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DR. SUCHIT KUMAR SHAH
MDGP-1st YEAR RESIDENT
APPROACH TO LOWER GI BLEED
• MODERATOR: Dr. Asraf Hussain
APPROACH TO LOWER GI BLEED
• IT WILL TAKE AROUND 30-45 MINUTES TO COMPLETE THE SESSION.
SYSTEM
• GASTRO INTESTINAL TRACT
GENERAL OBJECTIVES
• AT THE END OF THE SESSION PARTICIPANTS WILL KNOW ABOUT
LOWER GI BLEED AND ITS MANAGEMENT
SPECIFIC OBJECTIVE
• DEFINATION
• ETIOLOGY
• CLINICAL FEATURES AND APPROACH TO LOWER GI BLEED
• DIAGNOSTIC AND THERAPUTIC MODALITIES IN ACUTE
LOWER GI BLEED
CLINICAL SENARIO
• A 25 Year old male , resident of Birgung, occasional smoker, non
alcoholic
Low to moderate grade fever- 25 days
Bleeding per rectum- 8 hours
• Bright red
• Profuse, intermittent
• Not mixed with stool/mucus
• Not associated with abdominal pain
• No h/o significant weight loss / Loss of appetite
ON EXAMINATION
• GPE: Pallor++, severe dehydration+
• Pulse : 125/min
• Bp : 80/50 mmHg
• SYSTEMIC EXAMINATION
Per abdomen- soft, non tender, no organomegaly
• LAB Parameters:
Hemoglobin: 5.6 g/dl
Platelets, WBC- Normal
LFT, RFT- pre Renal AKI
GASTRO INTESTINAL BLEEDING
• Presents with Hematemesis, hematochezia, Melena
• Sequele of different etiologies- infection, vascular anomaly,
inflammatory disease, trauma and Malignancy
• While GI bleeding is potentially life threatening, can be safely
managed in OPD basis
• The management of GI bleed relies on prompt resuscitation, initial
risk evaluation and appropriate definitive management.
CATEGORIZATION OF GI BLEED
REVISED CATEGORIZATION
CLASSIFICATION OF LGI BLEED
• Based on duration
Acute – Recent duration( arbitrary<3days)
Chronic- usually over a period of several days.
• Based on presentation
Overt- Frank hematochezia
Occult-Presenting with Positive FOBT/ unexplained IDA
Obscure- Bleeding of unknown origin that persists or recurs
with negative bidirectional endoscopic procedures
Can be occult or overt
PROBLEM STATEMENT
• 20% of all gastro intestinal bleeding is LGIB
• Male> Female
• Incidence increases by age.
• 1-2% of Hospital Emergency
• 80% acute LGIB resolve spontaneously
• Overall mortality <5%
ETIOLOGY
PRESENTATION OF LGIB
• Hematochezia- passage of bright red blood, maroon stools, or
blood clots
Blood originating from left colon, rectum- bright red
Blood originating from right colon- dark red or maroon
color
15% hematochezia have UGIB as a source
• Malena- Black tarry, foul smelling stool
Ceacal or right colonic bleeding
HISTORY TAKING
• Hematochezia – painless
Blood mixed with stool- colon carcinoma
Blood streak on stool- rectal carcinoma
Blood after defecation- haemorrhoids
Blood with constipation- SRUS
Blood alone – diverticular disease
• Associated with
Abdominal pain- Crohn’s disease
Along with Fever- infective colitis.
SRUS- solitary rectal ulcer syndrome
HISTORY TAKING
• Changes in bowel habit
• Weight loss
Past history of
• Cardiovascular disease
• Abdominal radiation
• Diverticulosis
• Recent colonoscopy and procedure
• Steroids/ NSAIDS/ anti coagulants
• Recurrent childhood bleeding
EXAMINATION
• GENERAL PHYSICAL EXAMINATION
Signs of dehydration
Pallor- Severe acute GI bleed
Icterus- Liver cell failure- Rectal varices
Clubbing- IBD
Pedal edema – Liver cell failure
EXAMINATION
APPROACH TO A PATIEN WITH LGIB
• Patient presenting with hematochezia
1. Resuscitation and initial management
2. Definitive management
i. Localization of bleeding site
ii. Theraputic intervention to stop bleeding
RESUSCITATION
DIAGNOSTIC AND THERAPUTIC MODALITIES
ENDOSCOPIC METHOD
• PROCTOSCOPY
• FLEXIBLE SIGMIDOSCOPY
• COLONOSCOPY
• ENTEROSCOPY
NON ENDOSCOPIC METHODS
• CT ANGIOGRAPHY
• CATHETER ANGIOGRAPHY
• RADIO NUCLIDE IMAGING
COLONOSCOPY
• Colonoscopy is the investigation of choice in acute LGIB,
unless bleeding is massive and patient is hemodynamically
unstable.
