgb <

10

DiagnosisDiagnosis History History ExaminationExamination P.R for rectal lesions + cancer.P.R for rectal lesions + cancer. Proctoscopy for haemorrhoids (piles).Proctoscopy for haemorrhoids (piles). Sigmoidoscopy for I.B.DSigmoidoscopy for I.B.D Barium enema for mucosal lesionsBarium enema for mucosal lesions Colonoscopy for diagnosis + removal of Colonoscopy for diagnosis + removal of

polypspolyps Nuclear Bleeding Scans and Angiography for Nuclear Bleeding Scans and Angiography for

vascular lesionsvascular lesions Small Intestine Push Enteroscopy or Capsule Small Intestine Push Enteroscopy or Capsule

Imaging.Imaging.

Information about bleeding

Volume and frequency of bleeding Painful defecation? Relationship of bleeding to

defecation?

[before, during (mixed into faeces or coating surface?)

or after]

Associated abdominal pain? Colour of blood?

CLINICAL PRESENTATIONCLINICAL PRESENTATION

Presentation correlates not with Presentation correlates not with

location but with the rate of location but with the rate of

transit:transit: Hematemesis almost always UGI.Hematemesis almost always UGI. Hematochezia 3/4 patient with have a Hematochezia 3/4 patient with have a

LGI source.LGI source. Melena more likely UGI than LGI.Melena more likely UGI than LGI.

NGTL (+) highly suggestive of UGI.NGTL (+) highly suggestive of UGI.

CLINICAL PRESENTATIONCLINICAL PRESENTATION

Hematemesis:Hematemesis: Vomiting of blood; clots or coffee grounds.Vomiting of blood; clots or coffee grounds. Suggestive of an UGI source.Suggestive of an UGI source.

Hematochezia:Hematochezia: The passage of liquid blood or clots per The passage of liquid blood or clots per

rectum.rectum. 3/4 colonic source; 11% prox lig of Treitz.3/4 colonic source; 11% prox lig of Treitz.

Melena:Melena: Stools with altered blood that are black and Stools with altered blood that are black and

tarry and have a distinctive odor.tarry and have a distinctive odor. Suggestion of UGI source.Suggestion of UGI source. May cont for days p bleeding stops.May cont for days p bleeding stops.

TAGGED RBC SCANTAGGED RBC SCAN

AdvantagesAdvantages Safe, noninvasiveSafe, noninvasive Readily availableReadily available Detects slow Detects slow

bleedsbleeds at a rate of 0.1 to at a rate of 0.1 to

0.5 m/min 0.5 m/min more sensitive more sensitive

than angiographythan angiography 73% - 100%73% - 100%

DisadvantagesDisadvantages only localizes only localizes

bleeding to an bleeding to an area of the area of the abdomen, not SB abdomen, not SB vs LBvs LB

not therapeuticnot therapeutic less specific than less specific than

endoscopy and endoscopy and angiographyangiography

TAGGED RBC SCAN

Meckel’s DiverticulumMeckel’s Diverticulum

Cecal angiodysplasia Cecal angiodysplasia with extravasationwith extravasation

Small bowel ulcerationSmall bowel ulceration due to NSAIDSdue to NSAIDS

TAGGED RBC SCAN

Useful: To confirm bleeding. In planning angiography.

Not useful: Massive bleeds or critical illness.

COLONOSCOPYCOLONOSCOPY

AdvantagesAdvantages Potential for precise Potential for precise

localization:localization: diagnostic success 51% diagnostic success 51%

- 90%.- 90%.

Potential for rxPotential for rx therapeutic success therapeutic success

69%-100%.69%-100%.

Ability to collect Ability to collect

pathologic pathologic

specimens.specimens.

DisadvantagesDisadvantages Requires a Requires a

technically skilled technically skilled

endoscopist, not endoscopist, not

available at all available at all

centers.centers. Various rates of Various rates of

rebleeding rebleeding

depending on depending on

source.source. Post bleed transit.Post bleed transit.

Bleeding Bleeding diverticulosisdiverticulosis

Colonic Colonic angiodysplasiaangiodysplasia

COLONOSCOPY

Diagnostic procedure of choice when bleeding has stopped.

Many reports of good localization of bleed (74-85%) even with hematochezia.

ANGIOGRAPHYANGIOGRAPHY

Advantages:Advantages: anatomic localization anatomic localization

is accurate: is accurate: Specificity- 100%.Specificity- 100%. Sensitivity 47% (acute Sensitivity 47% (acute

bleeding), 30% bleeding), 30%

(recurrent (recurrent

hemorrhage).hemorrhage). 41-86% bleeds 41-86% bleeds

localized.localized.

Therapeutic Therapeutic

intervention.intervention.

DisadvantagesDisadvantages Requires active Requires active

bleeding > 0.5 bleeding > 0.5 cc/min.cc/min.

CAPSULE ENDOSCOPY

Advantages: Higher yield (50-70%) for

bleeding than enteroscopy (30%). examination of the entire SB.

Disadvantages: does not permit tissue sampling. no therapeutic intervention. risk of retention. inexact localization.

Indications for capsule endoscopy:

1-Iron deficiency anaemia when obscure gastrointestinal bleeding is suspected.

2-Diagnosis of early or suspected small bowel Crohn’s disease.

3-Detection of benign and malignant small intestinal tumours (e.g. polyps, GISTs, lymphoma).

4-Identification of medication related to small bowel injury (e.g. NSAID-induced enteropathy).

CAPSULE ENDOSCOPYCAPSULE ENDOSCOPY

Image Spectrum: PillCam Capsule Image Spectrum: PillCam Capsule EndoscopyEndoscopy

BleedingBleeding

Celiac DiseaseCeliac DiseaseTumorsTumors

Suspected Crohn’sSuspected Crohn’s

ManagementManagement Is individualized for every Is individualized for every

casecase

Acute Lower Gastrointestinal Acute Lower Gastrointestinal BleedingBleeding

Treatment:Treatment: Therapeutic ColonoscopyTherapeutic Colonoscopy

High-risk lesions may now be treated High-risk lesions may now be treated

endoscopically with epinephrine endoscopically with epinephrine

injection, cautery, or application of injection, cautery, or application of

metallic endoclips. metallic endoclips. Intra-arterial Vasopressin or Intra-arterial Vasopressin or

Embolization:Embolization: Surgical Treatment:Surgical Treatment:

With increasing experience with urgent With increasing experience with urgent

colonoscopy and angiographic colonoscopy and angiographic

embolization, the need for surgical embolization, the need for surgical

treatment is decreasing. treatment is decreasing.

VASOPRESSIN INFUSION

Causes reliable arteriolar vasoconstriction and bowel contraction, resulting in decreased blood flow.

36-100% will stop bleeding: >90% of patients with LGIB due to

diverticular disease or angiodysplasia. Rebleed rate 26-71%.

May be used to temporize bleed prior to surgical resection.

Avoid in pts with cardiac dz.

EMBOLIZATION

definitive means of controlling hemorrhage: Stops bleeding 67-100%. Rebleed 0-33%.

LGI compared to UGI tract has weaker blood supply: Supplied by end arterties. 5-21% post-embolic ischemia reported. 0-40% required emergent lap for

bleeding and/or ischemia.

INDICATIONS FOR SURGERY

Bleeding refractory to other therapies.

Hemodynamic instability. Re-bleeding after non-operative

treatment, esp if localized.

Summary of Treatment

Lower GI bleed

Small volume

Large volume

Investigate cause

Manage cause

Resuscitate

Bleeding stops

Bleeding persists

? Surgical intervention

Thank you

Thank you

Documents

Lower GIT Bleeding