GIT Kurdistan Board GEH Journal club Lower GIB 2014.

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GIT Kurdistan Board GEH Journal club; Lower GIB ASGE Guidelines 2014.

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  • GIT Kurdistan Board GEH Journal club Lower GIB 2014.

    1. 1. Dealing with LGIB:Overview LGIB Algorhythm Causes Endoscopic interventions Recommend ations
    2. 2. Lower GIB: Overview F •Introduction A •Aetiologies S •Management algorythms T •Endoscopic hemostasis
    3. 3. Introduction: • LGIB is diagnosed in 20-30% of all patients presenting with major GI bleeding. • The annual incidence is 0.03%. • increases * 200 from 2nd- 8th decades of life. • The mean age at presentation is 63 - 77 years. • A full-time gastroenterologist manages >10 cases/ year. • Blood loss can be trivial or massive & life-threatening, but the majority have self-limited& uncomplicated hospitalization. • LGIB tend to present with a higher Hb &less likely to develop hypotensive shock or require blood transfusions. • Mortality is 2- 4%, usually from comorbidities& noscom infs. • Reported decreased incidence of LGIB & lower age/gender- adjusted fatality rate over the past decade.
    4. 4. Definitions: • Before deep enteroscopy: Bleeding from a source distal to the ligament of Treitz • Now: bleeding from a source distal to ICV. • Now small-bowel sources called midgut bleeding. • Acute LGIB: of recent duration (<3 days) that may result in hemodynamic instability, anemia&/or the need for blood transfusion. • Chronic LGIB: passage of blood per rectum over a period of several days or longer& usually implies intermittent or slow loss of blood& present with occult fecal blood, intermittent melena or maroon stools, or scant amounts of bright red blood per rectum.
    5. 5. Diverticular bleeding: • Present in up to 30% >50 ys, to 60% >80 ys. • Accounts for 20- 65% of acute LGIB episodes. • Clinically significant bleeding occurs in 3-15% with colon diverticula, usually as a result of trauma to the vasa recta at the neck or dome of the diverticulum. • NSAIDs increase the risk for diverticular bleeding. • Hypertension&anticoagulation also may contribute to severe bleeding.
    6. 6. Diverticular bleeding: • The clinical presentation: • Painless hematochezia, resolves spontaneously in 75-80% but recurs in 25-40% within 4 years. • Early rebleeding is uncommon after endoscopic treatment. • Using epinephrine/or thermal coagulation early (<30 days) rebleeding 0-38%. • Using endoscopic clips: no early rebleed & late rebleeding in 18- 22%. • Late rebleeding may occur from diverticula at a location different from that of the index bleed.
    7. 7. Diverticular bleeding: • The diagnosis is presumptive in most patients, based on the presence of colon diverticula& the absence of another obvious source. • A definitive diagnosis is made in 22% who have active bleeding or high-risk stigmata of a visible vessel or clot on colonoscopy. • Diverticular bleeding is detected by colonoscopy more commonly in the left side of the colon (50-60%)& by angiography more commonly in the right side of the colon (50-90%).
    8. 8. Ischemic colitis: • 1- 19% Of LGIB most commonly elderly results from a sudden, often temporary, reduction in mesenteric blood flow secondary to hypoperfusion, vasospasm, or occlusion of the mesenteric vasculature. • The typical locations affected by non-occlusive colon ischemia are the “ watershed” areas of the colon: the splenic flexure& rectosigmoid junction;sigmoid colon in 20.8%, descending colon to sigmoid colon in 9.9%, transverse colon to sigmoid colon in 4.2%, & pancolonic involvement in 7.3%. • Patients often have underlying CVD &present with hypotension or hypovolemia, which results in mesenteric hypoperfusion& vasoconstriction&bleeding results from reperfusion injury after the hypoperfusion has resolved.
    9. 9. Ischemic colitis: • Mesenteric occlusion related to cardiac thromboembolism in 1/3 • Hypercoagulable states,vasculitis&medications are less common. • The clinical presentation: sudden onset of cramping abdominal pain, followed by hematochezia or bloody diarrhea within 24 hours. • Typical endoscopic findings: submucosal hemorrhage& ulcerations with segmental distribution with an abrupt transition between abnormal& normal mucosa. • The rectum usually is spared, because of its dual blood supply. • A single linear ulcer along the longitudinal axis of the colon on the antimesenteric border (“ single-strip” sign) also may occur. • None of these endoscopic findings are pathognomonic of ischemic colitis&infectious / inflammatory colitides should remain in the DD.