• The diagnostic yield of colonoscopy in LGIB- 48%-97%
Bowel Preparation:
Inadequate bowel preparation reduces the sensitivity to
21%
1. low cecal intubation rates
2. blood or stool in the lumen
TIMING OF COLONOSCOPY
• Early colonoscopy with 12-24 hours of admission
associated with shorter hospital stay
• Diagnostic yield increases when performed with active
ongoing bleed
• In patient with serious co morbid condition or no ongoing
bleed delayed colonoscopy.
ADVANTAGES
• Direct visualization of bleeding site
• Precisely localizes the site of bleeding
• To obtain biopsy specimens
• Stigmata of recent bleeding
1.Active bleeding
2.Visible bleeding
3. Adherent clots
• Therapeutic intervention
COMPLICATIONS
• Fluid overload
• Aspiration pneumonia
• Bowel perforation
• Sepsis
ENDOSCOPIC THERAPY
• Injection
• Thermal coagulation
• Mechanical devices
MECHANICAL DEVICES
• Used for active bleeding
• Secure definitive bleeding control
1. Clips
Placed either over or side of the bleeding source
Clip retention time 2-4 week
2. Bands
Mainly used for hemorrhoidal bleed
Ligated at the neck of the lesion.
ENTEROSCOPY
• Balloon enteroscopy
• Capsule enteroscopy
• Sound enterocopy
BALLOON- ASSISTED ENTEROSCOPY
• Two forms of balloon-assisted enteroscopy:
1. Double- balloon enteroscopy
2.Single balloon enteroscopy
The enteroscopes – working length of 200 cm.
Push-and Pull method, inflation and deflation of balloons
and telescoping of the intestine onto the overtube.
Balloon-assisted enteroscopy can be performed via the
oral(anterograde) and aboral(retrograde) approach.
ADVANTAGES
It allows deeper access to the small bowel than push enteroscopy
The diagnostic yield- 60-80%
Therapeutic intervention- 40-70%
Total enteroscopy, success rate- 16-86%
2. CAPSULE ENDOSCOPY
• 26 mm capsule containing a camera, transmitter and other accessories
• 2 images per second and around 60000 images generated in 8 hours
• Diagnostic yield of capsule endoscopy in LGIB is 40-80%
• It is non invasive and patient friendly with low complication rate
• Capsule retention can occur in 1.4% case mainly with stenosis.
• Main drawbacks: No therapeutic intervention, process is passive.
CT ANGIOGRAPHY
• Diagnostic accuracy 0.3 mL/min
• Sensitivity of 50-60% and Specificity of 92-95%
• Identify site of bleeding and etiology of LGIB
• Oral contrast not recommended
• Diagnostic tool; no therapeutic intervention
• It provides information about vascular anatomy endovascular
intervention or surgical planning
CATHETER ANGIOGRAPHY
• Recommended for patients- massive bleed and hemodynamically
unstable, persistent or recurrent bleeding
• Detects the bleed at the rate of 0.5-1 ml/min
• High specificity-95-100%
• Low sensitivity- 30-47%
EMBOLIZATION
• Using coils, gel foam, poly vinyl alcohol particles-
Success of 44-86%,
Re- bleeding in about 15% of case
High incidence of bowel ischemia- 20%
SUPER SELECTIVE EMBOLIZATION
• Target artery- the vasa –recta
Along the marginal arteries and the distal intestinal arcades
RADIONUCLIDE SCANNING
• Radio labelled substances into patient blood stream and performing
serial scintigraphy
• Two methods exist- Tc99m sulfur colloid, Tc99m labelled RBC(latter is
better)
• The rate of bleeding detection is a low as 0.1-0.5 ml/min
• PPV-45%, Diagnostic accuracy to localize the bleeding site-78%
• Highly helpful in obscure bleeding.
ROLE OF SURGERY
• Indicated as an emergency life saving procedure
1. Inability to maintain hemodynamically stability
2. Failure of available therapeutic modalities
3. Requiring blood transfusion more than 6 units within 24 hours
4. Recurrence of severe bleeding after initial control.
RE- BLEEDING IN ACUTE LGIB
• Mean rate of acute re- bleeding- 22%
late re-bleedin-16%
• Factors predisposing rebleeding in LGIB
1. source of index bleeding
2. Initial hemostasis modality
3.Medication use
4. Co morbid condition
• Increased mortality risk
PROGNOSIS
• Most of LGIB will stop spontaneously (80%)
• Continued bleeding occurred in 10-40% of cases
• About 5% of cases required surgical homeostasis
• Mortality <5%
• Patient who bleeds while hospitalized for separate disease- higher risk
of death than admitted for LGIB
TAKE HOME MESSAGE
• Prompt resuscitation is the first step in the management of LGIB
• Colonoscopy is the investigation of choice in the evaluation
• Angiography to be considered in patient hemodynamically unstable.
