Dr Anshuman Aashu
1st year PGT,
Department of General Surgery,
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.
Incidence increases with age of the patient.
Most of the time bleeding is intermittent with
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
ACUTE LOWER GI BLEEDING
Acute lower GI bleeding should be treated as any other
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
The ABC of initial emergency management followed
Adequacy of airway and breathing is assessed and
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
Risk factors for morbidity and mortality on Acute GI
Comorbid diseases – Renal, liver, respiratory, cardiac.
Magnitude of hemorrhage
Persistent or recurrent hemorrhage
Onset of hemorrhage during hospitalisation
Need for Surgery.
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.
More severe the bleeding, more aggressive the
Single leading cause of morbidity and mortality is
multiorgan failure related to inadequate initial or
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
Hematocrit >30 in older adults and >20 in young.
Clinical presentation, history and physical
Urgent NG aspiration and proctoscopic examination to
rule out Upper GI bleeding and identify ano-rectal
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.
Most appropriate in the setting of minimal to
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%
Beneficial as has got therapeutic role as well.
May identify diverticula, angiodysplasia, colitis or
neoplastic lesions as source of bleeding.
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%
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
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
Major advantage being the therapeutic potential.
Local injection of vasopressin or other
vasoconstrictors, or embolization that may be
temporary (gelfoam) or permanent (coils).
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
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
Unstable patients require an end ileostomy with closure
of the rectal stump or a mucous fistula
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
In upto 75% of cases bleeding stops spontaneously
with upto 10% risk of rebleeding within 5 years.
Best method of diagnosis and treatment is
Endoscopic injection of
clips successfully employed.
Failure of these maneuvres
lead to consideration of
(success rate >90%)
Failure of all these techniques
warrant surgical treatment in
the form of segmental
resection (if source defined) or
subtotal colectomy (source
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
On colonoscopy, seen as red
stellate lesion with
surrounding pale mucosa.
In unstable patients with
visualisation in colonosopy is
Managed usually with
endosopic and angiographic
Surgery reserved for cases
that don’t respond or rebleed.
Segmental resection is
Colorectal carcinoma is the most important cause to
Bleeding is usually painless, intermittent and slow in
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.
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.
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
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.
Predisposing factors include pre-existing
cardiovascular disease, recent abdominal vascular
surgery, hypercoagulable states and vascuiltis.
Acute colonic ischemia is the most common type of
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.
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
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
Crohn’s disease, Meckel’s diverticulum, small bowel
erosions or NSAIDs use and radiation exposure are the
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.
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