    10. 10. Ischemic colitis: • Angiography should be considered in severe ischemic colitis or right-sided involvement, when there is suspicion for an underlying thromboembolism or concomitant mesenteric ischemia involving the small bowel. • The majority improve with conservative management including: • IV hydration. • Correction of the underlying etiology. • Involvement of the right side of the colon& total colon ischemia (usually after a major abd surgery) may have unfavorable outcome because of concomitant small-bowel ischemia or transmural infarction & may require surgical management.
    11. 11. Angioectasias(angiodysplasias): • The prevalence varies with clinical presentation (1-2% in asymptomatic patients undergoing screening colonoscopy; 40- 50% in those presenting with hematochezia). • Account for 3-15% of patients with LGIB. • The incidence increases with age& >2/3 of these lesions are seen in > 70 years. • Angioectasias are caused by degenerative changes& chronic intermittent low-grade obstruction in the submucosal vessels. • They are located predominantly in the cecum & the ascending colon. • Multiple angioectasias may be seen on colonoscopy appear as red, flat lesions, 2 mm- several cms, with ectatic blood vessels radiating from a central feeding vessel
    12. 12. Angioectasias(angiodysplasias): • Risk factors include: • Advanced age, comorbidities, the presence of multiple angioectasias & the use of anticoagulants or antiplatelet agents. • Patients can present with occult bleeding, melena, or painless intermittent hematochezia. • Colonoscopy has a sensitivity of 80% for detection of angioectasias. • Narcotics for sedation may reduce mucosal blood flow and impair the detection of these lesions at colonoscopy. • Bleeding from angioectasias in AS( Heyde syndrome) explained that severe AS may result in type 2 VWD, which precipitates bleeding in patients with underlying angioectasias. • There is a high rebleeding rate despite endoscopic treatment& defi nitive management may involve AV replacement.
    13. 13. Hemorrhoids: • Aplexus of dilated AV vessels that arise from the superior & inferior hemorrhoidal veins,located in the submucosa of the distal rectum classified as internal or external, based on their location relative to the dentate line. • Although may be present in up to 75% with LGIB, the majority are considered incidental findings. • Hemorrhoidal bleeding accounts for only 2- 10- 24- 64.4% of acute LGIB or hematochezia. • Patients typically present with painless, intermittent, scant hematochezia characterized by bright red blood on the toilet paper, coating the stool, or dripping into the toilet bowl.
    14. 14. CR neoplasias: • Bowel habit changes&weight loss should raise suspicion for a colorectal neoplasia&prompt colonoscopy in patients with LGIB. • Accounts for up to 17% of GIB & presents more commonly with occult bleeding. • Acute LGIB associated with colorectal neoplasia usually results from surface ulcerations of an advanced tumor. • Patients with tumors in the right side of the colon are more likely to present with occult blood loss &IDA whereas those with left-sided tumors more commonly present with hematochezia. • Endoscopic hemostasis is rarely required because bleeding is slow in the majority.
    15. 15. Postpolypectomy bleeding: • Account for 2- 8% of acute LGIB, 8.7/1000 procedures.
    16. 16. NSAID use : • Associated with increased risk of LGIB, including DD. • NSAID users had a significantly higher incidence of lower GI adverse events, including bleeding • The prevalence of NSAID use is up to 86% LGIB. • Mechanisms not well understood: local mucosal trauma &platelet inhibition in susceptible individuals & concomitant use of warfarin&other antiplatelets. • Use of NSAIDs is associated with exacerbations of IBD. • NSAIDs can induce NSAID colopathy, which may be misdiagnosed as IBD, characterized by colon ulcerations and diaphragm-like strictures, predominantly located in the terminal ileum& right side of the colon. • NSAID colopathy may be associated with LGIB &perforation.
