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1. MANAGEMENT OF MASSIVE LOWER
GASTROINTESTINAL HEMORRHAGE
DR ADESIYAKAN A.A

2. OUTLINE
• INTRODUCTION
• EPIDEMIOLOGY
• RELEVANT ANATOMY
• ETIOLOGY
• PATHOGENESIS
• CLASSIFICATION
• CLINICAL FEATURES
• INVESTIGATIONS
• MANAGEMENT
• COMPLICATIONS
• PROGNOSIS
• CONCLUSION

3. INTRODUCTION
• Lower gastrointestinal hemorrhage refers to bleeding from the
gastrointestinal(GI) tract distal to the ligament of treitz
• Ranges from trivial to massive
• MASSIVE lower gastrointestinal bleeding is a life threatening condition
especially in the elderly in whom the disease is more common

4. INTRODUCTION (2)
• Criteria for diagnosing MASSIVE lower gastrointestinal bleeding(LGIB)
include;
• transfusion of at least 4 units of blood within 24 hours
• Hemodynamic instability and shock
• Decrease in hematocrit to 6g/dl or less
• Bleeding continues for 3 days
• Significant rebleeding within 1week

5. EPIDEMIOLOGY
• Worldwide, acute LGIB accounts for 1%-2% of hospital emergencies
• 15% of this fulfill the massive LGIB criteria with 5% of them requiring
emergent operative intervention
• Annual incidence rate of 20.5 patients per 100,000
• Male : female - 1.8 - 1
• AGE - 65

6. EPIDEMIOLOGY
DISEASE PATIENT (%)
DIVERTICULOSIS 60%
UNKNOWN 13%
HEMORRHOIDS 11%
NEOPLASIA 9%
COAGULOPATHY 4%
ANGIODYSPLASIA 3%
Vernava AM et al nationwide study of the incidence and etiology of LGIB (US)

7. 38%
5%
17%
16%
6%
19%
hemorrhoids diverticulosis
carcinoma polyps
AVM UNIDENTIFIED
Akande et al-2015
Olookoba et al-2013
Dakubo et al -2008
Alatise et al- 2007

8. EPIDEMIOLOGY

9. RELEVANT ANATOMY
• Lower gastrointestinal tract extends from the ligament of trietz to the anus
• Conduit in which digestion absorption and secretion occurs
• Consists of the jejunum and ileum - small intestine
• Caecum, ascending colon, transverse , descending colon , sigmoid rectum
and anal canal

10. RELEVANT ANATOMY(2)

11. RELEVANT ANATOMY
(3)
• The superior rectal arteries and its branches
• The super and inferior hemorrhoidal
plexuses
• Hemorrhoids components- (a)mucosa
(b)stroma- blood vessels, smooth muscles
(c)anchoring connective tissue-secures the
hemorrhoids to the internal sphincter and
conjoined longitudinal coat.

12. CLASSIFICATIONS
CLASS EXAMPLES
ANATOMIC HEMORRHOIDS, DIVERTICULOSIS,
VASCULAR
ANGIODYSPLASIA,ISCHAEMIC, RADIATION
INDUCED,AORTOCOLONIC FISTULA
INFLAMMATORY INFECTIOUS AND NON-INFECTIOUS
NEOPLASTIC COLORECTAL CANCER,POLYPS

13. CLASSIFICATION
SITE PROPORTION %
COLON 80 - 85
SMALL INTESTINE 0.7 - 9
UPPER GIT 10
UPPER GIT(MASSIVE) 33

14. PATHOGENESIS
• DIVERTICULOSIS-
• Diverticulum herniates at the site of vasa recta
• The vessel becomes draped over the dome of the diverticulum, separated
by just mucosa
• Segmental weakening of the artery which ruptures and bleeds
• Bleeding is more common on the right ( Wong S.K et al found that right
sided diverticula are twice likely to bleed -similar to most studies

16. PATHOGENESIS

17. PATHOGENENESIS
• HEMORRHOIDS
• Deterioration of the connective tissue that anchors the hemorrhoids occur
with age
• begins at the 3rd decade and progresses depending on individual differences
and risk factors- Haaspa et al
• Morinaga K et al postulated that they imbalances between arterial supply and
drainage
• Thus patients who had ligation of the arterial supply had resolution of
symptoms

18. PATHOGENESIS
• ANGIODYSPLASIA
• Colonic angiodysplasias are acquired mucosal or submucosal telangiectasia of degenerative
origin.They are dilated and tortuous with the blood vessel walls lacking smooth muscles.
• Degenerative lesions from chronic intermittent low grade colonic contraction
• Leads to obstruction of mucosal venous drainage
• Over time, mucosal capillaries dilate become incompetent and form an AVM
• Bleeding more on the right
• Saperas et al found that the burden of the disease is in its tendency to re-bleed
• Associated with aortic stenosis, VWD, chronic renal failure