• Timely surgical consultation.
•THANK YOU

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Lower gi bleed

  • 1. DR. SUCHIT KUMAR SHAH MDGP-1st YEAR RESIDENT APPROACH TO LOWER GI BLEED • MODERATOR: Dr. Asraf Hussain
  • 2. APPROACH TO LOWER GI BLEED • IT WILL TAKE AROUND 30-45 MINUTES TO COMPLETE THE SESSION.
  • 4. GENERAL OBJECTIVES • AT THE END OF THE SESSION PARTICIPANTS WILL KNOW ABOUT LOWER GI BLEED AND ITS MANAGEMENT
  • 5. SPECIFIC OBJECTIVE • DEFINATION • ETIOLOGY • CLINICAL FEATURES AND APPROACH TO LOWER GI BLEED • DIAGNOSTIC AND THERAPUTIC MODALITIES IN ACUTE LOWER GI BLEED
  • 6. CLINICAL SENARIO • A 25 Year old male , resident of Birgung, occasional smoker, non alcoholic Low to moderate grade fever- 25 days Bleeding per rectum- 8 hours • Bright red • Profuse, intermittent • Not mixed with stool/mucus • Not associated with abdominal pain • No h/o significant weight loss / Loss of appetite
  • 7. ON EXAMINATION • GPE: Pallor++, severe dehydration+ • Pulse : 125/min • Bp : 80/50 mmHg • SYSTEMIC EXAMINATION Per abdomen- soft, non tender, no organomegaly • LAB Parameters: Hemoglobin: 5.6 g/dl Platelets, WBC- Normal LFT, RFT- pre Renal AKI
  • 8. GASTRO INTESTINAL BLEEDING • Presents with Hematemesis, hematochezia, Melena • Sequele of different etiologies- infection, vascular anomaly, inflammatory disease, trauma and Malignancy • While GI bleeding is potentially life threatening, can be safely managed in OPD basis • The management of GI bleed relies on prompt resuscitation, initial risk evaluation and appropriate definitive management.
  • 11. CLASSIFICATION OF LGI BLEED • Based on duration Acute – Recent duration( arbitrary<3days) Chronic- usually over a period of several days. • Based on presentation Overt- Frank hematochezia Occult-Presenting with Positive FOBT/ unexplained IDA Obscure- Bleeding of unknown origin that persists or recurs with negative bidirectional endoscopic procedures Can be occult or overt
  • 12. PROBLEM STATEMENT • 20% of all gastro intestinal bleeding is LGIB • Male> Female • Incidence increases by age. • 1-2% of Hospital Emergency • 80% acute LGIB resolve spontaneously • Overall mortality <5%
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  • 15. PRESENTATION OF LGIB • Hematochezia- passage of bright red blood, maroon stools, or blood clots Blood originating from left colon, rectum- bright red Blood originating from right colon- dark red or maroon color 15% hematochezia have UGIB as a source • Malena- Black tarry, foul smelling stool Ceacal or right colonic bleeding
  • 16. HISTORY TAKING • Hematochezia – painless Blood mixed with stool- colon carcinoma Blood streak on stool- rectal carcinoma Blood after defecation- haemorrhoids Blood with constipation- SRUS Blood alone – diverticular disease • Associated with Abdominal pain- Crohn’s disease Along with Fever- infective colitis. SRUS- solitary rectal ulcer syndrome
  • 17. HISTORY TAKING • Changes in bowel habit • Weight loss Past history of • Cardiovascular disease • Abdominal radiation • Diverticulosis • Recent colonoscopy and procedure • Steroids/ NSAIDS/ anti coagulants • Recurrent childhood bleeding
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  • 19. EXAMINATION • GENERAL PHYSICAL EXAMINATION Signs of dehydration Pallor- Severe acute GI bleed Icterus- Liver cell failure- Rectal varices Clubbing- IBD Pedal edema – Liver cell failure
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  • 22. APPROACH TO A PATIEN WITH LGIB • Patient presenting with hematochezia 1. Resuscitation and initial management 2. Definitive management i. Localization of bleeding site ii. Theraputic intervention to stop bleeding
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  • 31. DIAGNOSTIC AND THERAPUTIC MODALITIES ENDOSCOPIC METHOD • PROCTOSCOPY • FLEXIBLE SIGMIDOSCOPY • COLONOSCOPY • ENTEROSCOPY NON ENDOSCOPIC METHODS • CT ANGIOGRAPHY • CATHETER ANGIOGRAPHY • RADIO NUCLIDE IMAGING
  • 32. COLONOSCOPY • Colonoscopy is the investigation of choice in acute LGIB, unless bleeding is massive and patient is hemodynamically unstable. • The diagnostic yield of colonoscopy in LGIB- 48%-97% Bowel Preparation: Inadequate bowel preparation reduces the sensitivity to 21% 1. low cecal intubation rates 2. blood or stool in the lumen
  • 33. TIMING OF COLONOSCOPY • Early colonoscopy with 12-24 hours of admission associated with shorter hospital stay • Diagnostic yield increases when performed with active ongoing bleed • In patient with serious co morbid condition or no ongoing bleed delayed colonoscopy.
