Acute Lower Gastrointestinal Bleeding Essentials of Diagnosis:

Hematochezia usually present. Ten percent of cases of hematochezia due to upper gastrointestinal source. Evaluation with colonoscopy in stable patients. Massive active bleeding calls for evaluation with sigmoidoscopy, upper endoscopy, angiography, or nuclear bleeding scan.

LGI hemorrhage

Sites:

Colon 95-97%. Small bowel 3-5%.

Only 15% of massive GI bleeding.

Finding the site:

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

Aetiology

Causes of lower G.I. bleeding:

1. Auto-Immune

Inflammatory bowel disease (I.B.D) eg.

UC & CD

2. Inflammatory
Bacterial Dysentry Parasitic Bilharzial Viral Solitary ulcer of the rectum

3. Tumours
Polyps Cancer caecum Cancer sigmoid

4. Vascular
Angiodysplasia Ischaemic colitis Piles

5. Meckels diverticulum and Diverticular disease. 6. Anal Fissures.

NB:

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

Lower Gastrointestinal Bleeding

Etiology:

Hemorrhoids and anal fissures:

Bleeding is typically small volume and intermittent, with bright red blood on the surface of the stool. Occasionally bleeding is severe. The diagnosis can be confirmed on anoscopy and/or flexible sigmoidoscopy. Severe or recurrent bleeding are indications for hemorrhoidal band ligation or hemorrhoidectomy. Anal fissures: may also bleed, but bleeding is usually minimal and is associated with anal discomfort. Fiber supplementation and laxatives are advised.

Hemmorrhoids

Lower Gastrointestinal Bleeding

Etiology:

Colonic diverticula:
brisk but usually self-limited bleeding.
Rarely bleeding is massive on presentation, requiring emergent diagnostic angiography followed by intra-arterial infusion of vasopressin or segmental resection.

Local erosion into one of the arteries leads to

Diverticulosis

Lower Gastrointestinal Bleeding

Etiology:

Vascular anomalies:

Sporadic and secondary angiodysplasia are a common cause of bleeding from the small bowel and colon. Vascular ectasias (or angiodysplasias) occur throughout the upper and lower intestinal tracts and cause painless bleeding ranging from melena or hematochezia to occult blood loss.

Lower Gastrointestinal Bleeding

Etiology:

Colorectal neoplasm:

Benign polyps and carcinoma are associated with chronic occult blood loss or intermittent anorectal hematochezia. However, colonic neoplasms may cause up to 10% of acute lower gastrointestinal hemorrhage. Although colorectal cancer is most commonly associated with occult blood loss rather than overt bleeding, patients with rectosigmoid lesions may present with hematochezia. The diagnosis is readily made on endoscopy.

Colonic Polyps

Malignancy

Colon Carcinoma

Lower Gastrointestinal Bleeding

Etiology:

Infectious, inflammatory or ischemic colitis:

A variety of infectious, inflammatory and ischemic colitides may present with bloody diarrhea. The diagnosis of infectious colitis is usually confirmed by stool culture or assay for Clostridium difficile toxin, but occasionally stool studies are negative. Endoscopy is always indicated in the setting of possible inflammatory or ischemic colitis, unless there is clinical evidence for perforation. Again, mucosal biopsies are usually diagnostic.

Lower Gastrointestinal Bleeding

Etiology:

-Inflammatory Bowel Disease:

Patients with inflammatory bowel disease (especially ulcerative colitis) often have diarrhea with variable amounts of hematochezia. Bleeding varies from occult blood loss to recurrent hematochezia usually mixed with stool. Symptoms of abdominal pain, tenesmus, and urgency are often present.