21. PATHOGENESIS
• NEOPLASIA
• Mucosal ulceration and erosion
• Vascular invasion
• Friable neovasculature
• OTHERS - IBD, ischemic colitis, infectious colitis, radiation induced colitis,
aorto- colonic, post procedure

22. CLINICAL FEATURES
• BIODATA
• Presenting complaints :Hematochezia, Melena ??, Hematemesis
• Anaemia - weakness, palpitation dizziness ,syncope
• Shock
• Abdominal complaints
• Past medical history and procedures- Recent polypectomy, colonoscopy, bleeding
dycrasias
• History of risk factors-previous bleeding, radiation, NSAIDS, anticoagulants , AAA graft,
Liver disease, HIV status, family history of colon cancer recent weight loss

23. CLINICAL FEATURES
PATHOLOGIC
CONDITION
CLASSIC PRESENTATION
EXTERNAL
HEMORRHOIDS
PAINFUL,SPORADIC LOW VOLUME BLEEDS WITH RED
BLOOD COATING STOOL
INTERNAL
HEMORHOIDS
PAINLESS, LOW- HIGH VOLUME
DIVERTICULAR
BLEEDING
PAINLESS/MILD CRAMPING,EPISODIC BURSTS OF
ARTERIAL BLEEDING,HIGH VOLUME,CLOTS,INCREASED
PREVALENCE WITH CERTAIN RISK FACTORS
ANGIODYSPLASIA
PAINLESS/MILD CRAMPING,EPISODIC VENOUS
BLEEDING,OVERT OR OCCULT,OFTEN AT LOW VOLUME(
BUT CAN BE MASSIVE), PREVALENT IN THE ELDERLY
COLON CANCER
CRAMPING OR PAINLESS,WEIGHT LOSS,MELENA,FAMILY
HISTORY
TRAUMA IATROGENIC, DOMESTIC

24. CLINICAL FEATURES
• Physical examination should be thorough and include the assessment of anorectum,
oropharynx, nasopharynx and the hemodynamic status of the patient ,tempo and extent of
blood loss, risk assessment
• Horizontal approach
• General physical examination - shock
• Abdominal examination
• Nasogastric tube aspiration and warm saline gastric lavage if necessary -
• Gentle DRE + proctoscopy
• Discovery of a benign pathology doesn’t rule out other etiology

26. RESUSCITATION
• ATLS
• RISK ASSESSMENT - HDU/ICU
• Vasopressors
• Urethral catheter
• Blood transfusion - target blood pressure
• Fresh frozen plasma - target INR
• Reassessment and monitoring
Ongoing Bleeding -
BLEED CRITERIA
Low SBP - < 100mmHG
Elevated PT ->1.2
Erratic mental status
Unstable Co-morbid Disease

27. INVESTIGATIONS
• FBC ( urgent PCV after resuscitation, normocytic vs microcytic)
• Blood group and cross match
• E/U/Cr - BUN/creatinine ->30:1 ,urea/creatinine ratio - 100:1
• Shock- base deficit, anion gap, serum lactate
• LFTs and clotting profile
• Nasogastric tube aspiration
• Proctoscopy

28. DIAGNOSTIC
INVESTIGATIONS
• Aim is to identify and localize
• Sequence depends on such factors as rate of bleeding, Hemodynamic
status of the patient, success at localization of the lesion
• Most of these overlap as diagnostic and therapeutic measures
• They include Computed tomography, Colonoscopy, angiography, CT-
angiography, radionuclide imaging each with its relative merit and demerit

29. COLONOSCOPY
• Fiberoptic flexible colonoscopy is the initial Diagnostic modality of choice
for stable patients
• Successfully identifies site in 80 -90 %
• Also offers opportunity of therapeutic interventions
• Relatively safe

30. COLONOSCOPY
• PATIENT CRITERIA - Hemodynamically stable, nil ongoing brisk bleeding (vs emergent )
• BOWEL PREPARATION-
- Blood is cathartic alone - poor cecal intubation rate (18%)
- Aggressive lavage - 4-6 liters of polyethylene glycol -(bleeding)
- Metoclopamide
- Hydro flush colonoscopy - mechanical suction devices and water jet pumps-
- TIMING-
- urgent colonoscopy(<12hrs) has comparative advantage in detection of the source of hemorrhage vs expectant colonoscopy but its advantage
in terms of length of hospital stay and re-bleed rates is unclear.
- Emergent has much Lower diagnostic yield but may be the only option

