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Upper GI bleeding: bleeding that occurs proximal to the ligament of Treitz. The upper GI tract includes the esophagus, stomach, and first part of the small intestine.
Lower GI bleeding : bleeding that occurs distal to the ligament of Treitz. This includes the last 1/4 of the duodenum and the entire area of the jejunum, ileum, colon, rectum and anus.
Presentation:It is usually suspected when patients complain ofhematochezia.Although, the distinctions based upon stool colorare not absolute since melena can be seenwith LGI bleeding from the right colon (orsmall intestine), and hematochezia can beseen with massive upper GI bleeding.
Incidence:- 20-33% of episodes of gastrointestinal (GI) hemorrhage.- annual incidence of about 20-27 cases per 100,000 population.- The incidence rises steeply with advancing age.- 80% resolve spontaneously.- 25% will re-bleed.
Categorization of (LGI) bleeding by intensity: Massive bleeding Moderate bleeding Occult bleeding
Most common site• Diverticula can occur throughout the colon but are most common near the end of the left colon referred to as the sigmoid colon.
Risk factors• increasing age• constipation• a diet that is low in dietary fiber• high intake of meat and red meat• connective tissue disorders (such as Mara fan syndrome) that may cause weakness in the colon wall• hereditary or genetic predisposition
The muscular wall of the colon grows thicker with age,although the cause of this thickening is unclear. It may reflectthe increasing pressures required by the colon to eliminatefeces. For example, a diet low in fiber can lead to small, hardstools which are difficult to pass and which require increasedpressure to pass. The lack of fiber and small stools also mayallow segments of the colon to close off from the rest of thecolon when the colonic muscle in the segment contracts. Thepressure in these closed-off segments may become high sincethe increased pressure cannot dissipate to the rest of thecolon. Over time, high pressures in the colon push the innerintestinal lining outward (herniation) through weak areas inthe muscular walls. These pouches or sacs that develop arecalled diverticula.
What are the symptoms of diverticular disease? • Most patients with diverticulosis have few or no symptoms. • The most common symptoms of diverticular disease include: abdominal cramping, constipation, and diarrhea. These symptoms are related to difficulty in passing stool through the left colon, which is narrowed by diverticular disease.
• The most common complication is diverticulitis which is a condition in which diverticuli in the colon rupture. Which results in infection in the tissues that surround the colon
What are the complications of diverticulitis? • Bleeding:caused by a small blood vessel in a diverticulum that weakens and then bursts
Abscess, Perforation, and Peritonitis• Diverticulitis may lead to infection, which often clears up after a few days of treatment with antibiotics. If the infection gets worse, an abscess may form in the wall of the colon.• Infected diverticula may develop perforations.• Sometimes the perforations leak pus out of the colon and form a large abscess in the abdominal cavity, a condition called peritonitis.
Fistula• When diverticulitis-related infection spreads outside the colon, the colonic tissue may stick to nearby tissues. The organs usually involved are the bladder, small intestine, and skin.• The most common type of fistula occurs between the bladder and the colon.• This type of fistula affects men more often than women. It can result in a severe, long-lasting infection of the urinary tract. The problem can be corrected with surgery to remove the fistula and the affected part of the colon.
Intestinal Obstruction• Scarring caused by infection may lead to partial or total blockage of the intestine, called intestinal obstruction
How is the diagnosis of diverticular disease made?• Colonoscopy
• Barium X-rays (barium enemas) can be performed to visualize the colon. Diverticula are seen as barium filled pouches protruding from the colon wall.• ultrasound and CT scan examinations of the abdomen and pelvis can be done to detect collections of pus.
Incidence and Epidemiology:• Hemorrhoids affect >1 million in western civilization per year.• The prevalence is less in the underdeveloped countries and not selective for age or sex.• Common among pregnant women.
Predisposing factors:• Constipation.• Sitting for long periods of time.• Obesity.• Heavy Lifting.
Angiodyplasia• It is a tourtious dilatations of submucosal and mucosal blood vessels are seen most often in the cecum or right colon
Incidence:Age • >70 Sex equal Bleeding from angiodysplasia is usually self-Mortality/Morbidity limited, but it can be chronic, recurrent, or even acute and life threatening. Site:77% of angiodysplasias are located in the cecum and ascending colon, 15% are located in the jejunum and ileum, and the remainder is distributed throughout the alimentary tract.
