LOWER GASTROINTESTINAL BLEEDING

Lower GI bleeding may be: Frank - blood is visible - massive bleeds rare (will show hypovolaemic shock) and often stop spontaneously. - small bleeds more common at all age groups Occult blood or its breakdown products in stool not macroscopically visible. - may manifest early as altered colour of faeces (use faecal occult blood (FOB) test to confirm presence of blood in the stool samplebut a negative result does not exclude GI pathology as bleeds can often be intermittent ) - may present later with symptoms of iron deficiency anaemia

Aetiology Source of bleeding may be in the small bowel, large bowel or anal canal. Cause of bleeding may be underlying GI pathology, trauma anywhere along the GI tract or iatrogenic (e.g. radiation proctitis; post-polypectomy bleeding) Massive and rapid upper GI bleeds may also occasionally manifest as bleeding per rectum. Pathological causes of lower GI bleeding: Small intestines & proximal colon: Meckels Diverticulum (commonest cause in teenagers) Intussusception (usually in young children) Enteritis Angiodysplasia* (usually in elderly) Caecal carcinoma Colon: Carcinoma * Polyps* Diverticular disease* (usually in elderly) Colitis - ulcerative colitis - Crohns disease - ischaemic colitis - infective colitis Rectum: Rectal carcinoma Proctitis Solitary rectal ulcer Anus: Haemorrhoids* Anal fissure (common cause in children) Anal warts Anal carcinoma

* common causes of lower GI bleeds Perianal Crohns disease Management For major GI bleeds it is necessary to resuscitate and stabilise (IV fluids and crossmatch blood for transfusion) patient before assessing the cause of bleeding. An oesophagogastroduodenoscopy (OGD) will also often be done to exclude upper GI causes.

The aim of management is to locate the site of bleeding, arrest bleeding (if it has not already stopped spontaneously) and treat the cause. History: Important information about the bleeding: Volume and frequency of bleeding Is defecation painful? Painful defecation with bleeding usually due to anal fissure Relationship of bleeding to defecation: before during after: bleeding most likely from an anal condition unrelated: blood from a rapidly bleeding source collecting in the rectum, giving rise to the desire to defecate. If bleeding is during defecation, is the blood mixed into the faeces or just coating the surface? If the blood is mixed in with the faeces, source of bleeding likely to be proximal to the sigmoid colon (as stool softness and transit time needs to be sufficient to allow mixing). If coating surface of faeces, source of bleeding usually from the lower sigmoid colon, rectum or anal canal. Associated abdominal pain? If present bleeding likely to have an inflammatory cause Colour of blood? bright red blood likely to have its source in the lower rectum or anal canal. dark red blood likely to have its source in a more proximal region of the bowel. Investigations: Bloods: FBC (may have low Hb; raised WCC if inflammatory cause) U&Es (baseline; upper GI bleeds leads to elevated urea levels) Inflammatory markers e.g. CRP (if inflammatory cause of bleeding) LFTs (abnormality may indicate liver pathology e.g. 2o metastases) Clotting screen (bleeding diatheses; liver pathology) Tumour Markers e.g. CEA Rectal examination and proctoscopy (may reveal low-lying pathology) Rigid and flexible sigmoidoscopy (may reveal left sided colonic pathology) Colonoscopy (may reveal pathology anywhere along entire colon) Barium Enema (usually used if colonoscopy would not be tolerated or high risk of perforation present)

Angiography (if bleeding persists in severe acute haemorrhage and urgent need to find the cause.)

Treatment: Minor GI bleeds: Varies depending on the cause of the bleed. Involves management of the underlying condition. If chronic bleed has led to anaemia, then oral iron may be given. Major GI bleeds: Most lower GI bleeds will terminate spontaneously; therefore once the patient is stabilised treatment will centre on managing the primary cause of the bleed as in minor bleeds. Surgical intervention rare but if the bleeding persists and source is known resection of the involved bowel may be required. Bleeding from vascular malformations can be stopped by embolizing the vessel radiologically. If bleeding persists but source is unclear, a laparotomy and intraoperative colonoscopy may be needed to find the site. If location still elusive then a total colectomy may be needed.