Lower GI Bleeding

LOWER GI BLEEDING Clinical Consideration Ali Salah Alkhudair Supervision by Dr. Atef Khan

OBJECTIVES
By the end of this presentation,we are able to:
Defention of Lower GI Hemorrhage .
Classification
Deferential Diagnosis
Workup and investigation
Interventions and Treatments
Case Senario

LOWER GI HEMORRHAGE
Defined as an abnormal intraluminal blood loss from a source distal to the Treitz ligamentum.

CLASSIFICATION
Massive
Moderate
Mild

MASSIVE LOWER GI BLEEDING
Passage of a large volume of red or maroon blood through the rectum
Hemodynamic instability and shock ( Systolic blood pressure of less than 90 mm Hg )
Initial decrease in hematocrit level of 6 g/dL or less
Transfusion of at least 2 units of packed red blood cells
Bleeding that continues for 3 days
Significant rebleeding in 1 week

DEFERENTIAL DIAGNOSIS
DIAGNOSIS OF ANAL CONDITIONS WHICH PRESENT WITH:
PAIN AND BLEEDING:
Fissures
PAIN, LUMP AND BLEEDING:
Prolapsed haemorrhoids
Carcinoma of the anal canal
Prolapsed rectal polyp or carcinoma
Prolapsed rectum

DEFERENTIAL DIAGNOSIS
DIAGNOSIS OF CONDITIONS PRESENTING WITH RECTAL BLEEDING BUT NO PAIN:
Blood mixed with stool  colon carcinoma
Blood streak on stool  rectal carcinoma
Blood after defaecation  haemorrhoids
Blood and mucus  colitis
Blood alone  diverticular disease
Melaena  peptic ulcer

DEFERENTIAL DIAGNOSIS IN ADULT

DEFERENTIAL DIAGNOSIS IN CHILDREN

HEMORRHOIDS (PILES)
* it is one of the commonest cause of rectal bleeding
Causes:
carcinoma of the rectum
pregnancy:
Chronic constipation
Also, heart failure, excessive use of laxatives and portal HTN are causes.

HEMORRHOIDS (PILES) TYPES
INTERNAL HAEMORRHOIDS:
-develops above the dentate line.
-covered by anal mucosa.
-lacks sensory innervation (painless)
-bright red or purple in color.

EXTERNAL HAEMORRHOIDS:
-arise below the dentate line.
-covered by St. sq. epith.
-innervated by the inferior rectal nerve.

Internal H. drains into sup. Rectal veins  portal system
External H. drains into inf. Rectal veins  I.V.C.

HEMORRHOIDS (PILES) GRADING FOR INTERNAL TYPE
Internal H. are classified by the degree of tissue prolapse into the anal canal.

GRADE 1: they are confined to the anal canal with minimal bleeding or maybe asymptomatic but do not prolapse.

GRADE 2: they prolapse on defecating or straining then reduce spontaneously.

GRADE 3: prolapse with or without straining and require manual reduction.

GRADE 4: chronically prolapsed and if reducible fall out again. Others fall out of the anus and are irreducible (strangulated)  surgical emergency.

HEMORRHOIDS (PILES) SYMPTOMS
Grade 1 usually are asymptomatic or with minimal bright red bleeding on defecation.
1-bleeding:
-the main and earliest symptom
-starts as bright red bleeding on the surface of the stool or on the toilet paper.
2-prolapse:
-a much later symptom
-starts transiently on defecation, but occurs with increasing frequency
until 3 rd degree H. develop.
3-discharge:
-a mucous discharge accompanies a prolapsed pile.
4-pruritis
5-pain

HEMORRHOIDS (PILES) SIGNS
the pt. should be in the left lateral position.
INSPECTION:
-1 st degree H. show no outward abnormality
-2 nd degree H. may show the skin covered components when the buttocks are separated or piles may prolapse when the pt. strains.
-3 rd degree H. shows the red anal mucosa in their position (3,7,11)

DIGITAL EXAMINATION: internal H. can’t be felt unless they are thrombosed or in the long standing thickened piles.
And should not apply PR

HEMORRHOIDS (PILES) INVESTIGATION
1-sigmoidscopy: essential to exclude co-exclude rectal pathology as carcinoma or polyps.