    17. 17. Rectal ulcers : • 8% of severe hematochezia&32% LGIB after ICU admissions for other critical illnesses. • Patients often have major medical comorbidities: • ESRD on HD • Respiratory failure requiring mechanical ventilation, • Decompensated cirrhosis • Malignancy. • Endoscopic findings:clean-based ulcers (82%),adherent clots (17%),nonbleeding visible vessels (33%),active bleeding (50%). • Early rebleeding after endoscopic treatment is 44% -48% &mortality rate of 33-48% in high-risk stigmata who have multiple comorbidities.
    18. 18. Radiation proctopathy: • LGIB occurs in 4-13% with rad colitis. • This disorder is caused by radiation-induced endarteritis obliterans, which results in neovascularization& telangioectasias in the rectum.
    19. 19. IBD: • Commonly present with LGIB. • Acute LGIB requiring hospitalization is uncommon & reported to account for only 1.2-6% of all admissions in patients with Crohn’ s disease &0.1- 4.2% in patients with ulcerative colitis. • Clinically significant bleeding in Crohn’ s disease is more common in patients with colon involvement than in those with isolated small-bowel disease. • Bleeding resolves spontaneously in up to 50% of patients, but there is a recurrence rate of up to 35%. • Medical management with biologics can be effective in the management.
    20. 20. HIV: • LGIB occurs in 2.6% of patients with HIV, usually in the setting of AIDS-related thrombocytopenia&associated with an inpatient mortality rate of 28%. • The most common etiologies of LGIB in these patients are opportunistic infections, including cytomegalovirus, herpes simplex virus, Kaposi’ s sarcoma& idiopathic proctocolitis.
    21. 21. U& SI source of LGIB : • UGI source may be present in 11- 15% of patients with suspected LGIB • Small-bowel sources constitute 2-15% of cases.
    22. 22. Management: Resuscitation/ evaluation • Initial assessment: whether or not an urgent intervention is necessary. • The majority, manifesting as occult fecal blood or scant hematochezia, can be managed electively in OP. • Patients presenting with acute LGIB with melena or hematochezia usually require inpatient management, because the majority are elderly with significant comorbidities. • Should undergo stabilization&resuscitation with crystalloids or blood products. • Coagulation factors &platelets may be necessary in patients who are on antithrombotics or with underlying bleeding disorders.
    23. 23. Management: Resuscitation/ evaluation • ICU admission: • Clinical evidence of ongoing or severe bleeding. • Transfusion > 2 units of packed RBCs • Significant comorbidities. • NGT lavage to exclude an upper GI bleeding source should be considered in patients presenting with hematochezia & hemodynamic instability. • An actively bleeding upper GI source is unlikely if bile is seen in NG Lavage, but it cannot be ruled out with clear aspirate. • A targeted history: NSAID use, prior bleeding episodes, recent polypectomy, radiation therapy for prostate or pelvic malignancies, IBD, CRC risk.
    24. 24. Management: Resuscitation/ evaluation • Risk stratification: • High risk of severe bleeding 80%: > 3 the following RFs. • Moderate risk (45%) with 1-3 RFs. • Low risk No Rfs (< 10%):. • HR 100/minute, systolic blood pressure % 115 mm Hg, syncope, nontender abdominal exam, rectal bleeding during the first 4 hours of evaluation, aspirin use, multiple comorbid illnesses.
    25. 25. Management: Resuscitation/ evaluation • Another model: independent predictors of severe LGIB. • Initial hematocrit! 35%, presence of abnormal vital signs (SBP<100 mm Hg or HR> 100/minute) 1 hour after initial medical evaluation& gross blood on initial rectal exam. Kollef et al100 developed and validated another • BLEED model; Outcome prediction tool for UGIB&LGIB: predict resource utilization& inpatient adverse events, including mortality. • Ongoing bleeding, low SBP, elevated PT, erratic mental status, &unstable comorbid illness.
    26. 26. Occult GI bleeding • Colonoscopy for evaluation of underlying CR neoplasia. • CT colonography may be an alternative if high risk for colonoscopy-related adverse events& for the detection of proximal lesions in those who have had an incomplete colonoscopy. • An EGD should be considered if a bleeding source is not identifi ed in the colon, especially in those patients with upper GI symptoms, IDA, or NSAID use( overall yield 13- 41%, with PUD &esophagitis) • Small-bowel evaluation if fecal occult blood&persistent anemia, after negative EGD &colonoscopy.
