Lower gi bleed neo

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Lower gi bleed

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Lower gi bleed neo

  1. 1. Lower GI bleed Dr nawin kumar
  2. 2. • as any bleed that occurs distal to the ligament of Treitz and superior to the anus • 20-33% of episodes of gastrointestinal (GI) hemorrhage – 85% from colon – 10% from UGI – 5% from SB • The mortality rate for LGIB is between 2–4%
  3. 3. • marginal artery of Drummond - Connects the inferior mesenteric artery (IMA) with the superior mesenteric artery (SMA) • The Arc of Riolan (Riolan's arcade, Haller's anastomosis or'meandering mesenteric artery) -connect the proximal middle colic artery with a branch of the left colic artery. This artery is found low in the mesentery, near the root. It is a poor anastomosis.
  4. 4. Aetiology angiodysplasia carcinoma Meckel’s diverticulum intussusception enteritis Crohn’s disease carcinoma proctitis colitis carcinoma polyps Diverticular disease solitary ulcer haemorrhoids fissure carcinoma warts Perianal Crohn’s disease
  5. 5. Rule out- Coagulopathy 1. SB 2. Colon 3. Benign anorectal DANI
  6. 6. Gastrointestinal Hemorrhage % SMALL BOWEL BLEEDING (5%) 0-40 Angiodysplasias -10 Erosions or ulcers (potassium, NSAIDs) -15 Crohn's disease -10 Radiation -8 Meckel's diverticulum -7 Neoplasia -4 Aortoenteric fistula -3
  7. 7. • infectious colitis – E. coli O157:H7 – Shigella – Salmonella – Campylobacter jejuni • Pseudomembranous colitis DANI
  8. 8. • Rectal polyps • Haemorrhoids • Anal fissures • Anal fistulas • Proctitis • Gonorrheal or mycoplasmal infections • Rectal trauma • Foreign objects BENIGN ANORECTAL CAUSES
  9. 9. Lower Gastrointestinal Bleeding in Children and Adolescents • Intussusception • Polyps and polyposis syndromes  Juvenile polyps and polyposis  Peutz-Jeghers syndrome  Familial adenomatous polyposis (FAP) • Inflammatory  Crohn disease  Ulcerative colitis  Indeterminate colitis • Meckel diverticulum
  10. 10. Clinical Approach • History • Physical Examination • Investigation • Diagnosis • Management
  11. 11. History • Presenting complaint(s) • History of presenting illness • Systemic review • Past medical and surgical history • Medication history (iatrogenic factors) • Family history • Social history
  12. 12. Information about bleeding • Volume and frequency (amount)of bleeding • Colour of blood? • Relationship of bleeding to defecation? [before, during (mixed into faeces or coating surface?) or after] • Associatiated symptoms eg, Painful defecation?, abdominal pain?
  13. 13. amount • trivial hematochezia to massive hemorrhage with shock.
  14. 14. BLEEDING FRANK OCCULT ANAEMIA SMALL BLEED MASSIVE BLEED (rare)
  15. 15. 3 groups
  16. 16. Stools may appear red in some patients after ingestion of beers
  17. 17. Colour- indicate the site • occult, microscopic bleeding • Black tarry -melena - usually indicates blood that has been in the GI tract for at least 8 hours. likely to come UGI • Maroon color suggests rt. Sided lesion • Bright red stool- called hematochezia- sign of a fast moving active GI bleed
  18. 18. Relationship of bleeding to defecation? • minor blood on toilet paper • streaks of bright red blood • Blood mixed stools • Slash in pan • Mixed with mucus
  19. 19. Associated symptoms • Bloody diarrhoea: – acute inflammation of the colon; amoebic colitis; ulcerative colitis; ischaemic colitis; rectal and colonic carcinoma; shigellosis
  20. 20. •Abdominal pain? –Carcinoma of the colon; ischaemic colitis (in elderly(; ulcerative colitis; amoebic colitis •No abdominal pain? –Painless bleeding from colonic diverticula, colonic angiodysplastic lesion; malignant lesion arising in the rectal ampulla
  21. 21. • anal pain? – External haemorrhoids; anal fissure, anal ulcer
  22. 22. • Fever? – Infectious colitis (amoebiasis, shigellosis); ulcerative colitis
  23. 23. • Vomiting of blood – Bleeding above ligament of Treitz
  24. 24. •A change in your bowel habits? •A change in the caliber of the stools? • colo-rectal Carcinoma
  25. 25. • Hypovolaemia – due to haemorrhage (e.g. pallor, dizziness hypotension, tachycardia, angina, syncope, weakness, confusion, stroke, myocardial infarction/heart attack, and shock)
  26. 26. • Nonspecific complaints • may include dyspnoea, abdominal pain, chest pain, fatigue