2-barium enema: indicated when sigmoidscopy and protoscopy can’t explain the symptoms.
3-CBC: anemia, rarely happen in longstanding piles.

HEMORRHOIDS (PILES) D.D.
Anal or rectal cancer.
Redunculated polyps.
Rectal prolapse.
Anal fissures or fistula or hematoma – if painful-

HEMORRHOIDS (PILES) COMPLICATION
Anemia
Strangulation: when a prolapsing pile become gripped by the external anal sphincter.
Thrombosis
Ulceration: superficial ulceration of the exposed mucous membrane.
Gangrene
Suppuration: uncommon
Fibrosis

HEMORRHOIDS (PILES) TREATMENT
1-first degree H.: bulk laxatives and high dietary fibers maybe enough  to decrease the constipation
2-injection therapy (sclerotherapy): -for the 1 st degree and early 2 nd degree H.
3- 5 ml of 5% phenol in almond oil is injected through a special syring to the base of the pile or just above the anorectal ring.
4- Rubber band ligation:
-effective with 1 st and 2 nd degree H.
-a small o-ring rubber band applied to constrict the mucosa at the base. This will lead to strangulation of the pile and subsequent sloughing of the pile over a period of 10 days or so.
5-infra-red photocoagulation.
6-cryotherapy: a cryoprope is applied to the overlying mucosa.
7-stretching of the anal sphincter : it improves venous drainage and decrease the need for straining. Overstretching may lead to anal incontinence.
8-haemorrhoidectomy:
Necessary for the 3 rd degree H. or in prolapsed thrombosis.
Complications of the procedure: Anal stenosis, acute urinary retention, post-operative haemorrhage.

CARCINOMA OF THE RECTUM
75% occur in the lower part of the rectal ampulla  papilliferous or a simple ulcer with everted edges.
25% in the upper part of the rectum  annular in shape.
90% or rectal cancers can be felt with a finger during PR.
MACROSCOPIC APPEARANCE:
It may be as follows:
papilliferous
ulcerating  commonest
stenosing  at rectosigmoid
colloid

CARCINOMA OF THE RECTUM
MICROSCOPIC APPEARANCE:
*90% are adenocarcinoma
*9% are colloid – adenocarcinoma with mucous production-
*1% highly anaplastic carcinoma simplex
*at the anus, sq. cc occur but, a malignant tumour protruding through the anal canal is more likely to be an adenocarcinoma of the rectum invading the anal skin.
Rectal ca is common in middle and old age (50-70 yrs) but can occur in young adults.
It is equally common in both sexes.

Rectal bleeding: small dark red streak on the stool. If a lot of blood accumulates it can pass as such but this is uncommon.
The surface of the tumour produces mucous which is expressed in a more liquid motion – diarrhea like- but if it pools it can be passed as liquid faeces.
There may be change in bowel habit usually towards constipation.
High annular cancers at the rectosigmoid junction may cause partial obstruction  presenting as alternating constipation and diarrhoea.
Tenesmus  tumour in the lower part of the rectum is large to fool the sensory mechanisims into thinking it is faeces.
Wight loss: this is common even if there isn’t any metastasis.
Small primary lesions maybe symptom less but associated with multiple metastasis especially to the liver. Here the pt. has upper abdominal pain, malaise and a palpable mass.
Pain is an uncommon symptom.
CARCINOMA OF THE RECTUM Symptoms

on Rectal Examination:
More commonly, only the lower edge of a malignant ulcer can be felt. It feels hard and bulges into the lumen of the rectum, the edges are everted and the base is irregular and friable.
Upon withdrawal of the finger, you will have blood and mucous on the gloved finger.
If the tumour is in the upper part of the rectum, only the lower edge is felt.
This position of the lesion makes it hard to decide if the tumour is in the rectum or out of it  sigmoidscopy is the answer.
PR is not reliable in fat people.
On general examination: the liver is the most common site for metastasis.
Other sites for metastasis are: supraclavicular lymph glands, the lungs and the skin.
Lung metastasis is uncommon, a chest x-ray is mandatory.
The inguinal LN are involved only if the tumour is below the Hiltons line to involve the skin.
If the pt. has palpable inguinal LN, the tumour is most likely to be sq. cc. of the anal skin.
CARCINOMA OF THE RECTUM SIGNS ON EXAMINATION

