Lower Gastrointestinal Hemorrhage (LGIH) Ext.

Ext. 6

Topic Review

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Anatomy of Upper and Lower Gastrointestinal Tract

Definition Upper GI Hemorrhage :

Ligament of Treitz
v

Hematemesis : Coffee ground :

Definition
v

Melena: acid hematin (Hb+acid= acid hematin) 50 1000 melena 5-7 days

Definition Lower GI Hemorrhage : jejunum (Bleeding below ligament of Treitz) Hematochezia: ,

Approach to the Patient with Acute Gastrointestinal hemorrhage

Mentioned Aspects in Gastrointestinal Hemorrhage

1.

2.

3.

Anatomical level & Nature of hemorrhage

Gastrointestinal hemorrhage
1.

Rapid assessment of hemodynamic status 2. Fluid resuscitation 3. History taking and physical examination 4. Diagnostic investigation 5. Treatment

History Taking
v v v v v v v

v v v

Characteristics of the bleeding Age Time of onset Volume Estimating Frequency blood loss The medical history e.g. Liver disease Antecedent symptom e.g. Vomiting, Epigastric distress Previous bleeding Weight loss Drug e.g. Salicylates, NSAIDs, ASA, SSRIs

manifestation of UGIH and LGIH

Manifestatio Likelyhood n UGI source Hematemes Assured is Probable Melena Unlikely Hematoche Rules out zia Possible Blood streak stool Occult Likelyhood LGI source Rules out Possible High probable Assured Possible

Assu Relationship between red

Algorithm for the diagnosis of Acute GIH

Acute Gastrointestinal Hemorrhage Nasogastric aspiration Blood / Coffee ground Non diagnosti c Massive hemorrha ge Angiogra phic Colonos copy Diagnos tic

No blood or bile EGD Diagnos tic Slow hemorrha ge Tagged RBC

Bile and no blood Angiogr aphy

Non diagnosti c Tagged RBC scan Meckels scan

Lower Gastrointestinal Hemorrhage

Lower gastrointestinal hemorrhage( LGIH):

v

jejunum (Bleeding below ligament of Treitz) Characteristrics of stool

Hematochezia : , Currant jelly stool Melena :

Approach to the Patient with Acute Gastrointestinal hemorrhage

General approach to the Patient with Acute GI Hemorrhage

Initial assessment and resuscitation Assess Airway, Breathing, Circulation (ABCs) Assess magnitude of bleeding Initiate appropriate monitoring Localize evaluation Laboratorybleeding Nasogastric tube aspirate Endoscopy Others as needed History and exam Identify risk factors Previous surgery Medications

Initiate therapy Pharmacologic Endoscopic Angiographic Surgical

Modified from Bass BL, Turner DJ, Acute gastrointestinal hemorrhage. In Sabiston text book of surgery 17th Ed. Philadelphia. Saunders. 2004;1200

Risk Stratification for admission or emergent evaluation

Risk factors for Morbidity and Mortality in Acute GI Hemorrhage 1. Age > 60 yr. 2. Comorbid disease : Renal disease, Liver disease, Respiratory insufficiency, Cardiac disease 3. Magnitude of hemorrhage 4. Persistent or recurrent hemorrhage 5. Onset of hemorrhage during hospitalization

Algorithm for diagnosis and management of LGIH

Initiate appropriate therapy Acute Lower gastrointestinal Y bleeding PR and E Proctosc S opy

Minor bleeding (Intermitte nt)

UGIH : NG aspiration or N EGD

N O Rule out

Y E S

Upper GI bleeding management Major bleeding (Persistent )

Algorithm for diagnosis and management of LGIH

Minor bleeding (Intermitte nt) Colonosco py

Lesion visualized Initiate appropriate Positiv therapy e Negati ve Colonosco py

No lesion visualized Small bowel series Enteroclysis Enteroscopy Capsule endoscopy

Algorithm for diagnosis and management of LGIH

Stable Major bleeding (Persistent ) Unsta ble

Tagged OR RBC scan Negati Positiv ve e Source : Uncert Small bowel Colon or Angiogra ain series small phy source Enteroclysis bowel and Enteroscopy Subtotal Treatmen Serial clamping Capsule or intraop. colectomy endoscopy t Segme Enteroscopy or Small ntal followed by resection

Specific causes of Lower Gastrointestinal Bleeding

Colonic diverticular disease

v

50 % 60 50 % Lower Gastrointestinal Hemorrhage Intraluminal pressure Segmentation Mucosa Submucosa Muscle Vasa recta Muscle Sudden massive

Colonic diverticular disease

v

Treatment :

Endoscopic intervention

Epinephrine injection Electrocautery Endoscopic clips Intraarterial vasopressin Embolization

Radiologic intervention

Surgery

Colonic diverticular disease

v

Indication for surgery

1,500 ml Resuscitation 2,000 ml Vital sign stable 24 72 Surgical methods : :

Angiodysplasia
v v

Acquired Arteriovenous malformations (AVMs) Muscle contraction submucosal vein Subserosa Venous hypertension Progressive dilatation submucosa Risk factors : chronic renal disease and recent anticoagulant therapy. Right sided colon Cecum

Angiodysplasia
v

Treatment :

Endoscopy :

Electrocoagulation Sclerosing agent injection Intraarterial vasopressin Selective Gel foam Embolization

Angiography

Surgery

Like Diverticulosis

Anorectal disease
v

Diagnosis : PR & Proctoscopy Most common site : Posterior midline

Anal fissure

Painful bleeding Treatment : Stool bulking agent, Increased water intake, Stool softeners, Diltiazem/Nitroglecerine ointment (relieve sphincter spasm)

Anorectal disease
v

Hemorrhoid

Painless bleeding Prolapsed tissue Grading Grading I : Bleeding Grade alone, No prolapse Treatment

Bulking agent Grade II : Prolapsed with spontaneous Increased dietary fiber reduction Adequate hydration III : Prolapsed Grade Rubber band ligation reduction manual Grade IV : Sclerosing agent injection Incarcerated, Infrared coagulation
irreducible

Colorectal Neoplasm
v

Colorectal carcinoma, Polyp Painless & intermittent (Slow in nature) Iron deficiency anemia Chronic blood loss Bowel habit change, Thin stool, Tenesmus, Feeling of

Colitis
v

Inflammatory colitis
)

Ulcerative colitis :
Rectum Colon Multiple bloody bowel movement

Abdominal cramping, tenesmus, abdominal pain

Crohns disease :
Skipped lesion, Transmural thickening Granuloma

Inflammatory colitis
v

Infectious colitis :

Mucous bloody diarrhea E. coli O157:H7, CMV, Salmonalla, Shigella and Campylobacter Pseudomembranous colitis Clostridium difficile
v

Radiation colitis :

Bright-red blooding per rectum, diarrhea, tenesmus crampy pelvic pain

Mesenteric ischemia
v

Major mesenteric vessel Thrombosis, Embolization Predisposing factors : Atrial fibrillation, Congestive heart failure, Acute myocardial infarction, Recent abdominal vascular surgery, hypercoagulable state Splenic flexor, Rectosigmoid colon

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