Pathophysiology of angiodysplasia most prominent theory• Repeated episodes of colonic distention associated with transient increase in pressure and size• This results in multiple episodes of incresing wall tension with obstruction of submucosal outflow
Neoplasm• Neoplastic bleeding can be from a polyp or carcinoma.• Colon cancer is the predominant cause of neoplastic bleeding and is responsible for around 10% of rectal bleeding in patients older than 50 years.• The bleeding is usually low-grade and recurrent, occurring as a result of mucosal ulceration or erosion. Though neoplastic bleeding can present as bright red blood per rectum, it is unusual for it to cause massive colonic bleeding.
Lower Gastrointestinal Bleeding in Children and AdolescentsIntussusceptionPolyps and polyposis syndromesJuvenile polyps and polyposisPeutz-Jeghers syndromeFamilial adenomatous polyposis (FAP)
Coagulopathy• (also called clotting disorder and bleeding disorder) is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical procedures.
Hypocoagulability• is an unusual susceptibility to bleeding, that is, an increased bleeding diathesis, due to an abnormality in coagulation.
Symptoms Symptom Disorders Wiskott-Aldrich syndrome, where they may resemble a few bruisesPetechiae (red spots) Acute leukemia Chronic leukemia Vitamin K deficiency Acute leukemiaPurpura and ecchymoses Chronic leukemia Vitamin K deficiency Wiskott-Aldrich syndrome, especiallyBlood in stool in infancy Acute leukemia Wiskott-Aldrich syndromeBleeding gingiva (gums) Acute leukemia Chronic leukemiaProlonged nose bleeds Wiskott-Aldrich syndrome
Complications Complication DisordersSoft tissue bleeding, e.g. deep-muscle bleeding, Hemophilialeading to swelling, numbness or pain of a limb. Von Willebrand diseaseJoint damage, potentially with severe pain and Hemophiliaeven destruction of the joint and development Von Willebrand diseaseof arthritisRetinal bleeding Acute leukemiaTransfusion transmitted infection, from blood Hemophiliatransfusions that are given as treatment.Adverse reactions to clotting factor treatment. HemophiliaAnemia Von Willebrand disease Von Willebrand disease AcuteExsanguination (bleeding to death) leukemia Vitamin K deficiencyCerebral hemorrhage Wiskott-Aldrich syndrome
Infection• (HIV) is an infrequent cause of LGIB.• HIV-related opportunistic infections and associated etiologies, including:1. (CMV) colitis,2. idiopathic colon ulcers,3. Kaposi sarcoma, and lymphoma
Drug-induced• Mainly by NSAID and aspirin use, and it is more common in the elderly.• The 2008 Scottish Intercollegiate Guidelines Network (SIGN) guideline on the management of acute upper and lower gastrointestinal bleeding warns that oral anticoagulants or corticosteroids should be used with caution in patients at risk of GIB, especially in those who take NSAIDs or aspirin
DIAGNOSIS• Despite improvement in diagnostic imaging & procedures, 10-20% of pts with Lower GIT bleeding have no demonstrable bleeding source.• Therefore, this complex problem requires systematic evaluation.
A- Initial EvaluationPatients history:-aspirin, vascular disease, past bleeding episodes, liver cirrhosis, IBD, coagulopathy.-duration, frequency, stool colour.Digital rectal examinationPhysical examination to assess the severity ofbleeding:-HR , BP, postural changes.
B- Laboratory Tests CBC ESR/ CRP Coagulation profile Liver function tests Renal function tests
C- Endoscopy1- Colonoscopy:Mainstay for evaluation.Candidates : hemodynamically stable pts.Hemodynamically unstable pts must undergovolume resuscitation 1st
Current recommendations advise thorough cleansing ofthe colon in acute LGIB to improve diagnostic yield &safety of the procedure.For optimal purge, the pt. takes 3-6 L of a polyethyleneglycol-based solution.While in pts with severe bleeding, urgent colonoscopymust sometimes be carried out without purge.
In cases of suspected perforation or obstruction,plain abdominal radiography should beperformed before colonoscopy to rule outthese complications.
Advantages of colonoscopy -Localize the bleeding lesion in 50-70% of pts -Identify pts who are at high risk of rebleeding-Definitive treatment, such as thermoregulation, epinephrine injection Disadvantages of colonoscopy - Must be performed by skilled endoscopists. - Technical problems - Perforation
Small Bowel Visualization1- wireless capsule endoscopy (WCE):increasingly being used as the test of choice for small bowel bleeding.
2-Push enteroscopy:• May be recommended as the initial test because of itstherapeutic capability.• Performed with a pediatric colonoscope and once the bleeding site is visualized, it can be treated or tattooed.