1-Sigmoidscopy: to inspect and take a biopsy.
2-Barium Enema: the indications for this procedure are:
* The growth isn’t visualized by sigmoidscopy
*if a second tumour is suspected
*ulcerative colitis
*familial polyposis
3-ultrasound of the abdomen to check liver metastasis and ascites.
CARCINOMA OF THE RECTUM SPECIAL INVESTIGATIONS

Benign growth
Carcinoma of the sigmoid prolapsing into the pouch of Douglas.
Ovarian or uterine tumours
Extension of a carcinoma in the prostate or cervix
Diverticular disease
Endometriosis
Lymphogranuloma inguinale
Faeces – known by indentation on examination-
CARCINOMA OF THE RECTUM DDx OF RECTAL TUMOUR

Curative:
Surgery depends on the distance of the tumour from the anal verge.
Upper third tumours  resection with anastomosis between the sigmoid and lower rectum (anterior resection)
Lower third tumours  less than 5 cm from the anal verge are ttt by abdominoperineal excision of the rectum + terminal colostomy + adjunctive radiotherapy to reduce recurrence.
Mid third tumours  anterior resection if distal clearance can be obtained. This easier in women due to the wide pelvic
CARCINOMA OF THE RECTUM TREATMENT

Palliative procedure:
Even if secondary tumours are present, palliation is best achieved when the primary is resected.
Colostomy is necessary for intestinal obstruction. But this doesn’t relieve the bleeding, discharge and sacral pain.
In inoperable cases, deep x-ray therapy, diathermy, or laser of the tumour may give temporary relief as may cytotoxic drugs.
CARCINOMA OF THE RECTUM TREATMENT

This disease may present in one of the following manners:
1-chronic left sided abdominal pain + change in bowel habits
2-acute abdominal symptoms
3- Rectal bleeding: acute, massive and fresh blood
Elderly pt. with this disease present with a little faint, lower abdominal pain, and a desire to defecate that when emptied pass large volume of fresh blood and clots.
The patients are rarely shocked and don’t require transfusion.
It is diagnosed via barium enema or colonscopy
DIVERTICULAR DISEASE

Causes of bleeding are:
Eroded artery in the mouth of the diverticulum
The disease is incidental and the bleeding is due to angiodysplasia of the chronic mucosa
Surgery is very rarely needed
DIVERTICULAR DISEASE

It is not a true hematoma but a thrombosis of a vein in the subcutaneous plexus.
SYMPTOMS:
1-Pain: usually due to the tension
*it begins gradually increasing in severity over a few hours and subsiding gradually over few days
*it is continuous.
*made worse by sitting, moving and defecating
*localized to the lump
2-Swelling:
*appears at the same time as the lump
*First it is small and spherical
* Then it may enlarge and become more painful

PERI-ANAL HEMATOMA

SYMPTOMS:
3-Bleeding: this happens only if:
*the lump bursts
*the skin over the lump ulcerates

4- The skin around the lump is itchy and moist due to the leakage of the mucous because the lump doesn’t allow the anus to close properly.

PERI-ANAL HEMATOMA

SIGNS ON EXAMINATION:
* Colour: if it is close to the overlying skin which is not edematous, it is deep red-purple. But if the skin is edematous then its colour can’t be seen.
* The lump is tender especially if it ulcerates.
* Shape and size: initially the lump is spherical and up to 1cm in diameter. If the skin is lax or edematous then the lump is polypoid.
* Surface: covered by skin and the surface beneath it is smooth
* Composition: solid, hard hemispherical mass
* Relations: the lump is superficial to the external sphincter. Not fixed to the skin or other structures. Cannot be reduced to the anal canal.
PERI-ANAL HEMATOMA

TREATMENT:
The symptoms may subside spontaneously after 2-3 days during which analgesia is given. If it is in the acute phase and the patient doesn’t want to wait, incision under local anaesthesia is the way to go.
PERI-ANAL HEMATOMA

