2. Definition
• Lower GI - bleeding is defined as abnormal hemorrhage into
the lumen of the bowel from a source distal to the ligament
of Treitz.
• Normal faecal blood loss - 1.2 ml/day
• Significant - > 10ml/day
3. Anatomy
The lower gastrointestinal tract comprises of:
(a) Bowel or intestine
Small intestine, which has three parts:
Duodenum - Starts from Ligament of Trietz
Jejunum
Ileum
Large intestine, which has three parts:
Cecum (the vermiform appendix is attached to the
cecum).
Colon (ascending colon, transverse colon, descending
colon and sigmoid flexure)
Rectum
(b) Anus
4. Ligament of TREITZ (Suspensory ligament/muscle
of duodenum )
A fibromuscular band that suspends duodenojejunal flexure from right crus of
diaphragm (a surgical landmark of duodenojejunal flexure)
6. Lymphatic drainage of small intestine
The small intestine is anchored to the abdominal by the
mesentery, a key structure involved in its lymphatics. The
mesentery contains an extensive lymphatic network of
approximately 150 lymph nodes which are arranged into
three stations:
the juxta-intestinal nodes (found along peripheral arterial
arcades)
the intermediate mesenteric nodes (along the jejunal and
ileal arteries), and
(central) superior mesenteric nodes (along the length of
the superior mesenteric artery).
Lymph from the lacteal passes sequentially through these
group of lymph nodes before finally ending up in the
superior mesenteric lymph nodes. Lymph from the
proximal duodenum flows through superior
pancreaticoduodenal, pyloric, hepatic lymph nodes which
drains to the celiac lymph nodes
7. Blood supply of Large intestine
Foregut; celiac
trunk
Midgut; Superior
mesenteric artery
Hindgut; Inferior
mesenteric artey
Superior and
Inferior mesenteric
arteries are
connected by
marginal artery of
Drummond
8.
9. Venous drainage
Drains into
1.Inferior mesenteric vein which joins with splenic vein then
2.Superior mesenteric vein to form Portal vein to flow into
liver
12. • Mesenteries are double layers of peritoneum in the abdominal cavity.
• They are the continuations of the visceral and parietal peritoneum with the serous
membranes adhered back to back so that the outer mesothelium secretes serous fluid
into the peritoneal cavity.
Mesentry
16. Presentation
Lower GI Bleeding typically presents with :
1. Hematochezia (which can range from bright-red blood to old
clots)
2. Melena (If the bleeding is slower or from a more proximal
source)
17.
18. • Presents as a large volume of bright red
blood PR
• Bleeding > 1.5 I / day
• Hemodynamic instability & shock
• in hematocrit level of 6 g / dL
• Common causes - D / A
• Transfusion of at least 2 units of packed
red blood cells
• Bleeding that continues for 3 days
Massive Bleeding
19. • Presents as haematochezia
or malena
• Hemodynamically stable
• Causes - Ano-rectal /
Cong./Infla.& Neoplastic
diseases
• Initial in hematocrit level
of 8 g / dL or less
Moderate Bleeding
20. Occult Blood
Detected by routine chemical
tests of the stool, with or
without systematic evidence of
chronic blood loss.
10 ml. of blood loss / day is
necessary to have stool
occult blood positive.
25. Painful
Fissure in Ano
Fistula in Ano
Ca. Anal Canal
Rup. perianal haematoma
Rup. Ano Rectal abscess
Endometriosis
Injury
26. Painless
1. Blood Alone
a. Polyp
b. Villous Adenoma
c. Diverticular diseases
2. Blood After Defecation
a. Hemorrhoids
3. Blood with mucus
a. Ulcerative colitis
b. Intussusception
c. Ishaemic Colon
4. Blood Streaked on stool
a. Ca. Rectum
27. Clinical Presentations
Bleeding Per rectum -
• Bright red blood - Piles / Polyps / Fissure
• Altered blood - Ca / Ulcer / IBD / Dysentery
• Maroon colour - Meckel's diverticulum
• Streaks of blood- Anal fissure
• Splash in pan - Piles
• Red currant jelly- Intussusception
• Blood with mucus - Colitis / Ca / Dysentery
28. If your bleeding starts abruptly and
progresses rapidly, you could go into
shock. Signs and symptoms of shock
include:
Vomiting blood, which might be
dark brown and resemble coffee
grounds in texture
Lightheadedness
Difficulty breathing
Fainting
Chest pain
Abdominal pain
Anemia
Drop in blood pressure
Not urinating or urinating
infrequently, in small amounts
Rapid pulse
Unconsciousness
29. Patient Assessment
1. AIRWAY
Drowsy patient -vomiting/ hematemesis is present ,then there is
increased risk of aspiration so,patient should be electively intubated
2. BREATHING
Provide supplemental oxygen
To keep SPO2 >95%
3. CIRCULATION
Intravenous access - bilateral with 2 large bore cannulae (16-gauge
minimum)
Rapid IV crystalloid infusion
30. Vitals
• Blood pressure, heart rate, Any postural hypotension
(Tachycardia is an early sign of shock)
• Narrowing pulse pressure (ind systolic hypotension)
• Patient’s conscious level – confused (shock)
• Compare current vitals with vitals in ED –
is there a worsening trend?
-Urine output:
General
inspection
• Pallor
• Confusion
Peripheries
• Signs of dehydration-CRT
• Any skin manifestation of IBD
Abdomen
• Any tenderness , epigastric mass
• Distension (++ blood in stomach)
31. Digital rectal
examination
• Any anal fissures or prolapsed hemorrhoids seen
• Hematoschezia,
• Rectal mass
Then proceed with proctoscope to look for any source of bleeding,active bleeding,mass