  27. 27. • past medical history – constipation or diarrhea- (hemorrhoids, colitis), – the presence of diverticulosis (diverticular bleeding), – receipt of radiation therapy (radiation enteritis), – recent polypectomy (postpolypectomy bleeding), and – vascular disease/hypotension (ischemic colitis). – anticoagulant – A family history of colon cancer - colorectal neoplasm
  28. 28. Investigations &Management • Resuscitation for major bleeds • Find site • Treat the cause
  29. 29. Initial steps in the management of upper gastrointestinal bleeding Airway protection Airway monitoring Endotracheal intubation (if indicated) Hemodynamic stabilization Large bore intravenous access Intravenous fluids Red cell transfusion (for symptomatic anemia) Fresh-frozen plasma, platelets (if indicated) Consider erythropoeitin Nasogastric oral administration Large bore orogastric tube/lavage Clinical and laboratory monitoring Serial vital signs Serial hemograms, coagulation profiles, and chemistries (as clinically indicated) Electrocardiographic monitoring Hemodynamic monitoring (if indicated in high-risk patients) Endoscopic examination and therapy
  30. 30. localization
  31. 31. Colour- indicate the site • occult, microscopic bleeding • Black tarry -melena - usually indicates blood that has been in the GI tract for at least 8 hours. likely to come UGI • Maroon color suggests rt. Sided lesion • Bright red stool- called hematochezia- sign of a fast moving active GI bleed
  32. 32. LOCALIZATION • past medical history – constipation or diarrhea- (hemorrhoids, colitis), – the presence of diverticulosis (diverticular bleeding), – receipt of radiation therapy (radiation enteritis), – recent polypectomy (postpolypectomy bleeding), and – vascular disease/hypotension (ischemic colitis). – anticoagulant – A family history of colon cancer - colorectal neoplasm
  33. 33. localization nasogastric tube Blood UGI bleed bile UGI bleed- unlikely nondiagnostic (no blood or bile LGI bleed
  34. 34. COLONOSCOPY • Identifies lesion in 75 % or more • Can provide endoscopic therapyand disadvantages of common diagnostic procedures used in the evaluation of lower gastrointestinal bleeding Advantages Disadvantages • Therapeutic possibilities • Bowel preparation required • Diagnostic for all sources of bleeding • Can be difficult to orchestrate without on- call endoscopy facilities or staff • Needed to confirm diagnosis in most patients regardless of initial testing • Invasive • Efficient/cost-effective • No bowel preparation needed • Requires active bleeding at the time of the exam • Therapeutic possibilities • Less sensitive to venous bleeding
  35. 35. MESENTERIC ANGIOGRAM • Selective embolization initially controls hemorrhage in up to 100% of patients, but rebleeding rates are 15% to 40% and disadvantages of common diagnostic procedures used in the evaluation of lower gastrointestinal bleeding Advantages Disadvantages • Therapeutic possibilities • Bowel preparation required • Diagnostic for all sources of bleeding • Can be difficult to orchestrate without on- call endoscopy facilities or staff • Needed to confirm diagnosis in most patients regardless of initial testing • Invasive • Efficient/cost-effective y • No bowel preparation needed • Requires active bleeding at the time of the exam • Therapeutic possibilities • Less sensitive to venous bleeding • May be superior for patients with severe bleeding • Diagnosis must be confirmed with endoscopy/surgery • Serious complications are possible e • Noninvasive • Variable accuracy (false positives) • Sensitive to low rates of bleeding • Not therapeutic • No bowel preparation • May delay therapeutic intervention
  36. 36. RADIONUCLIDE SCAN •May be superior for patients with severe bleeding •Diagnosis must be confirmed with endoscopy/surgery • Seriouscomplications are possible e •Noninvasive • Variable accuracy(false positives) • Sensitive to lowratesof bleeding •Nottherapeutic •No bowel preparation •May delaytherapeutic intervention •Easilyrepeated if bleeding recurs •Diagnosis must be confirmed with endoscopy/surgery py •Diagnostic andtherapeutic • Visualizesonlythe left colon
  37. 37. Treatment Lower GI bleed Small volume Large volume Investigate cause Manage cause Resuscitate Bleeding stops Bleeding persists ? Surgical intervention
  38. 38. SURGERY • two settings: massive or recurrent bleeding. • Try to localize – Localisation- segmental rather – Not localise- blind subtotal colectomy.

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