31. COLONOSCOPY
• Large national study by Jensen and machicado, urgent colonoscopy yielded a definitive
diagnosis in 90% of patients with also therapeutic opportunity as an added benefit
• Patients also had significantly shorter hospital stay
• Urgent colonoscopy can be performed in the operating suite
• Therapeutic colonoscopy - bipolar probe coagulation, Epinephrine injection, hemospray,
clip application , argon plasma coagulation, application of formalin and a combination of
these
• Tattooing
• Incidentally discovered lesions are left alone

32. COLONOSCOPY
S/
N
ADVANTAGES DISADVANTAGES
1 High sensitivity
Requires skilled endoscopist - urgent and
emergent
2 Treatment Bowel prep delay
3
Comparative advantage in massive
LGIB that has stopped
Bowel perforation
4 Available Sedation risk

34. ENDOSCOPIC HEMOSTASIS
DIVERTICULI Clips, thermocoagulation
HEMORRHOIDS Band ligation, sclerosants,
ANGIODYSPLASIA
Non-contact thermal therapy using argon plasma
coagulation(APC),injection sclerotherapy
POST
POLYPECTOMY
Mechanical clips, thermal coagulation, vasoconstrictors
hemospray
VASOPRESSORS
Initial control of active bleeding and improve visualization
Combined with second hemostatic mechanism

35. NO PLACE FOR COLONOSCOPY IN ACTIVELY BLEEDING OR
HEMODYNAMICALLY UNSTABLE PATIENTS

36. ANGIOGRAPHY
• In 1965 Baum al first described selective mesenteric angiography
• It is useful for patients in whom active bleeding precludes colonoscopy or where colonoscopy fails to
identify the bleeding site
• May be emergent or elective
• Elective angiography -patients with multiple episodes of LGIB without a known source or diagnosis.
• Emergency angiography is very useful in patients with massive ongoing bleeding
• Requires active bleeding at 0.5 - 1 ml/min ,creatinine <1.5mg/dl, eGFR>60ml/min/1.73m, INR- <1.5,
platelets >50,000
• Evaluation begins at the superior mesenteric artery

37. ANGIOGRAPHY
FINDING PROBABLE DIAGNOSIS
EXTRAVASATION BLEEDING SITE
FILLING OF SPACES OUTSIDE
THE BOWEL LUMEN
ANEURYSM,PSEUDOANEURYSM
EARLY ARTERIAL FILLING
,ACCUMULATION IN VASCULAR
TUFTS,SLOW DRAINING
VESSELS ANGIODYSPLASIA
NEOVASCULARITY NEOPLASM
HYPEREMIA COLITIS

38. ANGIOGRAPHY
• Embolization- goal is to mechanically occlude the arterial blood supply to the bleeding site while
maintaining collateral perfusion to prevent ischemia
• Hyper selective process
• Agents - 1) TEMPORARY- e.g absorbable gelatin sponge(gelfoam)-long acting, bio degradable
and can be cut into small blocks mixed with saline and iodinated contrast
• may come in powdery form(unpredictable)
• 2) PERMANENT- coils, particles, glue, polymers of ethylene alcohol
• Vasopressin, propanolol, epinephrine ( rebound bleeding)-
• Initial rate of 0.2I/min - repeat angiography-observe for 24-48 hours, if not resolved or
complications occur -> surgery

39. ANGIOGRAPHY
ADVANTAGES DISADVANTAGES
DOES NOT REQUIRE BOWEL
PREPARATION
LOW SENSITIVITY
CAN BE USED IN EMERGENCY
SETTING
REQUIRES ACTIVE BLEEDING
THERAPEUTIC USES
COMPLICATION RATE ( thrombosis,
embolization, renal failure)

41. COMPUTED TOMOGRAPHY
• Triple phase helical CT scanning using IV contrast is safe, fast convenient
and accurate diagnostic tool
• Criteria for identification include :
• vascular dilatations, vascular extravasation, spontaneous hyper density of
the peribowel fat
• Presence of diverticula - this alone is not enough for localization
• Comparable identification rate to mesenteric angiography and colonoscopy

42. COMPUTED TOMOGRAPHY

43. CT- ANGIOGRAM
• This is different from CT with intravenous contrast
• Cost effective accurate and rapid tool in the diagnosis of acute LGIB
• Studies report a pooled sensitivity of 85.2%- 89% and a specificity of 74%-
96.9% and positive predictive value of 98.5%
• When combined with visceral arteriography it increases diagnostic and
localization yield- jacovides et al
• Can track vessel and identify exact bleeding vessel
• Requires bleeding at 0.3 - 0.5 ml/min