Radionuclide Scanning/Nuclear ScintigraphyIts role remains controversial.Radionuclide scans include the technetium-99( 99 Tc) sulfur colloidscan and the99m Tc pertechnetate–labeled autologous red bloodCell scan (TRBC scan), as well as indium-111 ( 111 In)labeled RBC scintigraphy.
• Nuclear scintigraphy is a sensitive diagnostic tool (86%)and can detect hemorrhage at rates as low as 0.1mL/min, as opposed to angiography, which detectsbleeding at rates of 1-1.5 mL/min. This technique ismore sensitive than angiography, but it suffers from alow specificity compared with endoscopy orangiography due to its limited resolution.• Radionuclide scans frequently are performed beforeangiography, because the scans detect bleeding at a slowerrate than what can be detected with angiography, therebypotentially eliminating the need for an invasive procedure.
Advantages:Noninvasive.High sensitivity.Disadvantages:High false localization rate (3% to 59% ) ,this often is due to the overlapping segments of boweland the migration of tagged RBCs in the large bowel. Another disadvantage of radionuclide scans is that thescans must be performed during active bleeding.
Angiography• Performed after colonoscopy has failed to identify a bleeding site ,can detect bleeding at a rate of more than 0.5 mL/min.• In a patient with active GI bleeding, the radiologist first cannulates the superior mesenteric artery, because most of the hemodynamically significant bleeding originates in the right colon. The extravasation of contrast material indicates a positive study finding. If the findings from the study are negative, the inferior mesenteric artery is cannulated, followed by the celiac artery.
Once the bleeding point is identified,angiography offers potential treatment options,such as selective vasopressin drip and embolization.
The advantages of angiography include:1- Accurate localization of the bleeding;2- Therapeutic utility that includes the use of vasopressin infusion or embolization;3-Does not require preparation of the bowel.The disadvantages of angiography include:1- It has a sensitivity of approximately 30-47%;2- It can only be performed during active bleeding;3- It has a complication rate of about 9%. Such complications include thrombosis, embolization, and renal failure.
Barium EnemaJustified only for elective evaluation of unexplainedLGIB.Barium enema examination is not used in the acutehemorrhage phase, because it makes subsequentdiagnostic evaluations, including angiography andcolonoscopy impossible.
Abdominal Radiography /CT• Plain abdominal radiography and/or CT might be carried out, depending on the clinical presentation and suspected etiology (such as ischemic or inflammatory colitis, or in cases where bowel obstruction or perforation are suspected).
Histologic FindingsMost colonic diverticula are false pulsion diverticula andcomposed only of mucosa and submucosa herniatedthrough the colonic wall musculature.Colonic angiodysplasias are vascular ectasias commonlylocated on the right side of the colon. Microscopically,vascular ectasia consists of dilated thin-walled venulesand capillaries localized in the submucosa of the colonicwall.
• Resuscitation and initial assessment.• Localization of the bleeding site.• Therapeutic intervention to stop bleeding at the site.
1) Resuscitation and Initial Assessment:• IV access and administration of normal saline.• Rapid assessment of vital signs, including heart rate, blood pressure, pulse pressure, and urine output.• Routine laboratory studies (CBC, electrolyte levels, and coagulation studies), blood should be typed and cross-matched.• The patients blood loss and hemodynamic status should be evaluated, and in cases of severe bleeding, the patient may require invasive hemodynamic monitoring .
• Patients in shock should receive fluid volume replacement without delay.Colloid or crystalloid solutions may be used to achieve volume restoration before administering blood products. Red cell transfusion should be considered after loss of 30% of the circulating volume.
2) Localization of the Bleeding Site• In patients who are hemo-dynamically stable with mild to moderate bleeding or in patients who have had a massive bleed that has stabilized, colonoscopy should be performed initially. Once the bleeding site is localized, therapeutic options include coagulation and injection with vasoconstrictors or sclerosing agents.• In cases of diverticular bleeding, bipolar probe coagulation, epinephrine injection, and metallic clips may be used.• If recurrent bleeding is present, the affected bowel segment can be resected.• In cases of angiodysplasia, thermal therapy, such as electro- coagulation or argon plasma coagulation, is generally successful.
3) Therapeutic intervention to stop bleeding at the site. Colonoscopy• Colonoscopy is useful in radiation therapy–induced gastrointestinal (GI) bleeding and in the treatment of colonic polyp lesions.• Endoscopic treatment of radiation- induced bleeding includes topical application of formalin, Nd:YAG laser therapy, and argon plasma coagulation.• Neoplastic bleeding due to polyps requires polypectomy. Patients diagnosed with colonic tumors may require surgical resection.
