Lower GI bleed Lower GI BleedLower gastrointestinal bleeding is defined asabnormal hemorrhage into the lumen of the bowelfrom a source distal to the ligament ofTreitz.Originates in the portion of GIT further down thedigestive system –small intestine--colon--rectum--anus
more common in male > female.This increase is largely attributable to thevarious colonic disorders commonly associatedwith aging (e.g., diverticulosis andangiodysplasia).In more than 95% of patients with lower GI bleeding,the source of hemorrhage is the colon.
Categorization by pathologyand intensityBy intensity – occult where the amount of blood isso small that it can only be detected bylaboratory testing . Acute mild Acute massive .By pathologyBenign Inflammatry Neoplastic
History We should assess the chronicity of bleeding andmedication use . Particularly regarding anti coagulants such aswarfarin. low molecular weight heparin. inhibitors of platelet aggregation such as NSAID . clopidrogel this can associated with mesentricischemia Use of digitalis should be documented because thiscan associated with mesenteric ischemia.
Causes of Lower GastrointestinalBleeding:Severe acute Moderate,chronic/subacuteDiverticular disease Anal disease(fissure,haemorrhoids)angiodysplasia Inflammatory bowel diseaseischemia carcinomaMeckel’s diverticulum Large polypsangiodysplasiaRadiation enteritisSolitary rectal ulcer
Other Causes of SevereHematochezia1. Diverticulosis2. Colon cancer or polyps3. Colitis4. Ischemic colitis5. Inflammatory bowel disease (IBD)6. Non-infectious colitis7. Infectious colitis8. Angioectasia9. Postpolypectomy bleeding10. Rectal ulcer11. Hemorrhoids12. Anorectal source (unspecified)13. Radiation colitis14. Rectal Dieulafoy’s lesions.15. Rectal varices.
symptoms bloody bowel movements, or black, tarry stools.Symptoms associated with blood loss can include : FatigueWeakness Shortness of breath Abdominal pain Pale appearance Bright red or maroon stool can be from either a lower GIsource or from brisk bleeding from an upper GI source. Long-termGI bleeding may go unnoticed or may causefatigue, anemia, black stools, or a positive test formicroscopic blood.
diagnosis Lower GI bleeding typically presents with1.hematochezia(which can range from bright-red blood to old clots.) 2.melena (If the bleeding is slower or from amore proximal source) Hemorrhage less severemore intermittent,commonly ceases spontaneously
The diagnostic modalities for lower GI bleeding are not assensitive or specific in making an accurate diagnosis. . After resuscitation has been initiated, the first step in theworkup is to rule out anorectal bleeding is either by ; Anoscopy. Flexible sigmoidoscopy. nuclear scintigraphy. Angiography. CT and computed tomography colonography. Colonoscopy. Barium enema. MRI Intraoperative endoscope
With significant bleeding, it is also importantto eliminate an upper GI source. An NG aspirate that contains bile and noblood effectively rules out upper tractbleeding in most patients.
colonoscopy Colonoscopy is most appropriate in thesetting of minimal to moderate bleeding;major hemorrhage interferes significantlywith visualization, and the diagnostic yieldis low. in the unstable patient, sedation andmanipulation may be associated withadditional complications and can interferewith resuscitation.
Although the blood is cathartic, gentlepreparation with polyethylene glycol, eitherorally or through an NG tube, can improvevisualization. Findings may include an actively bleeding site,clot adherent to a focus of mucosa or adiverticular orifice, or blood localized to aspecific colonic segment, although this can bemisleading because of retrograde peristalsis inthe colon. Polyps, cancers, and inflammatorycauses can frequently be seen
angiodysplasias are often very difficult tovisualize, particularly in the unstable patientwith mesenteric vascular constriction. Diverticula are identified in most patients,whether they are the source of thehemorrhage or not. Despite these limitations, recent studiesreport that colonoscopy is successful inidentifying the bleeding source in up to 95% ofpatients
Radionuclide Scanning These are helpful in identifying the sites ofongoing bleeding . The scan are more sensitive thanangiogram in detecting less rapid bleedingrate .1-.5 ml / min . Radionuclide scanning with technetium-99m (99mTc)-labeled RBCs is the mostsensitive .
It have a advantage of repeating the scan upto 24 hrs . After initial scan . This is particularly helpful in in those pt whosehave a slow bleeding in whom initial scan maynot demonstrate any source of bleeding . Initially, images are collected frequently andthen at 4 hour intervals for up to 24 hours. The tagged RBC scan can detect bleeding asslow as 0.1 mL/min and is reported to be morethan 90% sensitive.