44. CT ANGIOGRAM
ADVANTAGES DISADVANTAGES
NON-INVASIVE REQUIRES ACTIVE BLEEDING
GOOD LOCALIZATION RATE NOT THERAPEUTIC
PROVIDES ANATOMIC DETAILS RADIATION EXPOSURE
NO BOWEL PREPARATION IV CONTRAST

46. RADIONUCLIDE
• Requires bleeding at 0.1-0.5 ml/min - sensitive but low specificity
• Two types - technetium sulfur and 99m Tc pertechnetate labelled red blood cell
• Technetium sulfur is cleared rapidly from the intravascular space
• 99m Tc remains over 24 hours - intermittent
• Though these identify bleeding, the draw back of this is the poor localization as blood can move in
a peristaltic or antiperistaltic direction to a dependent area if still images are considered
• Thus it’s better if the dynamic images are assessed
• Studies have demonstrated a localization rate of < 26% with misdiagnosis of up to 25%- thus
segmental colectomy based on this is discouraged. Majorly suitable for selecting patients for
angiography

48. ADDITIONAL INVESTIGATIONS
• Esophagogastroduodenoscopy + PUSH ENDOSCOPY
• Capsule endoscopy
• Double balloon enteroscopy
• Enteroclysis
• Merkels scanning
• Barium enema
• Provocation -ryan JM et al,provocative bleeding studies with intraarterial heparin and tolazoline -
50%
• Alternate clamping

49. MANAGEMENT
• 1)Resuscitate and ICU care
• 2)Rule out UGIB and anorectal bleeding
• 3)localize as quickly as possible
• 4)therapeutic angiography or colonoscopy where available or feasible
• 5) operative intervention
• However use of these modalities depends on patients hemodynamic
status, rate of bleeding and local competence

51. OPERATIVE
• Reserved for cases in which other modalities fail or are unavailable or
poorly developed
• Selective segmental colectomy following localization is the preferred
surgical option
• Active bleeding from unidentified bleeding point may require subtotal
colectomy and ileostomy
• Blind segmental resection is discouraged - due to its high re bleeding rate,
morbidity and mortality

52. OPERATIVE
• Pre-operative measures -
• Intra-operative - laparotomy
• if bleeding vessel has been identified segmental colectomy
• If not ; Serial clamping
• Surgeon guided enteroscopy and colonoscopy based on local competence, may
require on table mechanical lavage
• Hemicolectomy

54. OPERATIVE
• subtotal colectomy and ileostomy +rectal stump
• secondary ileoproctostomy
• Hemorrhoidectomy, diverticulectomy
• Features of complications from other measures should be looked for and
treated
• Postoperative- elective ICU ,close monitoring

55. COMPLICATIONS
• Blood transfusion
• Procedure complications
• Surgery complications

56. PROGNOSIS
• Mortality rate of 10 - 20 % in developed countries where the full
armamentaria of diagnostic, therapeutic and emergency services are
available.
• Self-limiting in about 70 - 80 %
• Rebleeding is common especially is localization isn’t done
• Rebleed rates - early( <30 days)- 14.5 %
• Newer modalities and approach have reduced morbidity and mortality

57. CONCLUSION
• Massive lower gastrointestinal hemorrhage is a life threatening condition
• Multidisciplinary team of endoscopist, intervention radiologist and surgeons
are necessary for optimal care
• Accurate localization of the site and cause of bleeding are critical for
focused care
• Surgery is increasingly reserved as the last resort.

58. REFERENCES
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of three cases. Gastrointest Endosc 1994; 40:70.
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histopathological correlation, and results of endoscopic intervention. Am J Gastroenterol 1996; 91:2589.
3. Foutch PG. Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993; 88:807.
4. Jensen DM, Jutabha R, Machicado GA, et al. Prospective randomized comparative study of bipolar electrocoagulation versus
heater probe for treatment of chronically bleeding internal hemorrhoids. Gastrointest Endosc 1997; 46:435.
5. Trowers EA, Ganga U, Rizk R, et al. Endoscopic hemorrhoidal ligation: preliminary clinical experience. Gastrointest Endosc
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6. Barbatzas C, Spencer GM, Thorpe SM, et al. Nd:YAG laser treatment for bleeding from radiation proctitis. Endoscopy 1996;
28:497.
7. Strate et al, lower GI bleeding; epidemiology and diagnosis. Gastroenterol clin north am 2005; 34;643
8. F.charles brunicardi, Schwartz principle of surgery, lower GI bleeding mc GRAW hill, 10th edition
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10.Ahidjo et al ,angiography in UMTH, research gate. 2015

59. THANK YOU