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  • 35. ADVANTAGES • Direct visualization of bleeding site • Precisely localizes the site of bleeding • To obtain biopsy specimens • Stigmata of recent bleeding 1.Active bleeding 2.Visible bleeding 3. Adherent clots • Therapeutic intervention
  • 36. COMPLICATIONS • Fluid overload • Aspiration pneumonia • Bowel perforation • Sepsis
  • 37. ENDOSCOPIC THERAPY • Injection • Thermal coagulation • Mechanical devices
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  • 40. MECHANICAL DEVICES • Used for active bleeding • Secure definitive bleeding control 1. Clips Placed either over or side of the bleeding source Clip retention time 2-4 week 2. Bands Mainly used for hemorrhoidal bleed Ligated at the neck of the lesion.
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  • 42. ENTEROSCOPY • Balloon enteroscopy • Capsule enteroscopy • Sound enterocopy
  • 43. BALLOON- ASSISTED ENTEROSCOPY • Two forms of balloon-assisted enteroscopy: 1. Double- balloon enteroscopy 2.Single balloon enteroscopy The enteroscopes – working length of 200 cm. Push-and Pull method, inflation and deflation of balloons and telescoping of the intestine onto the overtube. Balloon-assisted enteroscopy can be performed via the oral(anterograde) and aboral(retrograde) approach.
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  • 45. ADVANTAGES It allows deeper access to the small bowel than push enteroscopy The diagnostic yield- 60-80% Therapeutic intervention- 40-70% Total enteroscopy, success rate- 16-86%
  • 46. 2. CAPSULE ENDOSCOPY • 26 mm capsule containing a camera, transmitter and other accessories • 2 images per second and around 60000 images generated in 8 hours • Diagnostic yield of capsule endoscopy in LGIB is 40-80% • It is non invasive and patient friendly with low complication rate • Capsule retention can occur in 1.4% case mainly with stenosis. • Main drawbacks: No therapeutic intervention, process is passive.
  • 47. CT ANGIOGRAPHY • Diagnostic accuracy 0.3 mL/min • Sensitivity of 50-60% and Specificity of 92-95% • Identify site of bleeding and etiology of LGIB • Oral contrast not recommended • Diagnostic tool; no therapeutic intervention • It provides information about vascular anatomy endovascular intervention or surgical planning
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  • 49. CATHETER ANGIOGRAPHY • Recommended for patients- massive bleed and hemodynamically unstable, persistent or recurrent bleeding • Detects the bleed at the rate of 0.5-1 ml/min • High specificity-95-100% • Low sensitivity- 30-47%
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  • 53. EMBOLIZATION • Using coils, gel foam, poly vinyl alcohol particles- Success of 44-86%, Re- bleeding in about 15% of case High incidence of bowel ischemia- 20%
  • 54. SUPER SELECTIVE EMBOLIZATION • Target artery- the vasa –recta Along the marginal arteries and the distal intestinal arcades
  • 55. RADIONUCLIDE SCANNING • Radio labelled substances into patient blood stream and performing serial scintigraphy • Two methods exist- Tc99m sulfur colloid, Tc99m labelled RBC(latter is better) • The rate of bleeding detection is a low as 0.1-0.5 ml/min • PPV-45%, Diagnostic accuracy to localize the bleeding site-78% • Highly helpful in obscure bleeding.
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  • 59. ROLE OF SURGERY • Indicated as an emergency life saving procedure 1. Inability to maintain hemodynamically stability 2. Failure of available therapeutic modalities 3. Requiring blood transfusion more than 6 units within 24 hours 4. Recurrence of severe bleeding after initial control.
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  • 63. RE- BLEEDING IN ACUTE LGIB • Mean rate of acute re- bleeding- 22% late re-bleedin-16% • Factors predisposing rebleeding in LGIB 1. source of index bleeding 2. Initial hemostasis modality 3.Medication use 4. Co morbid condition • Increased mortality risk
  • 64. PROGNOSIS • Most of LGIB will stop spontaneously (80%) • Continued bleeding occurred in 10-40% of cases • About 5% of cases required surgical homeostasis • Mortality <5% • Patient who bleeds while hospitalized for separate disease- higher risk of death than admitted for LGIB
  • 65. TAKE HOME MESSAGE • Prompt resuscitation is the first step in the management of LGIB • Colonoscopy is the investigation of choice in the evaluation • Angiography to be considered in patient hemodynamically unstable. • Timely surgical consultation.