Other diagnostics proceduresCT angiogram mesenteric angiography-to identifying the vascular patterns ofangiodysplasia,-localizing actively bleeding diverticula
Advantages and disadvantages of common diagnostic procedures used in the evaluation of lowergastrointestinal bleedingProcedure Advantages DisadvantagesColonoscopy • Therapeutic possibilities • Bowel preparation required• Diagnostic for all sources ofbleeding• Can be difficult to orchestrate without on -call endoscopy facilities or staff• Needed to confirm diagnosis inmost patients regardless of initialtesting• Invasive• Efficient/cost -effectiveAngiography • No bowel preparation needed • Requires active bleeding at the time of theexam• Therapeutic possibilities • Less sensitive to venous bleeding• May be superior for patients withsevere bleeding• Diagnosis must be confirmed withendoscopy/surgery• Serious complications are possibleRadionuclidescintigraphy• Noninvasive • Variable accuracy (false positives)• Sensitive to low rates of bleeding • Not therapeutic• No bowel preparation • May delay therapeutic intervention• Easily repeated if bleeding recurs • Diagnosis must be confirmed withendoscopy/surgeryFlexiblesigmoidoscopy• Diagnostic and therapeutic • Visualizes only the left colon• Minimal bowel preparation • Colonoscopy or other test usuallynecessary to rule out right -sided lesions• Easy to perform
Video Capsule Endoscopy Capsule endoscopy uses a small capsule with avideo camera that is swallowed and acquiresvideo images as it passes through the GI tract. This modality permits visualization of theentire GI tract, but offers no interventionalcapability. It is also very time consuming becausesomeone has to watch the video to identifythe bleeding source, and then a means to dealwith the pathology has to be developed.
Intraoperative Endoscopy Intraoperative enteroscopy is reserved forpatients who have transfusion-dependentobscure-overt bleeding in whom anexhaustive search has failed to identify ableeding source. This typically uses a pediatric colonoscopeintroduced through the mouth or throughan enterotomy in the small bowel made bythe surgeon.
1- Diverticular Diseasethe most common cause of significant lower GI bleeding.common in Western countries with frequency of 50% in olderadults. By contrast, diverticula are found in fewer than 1% ofcontinental African and Asian populations. colonic diverticula are herniations of colonic mucosa andsubmucosa through the muscular layers of the colon.Bleeding generally occurs at the neck of the diverticulum .believed to be secondary to bleeding from the vasarecti(small arteries) as they penetrate through the submucosa.Of those that bleed, more than 75% stop spontaneously,although about 10% rebleed within 1 year and almost 50%within 10 years
Diverticular hemorrhage should be classified carefully based onfindings at colonoscopy, angiography, anoscopy, terminalileum examination, push enteroscopy (when colonoscopyreveals diverticulosis without stigmata and no other significantlesions seen in colon and by anoscopy)Management: blood transfusion of fewer than four units of packed RBCs. Endoscopic Hemostasis - colonoscopic hemostasis ofactively bleeding diverticula has been reported using MPECcauterization, epinephrine injection(a sclerotherapy needle canbe used to inject epinephrine diluted 1:20,000 in saline),hemoclips, fibrin glue, or combinations of epinephrine andMPEC or hemoclips. Electrocautery can also be used, and most recently,endoscopic clips have been successfully applied to control thehemorrhage.
Hemostatic clip application in bleeding diverticulosis
If none of these maneuvers is successful or ifhemorrhage recurs—>Angiography and surgery – angiographyembolization can be performed in selected cases ofdiverticular bleeding, but with a risk of bowelinfarction, contrast reactions, and acute kidneyinjury.Surgical resection for diverticular bleeding israrely needed and is reserved for recurrent bleeding.The decision to operate is best guided bycolonoscopic, angiographic, or nuclear medicinestudies.Blind subtotal colectomy, often performed in thepast when a definite bleeding site could not beidentified, should be avoided as possible.
2- Angiodysplasia/VascularEctasias Hemorrhage secondary to angiodysplasiaaccounts for up to 40% of lower GI bleeding.Angiodysplasias of the intestine, also referred toas arteriovenous malformations (AVMs), aredistinct from hemangiomas and true congenitalAVMs.. They are thought to be acquired degenerativelesions secondary to progressive dilation ofnormal blood vessels within the submucosa ofthe intestine.
The hemorrhage tends to arise from the rightside of the colon,-the most common location=cecum- it can occur anywhere in the colorectum andsmall bowel. Most patients present with- chronic bleeding; in up to 15% of patients-hemorrhage may be massive.-Bleeding stops spontaneously in most cases
diagnosed by = colonoscopy=visceral angiography.=laparotomy with on tablecolonoscopytreatment of choice : endoscopic thermalablationIf these measures fail or bleeding recurs andthe lesion has been localized, segmentalresectionmost commonly right colectomy, is effective.