    27. 27. Melena: • EGD is the initial test in the evaluation of melena • Melena also may result from slow bleeding emanating from the colon or small-bowel. • Colonoscopy should, be pursued after negative EGD. • Persistent melena after negative results with bidirectional endoscopy warrant small-bowel endoscopy.
    28. 28. Intermitent scant hematochesia: • Is the most common pattern of LGIB. • Usually is caused by an anorectal or distal colon source • A digital rectal exam&flexible sigmoidoscopy ( yield of 9-58%), with or without anoscopy, may be sufficient for the evaluation of healthy patients aged< 40 years. • A colonoscopy should be pursued in the absence of a defi nitive source of bleeding on flexible sigmoidoscopy, patients aged> 50 years, IDA, CRC risk, or alarm symptoms of weight loss or bowel habit changes.
    29. 29. Severe hematochesia: • An emergent EGD is the test of choice for patients presenting with severe hematochezia & hemodynamic instability, followed by a colonoscopy after if the later is normal. • In hemodynamically stable patients with severe hematochezia, colonoscopy should be performed first, followed by an EGD, if the colonoscopy is negative. • The main advantage of colonoscopy lies in the ability to perform a therapeutic intervention in conjunction with diagnosis of the underlying lesion. • The diagnostic yield of colonoscopy is 45-100% in LGIB & significantly higher than radiologic evaluation with RBC scan & angiography.
    30. 30. Severe hematochesia: • Urgent colonoscopy should be performed within 8-24 hours of admission. • Early colonoscopy increases its diagnostic yield &likelihood of a therapeutic intervention. • Endoscopic therapy is performed in 10-40%, with immediate hemostasis achieved in 50-100%. • Earlier colonoscopy is associated with higher higher successful hemostasis,reduced duration of hospitalization&cost of care but no improvement rebleeding or surgery.
    31. 31. Severe hematochesia: • Colon preparation is important to improve visualization, increase the diagnostic yield&reduce the risk of perforation. • Polyethylene glycol– based solutions can be administered orally (or via NGT in patients at increased risk of aspiration or who are unable to complete oral consumption) at 1 L/30-45 minutes until the effluent is free of fecal material. • Colonoscopy is performed within 1- 2 hours of preparation. • The reaccumulation of blood in the colon after preparation may be helpful in localizing the bleeding source. • Endoscopic hemostatic interventions include epinephrine solution injection, thermal contact coagulation, argon plasma coagulation, hemostatic clips&band ligation.
    32. 32. Endoscopic hemostasis : Bleeding DD • Thermal contact modalities:heater probe&bipolar coagulation alone or in combination with epinephrine injection. • Epinephrine solution in a dilution of 1:10,000 or 1:20,000 is injected in aliquots of 1 mL-2 mL at the site of active bleeding or around a non-bleeding visible vessel. • An adherent clot, may be guillotined by using a polypectomy snare. • The visible vessel can be treated effectively by using a heater probe (10 J-15 J) or bipolar coagulation (10 W-16 W) with 2 to 3– second pulse&application of mild contact pressure. • Perforation reported with contact thermal coag in thin-walled right side colon in up to 2.5%, so higher settings or repeated applications avoided to prevent transmural injury.
    33. 33. Endoscopic hemostasis: Bleeding DD • Endoscopic clips is an alternative to thermal coagulation&has the advantage of quick&easy application. • Clips can be deployed over a bleeding vessel at the neck of the diverticulum or to oppose the walls& close the diverticular orifice, thereby tamponading a vessel within the dome. • The use of an endocap has been described to evert the diverticulum and facilitate clipping of bleeding vessels within the dome of a diverticulum. • There are no reports of early rebleeding after endoscopic treatment with clips.
    34. 34. Endoscopic hemostasis : Bleeding DD • Endoscopic band ligation described in some small series ,but limited by inadequate suction of diverticula with small orifi ces or large domes&high early rebleeding. • A tattoo should be placed adjacent to the bleeding diverticulum, if identified at colonoscopy, for future identifi cation in recurrent bleeding &necessity for repeat endoscopic or surgical intervention. • Placement of an endoscopic clip also may be useful to allow localization of the bleeding source at angiography.