A nal fissure is a longitudinal split in the skin of the anal canal
Acute fissures are common in children who pass bulky stool quickly
Chronic fissures are most common in the age group 20 and 40 years.
Chronic fissures are common in women after childbirth.
Anal fissures are more common in men than in women.
Multiple fissures may complicate Crohn’s disease.
FISSURE-IN-ANO

SYMPTOMS:

1-Pain:
fissures are the commonest cause of pain in the anal verge
both acute and chronic fissures are very painful
it begins at defecation and is described as tearing
it persists for minutes to hours after defecation
it is throbbing or aching in nature

2- Bleeding:
acute fissures may streak the stool with blood and stain the toilet paper
Chronic fissures bleed less and may produce little blood stain of the toilet paper if any.

3-a small skin tag called sentinel tag or sentinel pile may form at the lower end of a chronic fissure. This tag may be felt by the pt.
FISSURE-IN-ANO

4- Because of the pain, the pt. is usually constipated.
5-the fibrosis around the chronic fissure prevents a good seal around the anus leading to small amounts of mucous leak on the peri-anal skin  pruritus –could be the presenting symptom of a chronic fissure-
6-the symptoms are slow to develop and become long standing, there may be periods of remission
DDx: Crohn’s disease, Trauma (abuse of children), Carcinoma, TB, Syphilis and Psoriasis.
FISSURE-IN-ANO

TREATMENT:
Acute fissures:
*if early and small  may heal spontaneously.
*local anaesthetic ointment + lubricant laxative  relief
*application of GTN cream relaxes the anal sphincter  healing of the epithelium.
*more intractable cases respond to dividing the internal sphincter submucosally under general anaesthetic.
*chemical sphincterotomy using an injection of botox into the internal sphincter
*advantages of the chemical method are:
1-sphincter paralysis is short lived
2-gives a more sustained effect than GTN cream

Chronic fissures:
require excision

FISSURE-IN-ANO

DEFENITION:
A fistula is a track lined with epith. Or granulation tissue, connecting two epithelial surfaces. It may connect two body cavities or one cavity and the body’s external surface.
A fistula-in-ano connects the lumen of the rectum or anal canal with the external surface. It is usually lined by granulation tissue.
FISTULA-IN-ANO

LOW LEVEL FISTULAS:
The internal opening is below the anorectal ring.
They could be of the following:
1-trans sphincteric
2-inter sphinteric
3-subcutaneous or submucous

HIGH LEVEL FISTULAS:
The internal opening is above the anorectal ring.
They could be of the following:
1-extra sphincteric (pelvirectal supralevator)
2-trans sphincteric
3-inter sphincteric
FISTULA-IN-ANO

SYMPTOMS:
Watery or purulent discharge from the external opening of the fistula
Pain is episodic as the fistula fills with pus. If the pus doesn’t discharge  pain is more intense and throbbing
The discharge causes pruritus ani.
There may be minor bleeding from the external opening
The symptoms in general are episodic but the condition hardly ever cures itself
FISTULA-IN-ANO

GOODSALL’S RULE:
The internal opening of an anterior fistula lies along a radial line drawn from the external opening to the anus, whereas the internal opening of a posterior fistula lies in the mid line posteriorly.
FISTULA-IN-ANO

ON PR EXAMINATION:
The external opening is visible anywhere around the anus usually close to the anal margin but sometimes a few centimetres away.
The opening is not tender but the thickened tissue around it may be.
The serous or purulent discharge may be visible.
Rectal examination is not painful.
The internal opening may be felt. 2/3 are posterior, 1/3 are anterior.
Sigmoidscopy and protoscopy are essential to exclude underlying disease as chron’s or carcinoma or TB.
The inguinal LN are not enlarged except if there is inflammation or secondary infiltration by carcinoma.
Don’t forget general examination if there is a suspected systemic underlying cause.
FISTULA-IN-ANO

INVESTIGATIONS:
fistulogram, endoanal ultrasound, MRI
DDx:
pilonidal sinus, hidradenitis, suppurative, incontinence, chron’s, trauma.
FISTULA-IN-ANO