3- Colorectal cancer Colorectal cancer3rd commonest malignancy in UK M:F = 3:1 peak age 45-70yo Risk Factor’s: FH of Colorectal Ca, FAP, HNPCC, Prev Hx of Colon,Breast, Ovarian or Uterine Ca Prev Hx ofAdenomatous Polyps Chronic UC or Colonic Crohn’s disease Western diet, Obesity, Smoking Presentation depends on site: Left-sided:Altered bowel habit (constipation & diarrhoea), PR bleeding bright red coatingthe stool,Tenesmus, Painful defecation? Small diameter of Left Colon Tendency towardsobstruction Right-sided: Present later. Weight loss, Right abdo pain/mass,Tendency to bleed, Bloodmixed in with stools, high incidence of IDA Emergency (40%): Obstruction, Perforation w/Peritonitis, Acute Haemorrhage
Investigations: FBC Microcytic hypochromic anaemia, LFTs deranged with hepatic spread + Faecal occult blood Sigmoidoscopy/Colonoscopy + biopsy Lesion (w/ 3-5% synchronous) Barium Enema may show ‘Apple core’ appearance CT/MRI for rectal cancers, local pelvic spread and metastasis Liver US Hepatic Mets Raised Carcino-embryonic antigen (CEA) used for monitoring
Treatment: Surgical Resection with curative intent+/- Chemo Right Hemicolectomy Caecal, Ascending,Proximal Transverse Ca Left Hemicolectomy Distal Transverse,Descending Sigmoidectomy Sigmoid Ca Anterior Resection Low sigmoid/High Rectal Ca Abdominoperineal (A-P) Resection Low RectalTumours <8cm from Anal canal permanentcolostomy **Hartmann’s Carcinoma w/ Acute Obstruction(excision, colostomy, rectal stump) Other options: Chemotherapy (5-FU) for Duke’sB&C, RT, Palliation
4- Anorectal Disease The major causes of anorectal bleeding :1.hemorrhoids,2.anal fissures,3. colorectal neoplasia. hemorrhoids: the most common: only 5% to 10% bleeding.Anorectal hemorrhage is not massive andpresents as bright-red blood per rectum
Hemorrhoidal bleeding Anal fissure1. Bright red2.Occur : during/after defecation1.Bright red bleeding2.occur: during defecation + anal pain3.Diagnose by : protoscopy4.colonoscopy/barium enema-to exclude coexisting colorectalcancer3.May reqiure surgery(due to forceful straining during passageof hard stool may cause tears)5. age:over 40 years 4.Medically ttt: stool bulking agents: water intake: stool softners: topical nitroglycerinointment/ diltiazem
5- Colitis Inflammation of the colon is caused by a multitude of diseaseprocesses. inflammatory bowel disease (Crohns disease, ulcerative colitis) Infectious colitis . Ischemic colitis ;present as painless hematochezia (results from mucosal hypoxia andis thought to be caused by hypoperfusion of the intramural vessels ofthe intestinal wall) or painful hematochezia (caused by large vesselocclusion and has worse outcomes) with mild left-sided abdominaldiscomfort. Radiation proctitis after treatment for pelvic malignancies, andischemia.
Ulcerative colitis1. much more likely than Crohns disease topresent with GI bleeding.2. A mucosal disease3.starts distally in the rectum4. progresses proximally5.occasionally involve the entire colon. Patients can present with up to 20 bloodybowel movements per day. These episodes are accompanied byabdominal cramping, tenesmus, andoccasionally abdominal pain
Ulcerative colitis6.The diagnosis -careful history-flexible lower endoscopewith biopsy. 7. Medical therapy: steroids,:5-aminosalicylic acid:(ASA) compounds,:Immunomodulatoryagents,:supportive care 8.Surgical therapy -is rarely indicated(unless the patient develops a toxic megacolon orhemorrhage that is refractory to medicalmanagement.)
6- Mesenteric Ischemia Mesenteric ischemia can be secondary to either acute orchronic arterial or venous insufficiency. Predisposing factors -preexisting cardiovascular disease- recent abdominal vascular surgery-hypercoagulable states,- medications(vasopressors and digoxin),-vasculitis Patients present with abdominal pain and bloodydiarrhea. CT scanning often shows a thickened bowel wall.
The diagnosis: flexible endoscopywhich reveals edema, hemorrhage, and ademarcation between the normal and abnormalmucosa. Treatment :focuses on supportive care:bowel rest,:intravenous antibiotics,:cardiovascular support, and: correction of the low-flow state. In 85% of cases, the ischemia is self-limited andresolves without incident, although somepatients develop a colonic stricture.