    35. 35. Endoscopic hemostasis : Bleeding AD • Both contact& noncontact thermal coagulation • APC is useful in the endoscopic treatment of angioectasias. • APC is the preferred technique because of its ease use, ability to treat large surface areas& predictable depth of penetration. • Lower APC power settings of 30- 45 W & 1 L/minute, 1-3 mm away from the mucosal surface &at 1- 2– second pulses used to decrease the risk for perforation in the thin-walled right side of the colon. • APC showed a significant improvement in Hb& reduction in transfusion requirements with no adverse events. • The use of endoscopic clips with APC reported.
    36. 36. Non- endoscopic treatments: • Mesenteric angiography with or without a preceding RBC scan is reserved for patients with: • Severe bleeding who cannot be stabilized or prepped for a colonoscopy • Failed endoscopic management. • The multidetector row CT scan may be superior to the nuclear RBC scan for evaluation of LGIB& replaced RBC scan at several centers. • It decreases scan time, allows accurate acquisition of arterial images&demonstrates contrast material extravasation into any portion of the GI tract. • A mesenteric angiogram can detect bleeding at 0.5 mL/min.
    37. 37. Non - endoscopic treatments: • Superselective embolization with microcoils, polyvinyl alcohol particles, or water-insoluble gelatin (gel foam) improved the success rate of this technique&decreased the occurrence of the adverse event of bowel infarction. • Angiography & embolization as first-line therapy for LGIB found embolization to be an effective treatment for diverticular bleeding, with successful hemostasis in 85% compared with 50% of those with bleeding from other sources at 30-day follow-up with early re-bleeding after embolization in 22%. • The technique is less successful in angiodysplasia & with more re-bleeding 40%. • Major adverse events, including bowel infarction, nephrotoxicity,hematomas.
    38. 38. Non endoscopic treatments: Surgery • Surgery is rarely required &reserved for minority of patients who have persistent or refractory diverticular bleeding. • Indications for surgery: • Hypotension&shock despite resuscitation. • Persistent bleeding with transfusion of >units of Packed RBCs. • Lack of a diagnosis despite a pan-intestinal evaluation for persistent bleeding in a surgical candidate. • It is important to attempt localization of the bleeding site for a segmental colectomy opposed to a subtotal colectomy with significantly higher mortality rate. • Surgery should be performed elective, because there is a high mortality with emergent one.
    39. 39. Recommendations: • 1. We recommend colonoscopy in patients with occult GIB. • 2. We recommend EGD in patients with occult GIB if a bleeding source is not identified in the colon, especially in those patients with UGI symptoms, IDA or NSAIDs use. • 3. We suggest small-bowel evaluation after negative EGD& colonoscopy results in patients with occult GIB who have persistent anemia. • 4. We recommend colonoscopy for the evaluation of chronic intermittent scant hematochezia in patients > 50 years& for patients who have IDA, risk factors for CR neoplasia, or the alarm symptoms of weight loss or bowel habit changes. • 5. We suggest that in younger patients presenting with chronic intermittent scant hematochezia without alarm symptoms, a DRE &flexible sigmoidoscopy may be sufficient evaluation.
    40. 40. Recommendations: • 6. We recommend EGD in the initial evaluation of patients with melena followed by colonoscopy if the EGD is negative. • 7. We recommend an initial EGD in patients with severe hematochezia&hemodynamic instability to evaluate for a high-risk UGI lesion, followed by colonoscopy if EGD is –VE. • 8. We suggest colonoscopy within 24 hours of admission after a rapid bowel preparation in the evaluation of patients with severe hematochezia. • 9. We recommend endoscopic treatment with epinephrine solution injection combined with thermal coagulation or endoscopic clip placement as the preferred management in patients presenting with diverticular bleeding.
    41. 41. Recommendations: • 10. We recommend endoscopic clip or tattoo placement adjacent to a bleeding diverticulum if identifi ed at colonoscopy for future localization in the event of recurrent bleeding. • 11. We recommend endoscopic treatment with APC as the preferred management in patients with bleeding angioectasias. • 12. We recommend surgical &radiologic consultation in patients presenting with severe hematochezia who cannot be stabilized for endoscopy or in whom endoscopic evaluation has failed to reveal a bleeding source.

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