TRAETMENT:
Superficial and low level fistulas are laid open and allowed to heal by granulation. There is no loss of continence 
This is only done if the fistula lies below the anorectal ring
High fistulas (suprasphincteric, trans-sphincteric)  only the lower part of the fistula is laid open  a non-absorbable ligature (eg.: nylon) termed a seton is passed through the upper part of the fistula  left for 2-3 weeks  the sphincter is fixed by scar tissue  subsequent division of the upper part of the track either by a second operation or by tightening of the ligature.
Lying open the whole track will completely divide the sphincter  incontinence
FISTULA-IN-ANO

Symptoms
Pain
Ulcerative Colitis
Lower abdominal cramps
Relieved with Bowel Movement
Crohn's Disease
Constant pain often in right lower quadrant
Not relieved with Bowel Movement
Stool Blood
Grossly bloody stool in Ulcerative Colitis
Inflammatory Bowel Disease

Signs
Abdominal Mass
Ulcerative Colitis: No abdominal mass
Crohn's Disease: Mass often at Right lower quadrant
Gastrointestinal Tract Affected
Ulcerative Colitis
Affects only colon
Continuous from rectum
Crohn's Disease
Mouth to anus potentially affected
Discontinuous, "Skip" lesions
Bowel Tissue affected
Ulcerative Colitis: Mucosal disease (no granuloma)
Crohn's Disease: Transmural disease (granulomas)
Inflammatory Bowel Disease

LAB INVESTIGATION
Appropriate blood tests include :
CBC count
Serum electrolytes
B lood urea nitrogen, creatinine
blood grouping and cross matching
Coagulation profile including:
(aPTT)
(PT)
platelet count
bleeding time

INVESTIGATION FECAL OCCULT BLOOD TESTING
• Normally lose 0.5-1.5mL blood/day from GIT
• Three types of test
– Guaiac-based (Haemoccult II, Haemoccult II Sensa)
• Good for detecting large, more distal lesions
• Inconsistent
– Need >10mL daily blood loss for +ve test 50% of the time
– Can detect as little as 1mL of blood in stool
• Affected by dietary factors
– Foods which darken stool make it harder to read
– False positives from dietary iron
– Immunochemical
• Do not detect bleeding from upper GIT - localizes to the colon
• Can detect as little as 0.3mL of blood in stool
• Lab processing required
– Heme-porphyrin test
• Very sensitive
• High false positive rate
• Lab processing required

INVESTIGATION FECAL OCCULT BLOOD TESTING
• Sensitivity 60-80%
• False positive rate 5-13%
• If test is positive patients require a colonoscopy or double-contrast Barium Enema + sigmoidoscopy
• If test is positive and the colon has been “cleared”
unless iron deficiency is present no further Ix is
necessary

INVESTIGATION BARIUM ENEMA
• No role in diagnosis of active lower GIT bleeding
• If used will obscure any subsequent attempts to
visualize by arteriography or colonoscopy
• Double contrast enema has 70% sensitivity in
elective detection of nonbleeding colonic lesions

INVESTIGATION COLONOSCOPY
• Diagnostic and therapeutic capabilities
• Can be used even with ongoing massive bleeding
• Characteristic endoscopic findings of recent upper GIT
h’age are the same as for lower GIT h’age
– Active bleeding - focal adherent clots
– Nonbleeding visible vessels
• Timing ideally 6-24 hours post presentation
– Patient must be in stable condition
– Allows bowel prep
– This is the time when recurrent bleeding usually occurs

INVESTIGATION COLONOSCOPY
• Increased risk of bowel perforation
– Should not be attempted with ischaemia or severe mucosal inflammation
• Endoscopic coagulation tx of choice for bleeding AVMs
– 2% risk of perforation
• Diverticular bleeding usually not able to be endoscopically coagulated (technically challenging)
• CT Colonoscopy (Virtual colonoscopy)
– May have a role in assessment of pts with +ve FOB

BLEEDING DIVERTICULUM

INVESTIGATION NUCLEAR SCINTIGRAPHY
• Detects bleeding ≥0.05-0.1mL/minute13
• Two methods
– Technetium 99m (99mTc) sulfur-colloid
• Requires no preparation -> inject immediately
• Short half life
• Enhances liver and spleen -> can obscure bleeding sites
• Able to detect slower rates of bleeding
– 99mTc-labeled red blood cells
• Preferred method
• Good for intermittent bleeds
• Able to visualize bleeds near liver/spleen
• 73-98% sensitive

