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Lower Gastro-Intestinal Bleed


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  • 1. Dr Anshuman Aashu 1st year PGT, Department of General Surgery, IPGME&R
  • 2. INTRODUCTION  Bleeding distal to the ligament of Treitz.  One of the most common symptoms to be encountered in the out patients department.  About 20% as common as the upper GI bleeding.  Most often the colon is involved. Small intestine involved in only 5% of cases.  Male predominance.  Incidence increases with age of the patient.
  • 3.  Most of the time bleeding is intermittent with spontaneous stoppage.  Upto 42% of cases have multiple bleeding sites.  Presentation ranges from intermittent mild bleeding to severe hemorrhage with hemodynamic instability.  Hematochezia (passage of bright red blood from retum that may or may not be mixed with stool) is more common presentation.  Melena (passage of black tarry sticky stool) may appear with lower GI bleeding when source is higher up or the intestinal transit time is fairly slow.  Massive upper GI bleeding may present as bleeding P/R.
  • 5.  Diverticular diseases,  Benign anorectal diseases,  Fissure in ano,  Hemorrhoids,  Neoplasia,  Ischemia,  Colitis,  Inflammatory bowel diseases,  Infectious colitis,  Radiation exposure,  Angiodysplasia,  Meckel’s diverticulum,  Aortoenteric Fistula.  Other systemic causes like coagulopathy.
  • 6. ACUTE LOWER GI BLEEDING  Acute lower GI bleeding should be treated as any other surgical emergency.  Fundamental principles of initial evaluation and management must be followed.  Initial management in acute lower GI bleed is the same as acute upper GI bleed with similar approach for initial assessment, risk stratification, resuscitation and localization.
  • 7. INITIAL ASSESSMENT  The ABC of initial emergency management followed here also.  Adequacy of airway and breathing is assessed and assured.  Assessment of hemodynamic status:  Obtundation, agitation, hypotension (supine SBP<90) with cold clammy peripheries – Hemorrhagic shock (>40% of blood volume loss)  Resting heart rate >100, decreased pulse pressure – loss of 20-40% of blood volume.  Fall in BP >10 mm of Hg or elevation of heart rate >20 beats with postural changes – at least 20% blood volume lost.
  • 8. RISK STARTIFICATION  Risk factors for morbidity and mortality on Acute GI Hemorrhage:  Age>60 years  Comorbid diseases – Renal, liver, respiratory, cardiac.  Magnitude of hemorrhage  Persistent or recurrent hemorrhage  Onset of hemorrhage during hospitalisation  Need for Surgery.
  • 9.  BLEED: a classification tool to predict outcome  B: continuous Bleeding.  L: Low blood pressure (SBP<100).  E: Elevated prothrombin time (>1.2 times the control).  E: Erratic mental status.  D: comorbid Diseases.  Presence of any one of them indicates high-risk and increased incidence of inhospital complications.
  • 10. RESUSCITATION  More severe the bleeding, more aggressive the resuscitation.  Single leading cause of morbidity and mortality is multiorgan failure related to inadequate initial or subsequent resuscitation.  Initial resuscitaion should be done with bolus crystalloid solution, usually RL.  Supplemental oxygen, monitoring of urine output.  Assessment of the response to fluid administration.  Administration of blood depends upon the initial effects of crystalloid infusion and patient’s ongoing hemodynamic parameters.  Hematocrit >30 in older adults and >20 in young.
  • 11. LOCALIZATION  Clinical presentation, history and physical examination.  Urgent NG aspiration and proctoscopic examination to rule out Upper GI bleeding and identify ano-rectal causes resepectively.  Unstable patients shifted to operating room and managed accordingly with serial clamping or intraoperative enteroscopy and guided resection.  In stable patients, colonoscopy, tagged RBC scan or angiography useful for localization.  Capsule endoscopy, double balloon endoscopy helpful in obscure bleeding.
  • 12. COLONOSCOPY  Most appropriate in the setting of minimal to moderate bleeding.  Urgent colonoscopy in major bleeding is usually less revealing as bleeding itself obscures vision.  Gentle preparation of the bowel is helpful.  Helpful in identifying source of bleeding in upto 95% cases.  Beneficial as has got therapeutic role as well.  May identify diverticula, angiodysplasia, colitis or neoplastic lesions as source of bleeding.
  • 13. RADIONUCLIDE SCANNING  Technitium-99m labeled RBCs.  Most sensitive but least accurate.  Patients own red cells are labeled and reinjected.  Can detect bleeding as slow as 0.1 ml/min and is >90% sensitive.  Reported acuracy is 40-60%.  Not useful as definitive study before surgery but useful as guide to the usefulness of angiography.  Negative RBC scan indicates that angiography will be unrevealing.
  • 14. MESENTRIC ANGIOGRAPHY  Used for diagnosis of ongoing hemorrhage.  Can detect hemorrhage in the range of 0.5-1.0 ml/min.  Less sensitive but more accurate than RBC scan.  Particularly useful in diagnosing AVMs such as angiodysplasia.  Major advantage being the therapeutic potential.  Local injection of vasopressin or other vasoconstrictors, or embolization that may be temporary (gelfoam) or permanent (coils).
  • 15. TREATMENT  Pharmacologic,  Endoscopic,  Angiographic,  Surgical:  Hemodynamic instability despite vigourous resuscitation (>6U transfusion).  Failure of endoscopic techniques.  Recurrent Hemorrhage (with upto 2 attempts at obtaining endoscopic hemostasis.  Shock.  Continued slow bleeding with tenasfusion requirement >3U/day.
