Topic: Lower GI Bleeding

Ddx

- Colorectal carcinoma
- Colorectal polyps
- Diverticular disease
- IBD
- Ischaemic Colitis
- Angiodysplasia
- Haemorrhoids
- Anorectal fissure
- PUD
- Meckels diverticulum

History

1. When did it start?

2. Has this happened before?
3. Suddenly/gradually?
4. Constant/ comes and go?
5. How often?
6. How much?
7. Whats the colour?
8. Mixed with stool/on surface /on tissue paper? Streak of blood?
9. Mucus on passing stool?
10. Associated symptoms:
- Pain on passing stool?
- Changed in bowel habit?
- Do you ever get a feeling of not completely emptying your bowel?
- Malignancy weight loss, fatigues, back pain?
- Diverticular ds, PUD Abdominal pain? Nausea/vomiting? Heartburn?
- Anemia SOB? Dizziness? Faint? Palpitations? CP? Fatigue? Pale?

Risk Factors
1. Smoking
2. A. Fib
3. Warfarin, aspirin, Plavix, NSAIDs
4. Diet? low fibre, a lot of red meat
5. Family history of divericulitis/ bowel ds/ colon cancer

Investigations
1. ABG lactate (r/o ischaemic causes)
2. ECG
3. FBC (low Hb, plt), u&e (high urea:creatinine sign of upper GI bleeding),
CRP, ESR, LFTs (liver mets, liver failure, high alk phos), coag (high INR
from warfarin), group and xmatch 2-4units
4. Imaging
 - Erect CXR
- PFA obstruction, toxic megacolon
- Ultrasound abdomen liver cirrhosis
5. Others
- Proctoscopy- haemorroids
- Sigmoidoscopy UC
- Colonoscopy + bx minimal to moderate bleeding, visualize colon
- Small intestine push enteroscopy evaluate proximal/mid small
bowel
- OGD if suspect upper gi causes
6. Nuclear technetium scan not for acute case, can localize slow bleeding
7. CT angiography of persistent/massive haemorrage (0.5ml-1ml/min)

Management
1. 2 large wire bore peripheral lines
2. Fluid resusitation
3. Blood transfusion: aim for Hb >7g/dL, COD Hb >9-10d/dL
4. NG tube & lavage - controversial
5. Urinary catheter
6. Discontinue anticoagulation +/- reversal
7. Localisation of bleeding site
Colonoscopy, CT angiogram, radionuclide
scintigraphy
8. Consider site-specific therapy

- therapeutic colonoscopy
- mesenteric angiography w intra-arterial injection of
vasopressin and transcatheter embolization (gelfoam,
microcoil)

9. Surgery if active bleeding requiring >4-6units blood within 24hr

- preoperative localization achieved limited resection

- preoperative localistion not achieved total colectomy with
ileorectal anastomosis