INVESTIGATION NUCLEAR SCINTIGRAPHY
False localization rate ~20%1 (3-59%)
– Blood does not remain stationary within bowel lumen
• Reflux into small bowel
• Rapid transit through bowel with pooling in other areas
• Institution dependent
– Not available in all hospitals
– Variability in quality
• ?plan surgery on results
• Useful as a prelude to angiography to confirm active
haemorrhage +/- localization
– Increased diagnostic accuracy of angiograms in patients with +ve scans
• Not recommended for massive haemorrhage (delays treatment)

ACTIVE BLEEDING FROM ASCENDING COLON

INVESTIGATION ANGIOGRAPHY
• Selective mesenteric angiography
– Femoral artery punctured
– Evaluates SMA then IMA then coeliac axis
– Positive test if extravasation of contrast into bowel lumen
• Can detect haemorrhage rates ≥0.5mL/min14
• Diagnostic and potentially therapeutic
– Adrenaline infusion
– Embolization
• Sensitivity 40-86%
• Complication rate ~ 2%

NORMAL SELECTIVE IMA ANGIOGRAM

INVESTIGATION CT ANGIOGRAPHY
• New and evolving technology
• Requires modern CT scanner
• Fast - < 15mins
• Non-invasive
• Identifies large and small bowel haemorrhage
• Sensitivity and specificity 72-80%17
• ? Ix of choice in the future

INVESTIGATION CAPSULE ENDOSCOPY (CE)

OBSCURE GIT BLEEDING
• ~5% of patients have bleeding which remains
unlocalized despite extensive Ix
• Investigative options
– “ Push” enteroscopy / Sonde enteroscopy
– Capsule enteroscopy
– Small bowel follow-through
– Meckel’s Scan
– Diagnostic laparoscopy
– Exploratory laparotomy +/- enteroscopy

INVESTIGATION ENTEROSCOPY
• Requires special instruments
– “ push” Enteroscope
• 2.7m long thin scope
– Sonde Enteroscope
• scope with balloon attached to peristalses through the bowel
– Paediatric colonoscope use has been reported
• Permits inspection of SB
– to proximal jejunum with push enteroscopy
– entire SB with Sonde scope
• ~25% diagnostic yield in reported series15

INVESTIGATION MECKEL’S SCAN
• Meckel’s diverticulum = remnant of vitellointestinal
duct
• Disease of 2’s
• only picks up Meckel’s containing gastric mucosa 50%
• 99m-Tc-pertechnetate radioisotope used
– concentrated mainly by the mucous secretory cells of the stomach
• 85% sensitive
• 95% specific
• Useful in Ix of young patients with GIT bleeding

CASE SENARIO
A 67 year-old man presented to the emargency department with a 6 –hour history of bleeding per rectum .
The patient’s symptoms began after he developed an urge to defecate that was followed by several voluminous bowel movements containing maroon-colored stool mixed with blood clots.
The patient complains of feeling light headed just prior to arriving at the hospital but denies any abdmoinal pain his past medical history is significant for borderline hypertension managed with diet control.His surgical history is significant for a right inguinal hernia repair 2 years ago.
His blood pressure is 100/80, pulse rate 100/min , and respiratory rate 20/min.
The results of an examination of his abdomen are unremrkable. The rectal exmination revealed no masses and a large amount of maroon colored stool in rectal vault

Q
What should be our next step ?
What is the most likely Diagnosis ?
How would we confirm this Diagnosis?

REFERENCE
BROWSE’S book Last Chapter
Churchill’s pocket book of surgery pp 299-314.
Vernava A. Lower Gastrointestinal bleeding. Dis Colon Rectum 1997;40:846-858
Emedicene http://emedicine.medscape.com/article/195246-overview
Lecture about Investigation of Lower GI Bleeding by Dr.Dean Trotter

Lower GI Bleeding

by Ali Alkhudair

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Lower GI Bleeding Presentation Transcript

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