Inflammatory Bowel Disease

Some distinguishing characteristics of ulcerative colitis and Crohns disease:

Characteristics
Rectal bleeding Abdominal mass

Ulcerative Colitis
Usual Rare

Crohn's Disease
Sometimes

Often Often
5-10% Occasional Common Common Often Sometimes Rare

Abdominal pain
Perianal disease Upper GI symptoms Cigarette smoking Malnutrition

Sometimes
Extremely rare Never Very rare Sometimes

Low-grade fever
Rectal disease Continuous disease

Sometimes
Usual Usual

Cont.________________________

Characteristics
Granulomas Crypt abscesses Discrete ulcers Aphthoid ulcers

Ulcerative Colitis
Never Common Rare Rare

Crohn's Disease
10-30% Rare Common Common

Cobblestone lesions
Skip lesions Ileal involvement Fistulas Cancer

Never
No, except rarely in treated patients Rare, backwash ileitis Never Rare

Common
Common Usual Common Very rare Common Common

Microscopic skip lesions No, except rarely in treated patients Transmural inflammation Only in fulminant disease

Evaluation & Management

Lower Gastrointestinal Bleeding

Evaluation & Management:

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

Diagnosis

History
Examination P.R for rectal lesions + cancer. Proctoscopy for haemorrhoids (piles). Sigmoidoscopy for I.B.D

Barium enema for mucosal lesions

Colonoscopy for diagnosis + removal of polyps Nuclear Bleeding Scans and Angiography for vascular lesions Small Intestine Push Enteroscopy or Capsule 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 PRESENTATION

Presentation correlates not with location but with the rate of transit:

Hematemesis almost always UGI. Hematochezia 3/4 patient with have a LGI source. Melena more likely UGI than LGI.

NGTL (+) highly suggestive of UGI.

CLINICAL PRESENTATION

Hematemesis:

Vomiting of blood; clots or coffee grounds.

Suggestive of an UGI source.

Hematochezia:

The passage of liquid blood or clots per rectum.

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

Melena:

Stools with altered blood that are black and tarry and have a distinctive odor.
Suggestion of UGI source.

May cont for days p bleeding stops.

TAGGED RBC SCAN

Advantages Safe, noninvasive Readily available Detects slow bleeds

at a rate of 0.1 to 0.5 m/min more sensitive than angiography

Disadvantages only localizes bleeding to an area of the abdomen, not SB vs LB not therapeutic less specific than endoscopy and angiography

73% - 100%

TAGGED RBC SCAN

Meckels Diverticulum

Cecal angiodysplasia with extravasation

Small bowel ulceration due to NSAIDS

TAGGED RBC SCAN

Useful:

To confirm bleeding.

In planning angiography.
Massive bleeds or critical illness.

Not useful:

COLONOSCOPY

Advantages

Disadvantages

Potential for localization:

precise

diagnostic success 51% - 90%.

Requires a technically skilled endoscopist, not available at all centers. Various rates of rebleeding depending on source. Post bleed transit.

Potential for rx

therapeutic success 69%-100%.

Ability to collect pathologic specimens.

Bleeding diverticulosis

Colonic angiodysplasia

COLONOSCOPY

Diagnostic procedure bleeding has stopped.

of

choice

when

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

ANGIOGRAPHY

Advantages:

Disadvantages

anatomic localization is accurate:

Requires active bleeding > 0.5 cc/min.

Specificity- 100%. Sensitivity 47% (acute bleeding), 30% (recurrent hemorrhage). 41-86% bleeds localized.

Therapeutic intervention.

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.

CAPSULE ENDOSCOPY

Indications for capsule endoscopy:

1-Iron deficiency anaemia when obscure gastrointestinal bleeding is suspected. 2-Diagnosis of early or suspected small bowel Crohns 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).

Image Spectrum: PillCam Capsule Endoscopy

Bleeding
Suspected Crohns

Tumors

Celiac Disease

Management
Is individualized for every case

Acute Lower Gastrointestinal Bleeding

Treatment:

Therapeutic Colonoscopy

High-risk lesions may now be treated endoscopically with epinephrine injection, cautery, or application of metallic endoclips.

Intra-arterial Vasopressin or Embolization:

Surgical Treatment:

With increasing experience with urgent colonoscopy and angiographic embolization, the need for surgical 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 Resuscitate Bleeding stops Manage cause ? Surgical intervention Bleeding persists

Investigate cause

Thank you