15% of casessurgery is indicatedbecause of- progressive ischemia-gangrene.During the surgery -resection of the ischemicintestine and-creation of an end ostomy isindicated.
7- Meckels diverticulum Bleeding of the diverticulum is most commonin young children, especially in males who areless than 2 years of age Symptoms : bright red blood in stools(hematochezia), weakness,abdominal tenderness or pain, andeven anaemia in some cases
Diagnosis :- A technetium-99m (99mTc) pertechnetate scan,also called Meckel scan investigation of choice inchildren. Colonoscopy and screenings for bleedingdisorder. Angiography can assist in determining thelocation and severity of bleeding- Capsule endoscopy and double-balloonenteroscopy(via an oral or rectal approach). Treatment:Treatment is surgical, which is small bowel resection(with bowel complication) and simple resection(without complication).
8- Postpolypectomy bleeding Bleeding recurs after approximately 1% of colonoscopicpolypectomies.The bleeding occurs most commonly five toseven days after polypectomy but can occur from 1 to 14days after procedure; it generally self-limited and mild to moderate, with 50% to75% of patients requiring blood transfusions. Endoscopic management techniques:- for delayed postpolypectomy ulcer bleeding on the stigmaare found and similar to those used for peptic ulcerhemorrhage,- including : epinephrine injection, thermal coagulation,hemoclip placement, and combination therapy.
9- Dieulafoy’s lesion of thesmall intestine and rectum Uncommon causes of major gastrointestinal lesion It consists of a large caliber artery that protrudes through amucosal defect in the stomach causing significant and oftenrecurrent hemorrhaging from a pinpoint non-ulcerated arteriallesion. Rectal Dieulafoy’s lesions are large submucosal arteries withoverlying mucosal ulceration that cause massive bleeding. Andit can be treated by endoscopic hemostasis. history of NSAID intake, peptic ulcer symptoms, or alcoholabuse is usually absent, the condition is difficult to recognize. Dieulafoy lesion should be considered when evaluating anyacute and recurrent major gastrointestinal bleeding. If unrecognized, it may cause a life-threatening hemorrhage.Usually, the mean hemoglobin level on admission has beenreported to be between 8.4-9.2 g/dL in various studies.
Diagnosis:Awareness of the condition is a key to accurate diagnosis.It can be easily overlooked at endoscopy as concomitant lesionssuch as ulcers or varices may wrongly be considered responsiblefor the bleeding episode.Treatment:-by endoscopic modalities like electrocoagulation and successfullyachieves permanent hemostasis in 85% of cases.This case illustrates a rare and inherently difficult lesion torecognize, because it presents with very low hemoglobin, whichis usually uncommon in Dieulafoy lesion, and did not have anyrisk factor for gastrointestinal bleeding.In practice, we have to consider unusual causes of common diseasesto decrease their mortality and morbidity.-argon plasma coagulation.-Bipolar coagulation.-hemoclip placement.-proton pump inhibitor therapy.
Actively bleeding jejunal Dieulafoy lesionfound during double-balloon enteroscopy.Red blood pooled within a short segment ofjejunum (A).The area after water lavage,revealing a focal area of active bleeding and avery small protruding vascular structure (theDieulafoy vessel) (B). Another example offocal active bleeding from a Dieulafoy lesion,seen near the bottom of the endoscopicimage (C).Non-steroidal anti-inflammatory drug-induced jejunal ulcer (A) with a smallvisible vessel (on left side of ulcer, atapproximately 8 oclock position).Thevisible vessel began bleedingspontaneously during double-balloonenteroscopy (B). Hemostasis wasachieved with epinephrine injection andhemoclips placement (C).
10- Blue Rubber Bleb NevusSyndrome It is a rare syndrome characterized by venousmalformations in the skin, soft tissue, and GI tract. Bleeding usually occurs in childhood and continuesinto adulthood and results in chronic iron deficiencyrequiring iron replacement and transfusions. Diagnosis: On endoscopy , lesions appear as largeprotuberant polypoid venous bleb; they can occuranywhere in the GIT, but especially in the smallbowel and colon, Treatment: Endoscopic band ligation or surgicalresection.
Blue Rubber Bleb NevusSyndromeIntra-operative enteroscopy. Bluerubber bleb nevus of the distal jejunumVascular malformationtypically seen in bluerubber bleb nevussyndrome.Characteristic endoscopicappearancesof smallintestinalvenousmalformation in a patientwith bluerubber blebnevussyndrome(A, B).
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