  • 16. SURGICAL THERAPY  First objective in surgery focuses on the location of the intraluminal blood with the goal of segmentally isolating the possible sources of bleeding.  If no source appears obvious, may consider intestinal enteroscopy.  If the source of bleeding cannot be found, and it appears to arise from the colon, the surgeon should perform a subtotal or total colectomy  Stable patients will tolerate a primary ileosigmoid or ileorectal anastomosis  Unstable patients require an end ileostomy with closure of the rectal stump or a mucous fistula
  • 17. DIVERTICULAR CAUSES  Outpuching of the mucosa and submucosa through defects in the muscular layer of the bowel at sites of penetration of the vasa recta.  Sigmoid colon most common site.  Most significant cause of significant lower GI bleeding in the western world, upto 55%.  Bleeding generally occurs at the neck of the diverticulum.  In upto 75% of cases bleeding stops spontaneously with upto 10% risk of rebleeding within 5 years.  Best method of diagnosis and treatment is colonoscopy.
  • 18.  Endoscopic injection of epinehrine, electrocoagulation, endoscopic clips successfully employed.  Failure of these maneuvres lead to consideration of angiographic embolization. (success rate >90%)  Failure of all these techniques warrant surgical treatment in the form of segmental resection (if source defined) or subtotal colectomy (source unidentified).
  • 19. ANGIODYSPLASIA  Arterio-venous malformation (AVM) of the GI tract.  Cecum is the most common site.  Unlike hemangiomas and other true congenital AVMs, these are acquired degenerative lesions secondary to progressive dilation of normal blood vessels within the submucosa of the intestine.  Presentation with chronic bleeding more common but may present as acute severe bleeding.  Can be diagnosed by either colonoscopy or angiography.
  • 20.  On colonoscopy, seen as red stellate lesion with surrounding pale mucosa.  In unstable patients with mesentric casoconstriction, visualisation in colonosopy is particularly difficult.  Managed usually with endosopic and angiographic techniques.  Surgery reserved for cases that don’t respond or rebleed. Segmental resection is sufficient.
  • 21. NEOPLASIA  Colorectal carcinoma is the most important cause to rule out.  Bleeding is usually painless, intermittent and slow in nature.  Benign polyps are unusual causes of lower GI bleeding in elderly but Juvenile polyp is the 2nd most common cause in patients <20 years of age.  Diagnosed by colonoscopy and treated accodingly after proper staging and workup.
  • 22. HEMORRHOIDS  One of the most common causes of bleeding p/r in our part of the world.  Usually low volume, fresh bleeding seen in toilet as splash in the pan or on toilet papers.  Unless complicated, are usually painless.  Patients often present with iron deficiency anemia.  Managed conservatively with dietary modifications.  Minimally invasive techniques like sclerotheraphy, infrared coagulation, band ligation etc may be used.  Surgical treatment is hemorrhoidectomy or stapled hemorrhoidopexy for unresponsive cases.
  • 23. FISSURE IN ANO  Presents with painful defecation with streak of fresh blood over the stool.  Usually associated with constipation.  Canoe shaped ulcer seen, most commonly, in posterior midline at anal verge.  Bleeding is seldom massive.  Dietary modification with bulk forming agents and stool softeners often used.  Topical muscle relaxant ointment relieves sphincteric spasm and helps in ulcer healing.  Lateral sphincterotomy is the surgical option in unresolving cases.
  • 24. INFLAMMATORY BOWEL DISEASES  IBD is a common cause of lower GI bleed with UC involved more often than CD.  Crampy abdominal pain, tenesmus with sometimes over 20 episodes of bloody diarrhea in a day.  Diagnosis is usually done with colonoscopy and guided biopsy from the lesion.  Medical management with steroids, 5-ASA and immunomodulators are quite effective.  Surgery indicated in acute cases with toxic megacolon or hemorrhage refractory to medical management.
  • 25. MESENTERIC ISCHEMIA  Predisposing factors include pre-existing cardiovascular disease, recent abdominal vascular surgery, hypercoagulable states and vascuiltis.  Acute colonic ischemia is the most common type of mesenteric ischemia.  Tends to occur in watershed areas of splenic flexure and recto-sigmoid junction.  Patient presents as pain with bloody diarrhea.  Diagnosis confirmed by flexible endoscopy.  Treatment consists of supportive therapy with bowel rest, IV antibiotics, cardiovascular support.  Features of peritonitis indicate surgical management.
  • 26. OBSCURE GI BLEEDING  Bleeding that persists or recurs after an initial negative evaluation with an EGD and colonoscopy.  Further subdivided into obscured-occult or overt bleeding.  Occult bleeding presents with iron deficiency anemia and guaiac positive stool without visible bleeding.  Often treated with iron supplementation only.  Obscured-overt bleeding is usually due to small intestinal lesions.
  • 27.  Crohn’s disease, Meckel’s diverticulum, small bowel erosions or NSAIDs use and radiation exposure are the common causes.  Very frustrating for both the physician and the patient as the cause is most often not identified.  Repeat endoscopy is are helpful in identifying missed lesion in upto 35% patients.  Small bowel enteroclysis was a commonly used diagnostic technique that is now rarely used as yield was too low and test is poorly tolerated.  Video capsule endoscopy and small bowel endoscopy with pediatric colonoscope (push endoscope) or double balloon endoscopy are useful techniques of localisation of bleeding.
  • 28.  Intraoperative endoscopy is useful in those patients in whom exhaustive search has failed to identify a source.  Endoscope is usually introduced through an enterotomy in the small bowel.  Upto 25% cases remain undiagnosed and 33-50% of patients have rebleeding within 3-5 years.  Management strategy is planned as and according to the cause identified.  Long term iron supplementation with intermittent blood transfusion is occasionally necessary in undiagnosed cases, though this approach is not appealing.