Vasoconstrictive Therapy :• In patients in whom the bleeding site cannot be determined based on colonoscopy and in patients with active LGIB, angiography with or without a preceding radionuclide scan should be performed to locate the bleeding site as well as to intervene therapeutically.• Initially, Vasoconstrictive agents, such as vasopressin, epinephrine, propranolol can be used.• Vasoconstriction reduces the blood flow and facilitates plug formation in the bleeding vessel.• Although epinephrine and propranolol reduced mesenteric blood flow, they also caused a rebound increase in blood flow and recurrent bleeding.
• Vasopressin causes severe vasoconstriction in the splanchnic bed. Vasopressin infusions are more effective in diverticular bleeding, which is arterial, as opposed to angiodysplastic bleeding, which is of the venocapillary type.• Intra-arterial vasopressin infusions begin at a rate of 0.2 U/min, with repeat angiography performed after 20 minutes. The bleeding stops in about 91% of patients receiving intra- arterial vasopressin.• If bleeding persists, the rate of the infusion is increased to 0.4- 0.6 U/min. Once the bleeding is controlled, the infusion is continued in an intensive care setting for 12-48 hours and then tapered over the next 24 hours.
Superselective Embolization:• This therapeutic modality is useful in patients in whom vasopressin is unsuccessful or contraindicated.• Embolization involves superselective catheterization of the bleeding vessel to minimize necrosis.• Embolization with agents such as gelatin sponge, coil springs, polyvinyl alcohol, and oxidized cellulose.• It is performed using a 3 French (F) microcatheter placed coaxially through the diagnostic 5F catheter.• Once the bleeding vessel is identified, microcoils are used to occlude the bleeding vessel.• Although microcoils are most commonly used, polyvinyl alcohol and Gelfoam are also used alone or in conjunction with microcoils.
Complications:• Colonic infarction, bowel wall injury, Intestinal ischemia and infarction.• To prevent this complication, perform embolization as close as possible to the bleeding point in the terminal arteries.
Endoscopic Therapies:• Endoscopic control of hemorrhage is suitable for GI polyps and cancers, arteriovenous malformations, mucosal lesions, postpolypectomy hemorrhage, endometriosis, colonic and rectal varices.• It can be achieved using thermal modalities or sclerosing agents.• Absolute alcohol, morrhuate sodium, and sodium tetradecyl sulfate can be used for sclerotherapy of lower GI lesions.• Endoscopic epinephrine injection is used commonly because of its low cost, easy accessibility, and low risk of complications.
• Endoscopic thermal modalities (eg, laser photocoagulation, electrocoagulation) can also be used to arrest hemorrhage.• Postpolypectomy hemorrhage can be managed by electrocoagulation of the polypectomy site bleeding.• endoscopic coagulation of angiodysplasias is becoming a treatment of choice using either heated probe or lasers, such as Nd:YAG and argon.• Argon laser treatment is recommended for mucosal or superficial lesions, Nd:YAG lasers are more useful for deeper lesions.
Surgery• Emergent surgery is required in patients with (LGIB) if non operative management is unsuccessful.Indications of Surgery :• Persistent hemodynamic instability with active bleeding.• Persistent, recurrent bleeding.• Transfusion of more than 4 units packed red bloods cells in a 24-hour, with active or recurrent bleeding.• No contraindications exist with regard to surgery in hemodynamically unstable patients with active bleeding.
Segmental bowel resection and subtotal colectomy• Segmental bowel resection following precise localization of the bleeding point is a well-accepted surgical practice in hemodynamically stable patients.• Subtotal colectomy is the procedure of choice in patients who are actively bleeding from an unknown source.• Patients who are hemodynamically stable should have preoperative localization of the bleeding; once it is localized, intra-arterial vasopressin is used as a temporizing measure to reduce the bleeding before patients undergo segmental colectomy.• If the it is not localized, a subtotal colectomy with ileoproctostomy is performed.
Complications• The most common early postoperative complications are intra-abdominal bleeding, mechanical bowel obstruction, intra-abdominal sepsis, localized or generalized peritonitis, wound infection and/or dehiscence.• Intra-abdominal sepsis following colorectal surgery is a life-threatening complication and requires aggressive resuscitation.• Systemic conditions (eg, severe blood loss and shock, poor bowel preparation, diabetes, malnutrition, hypoalbuminemia) may adversely affect anastomotic healing.
• Changes in anatomy and physiology of the large bowel, high bacterial content, improper operative technique, and ischemia can cause anastomotic leak associated with abscess and intra-abdominal sepsis.• Delayed complications usually occur more than 1 week after surgery, the most common of which are anastomotic stricture, incisional hernia, and incontinence.