1. Asso. Prof. Utham Murali. M.S ; M.B.A.
IMS / MSU / Malaysia.
Lower GI - Bleed

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 - > 10 ml / day

3. 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)

6. Massive Bleeding
 Presents as a large volume of
bright red blood PR
 Bleeding > 1.5 l / 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
Moderate Bleeding
 Presents as haematochezia
or malena
 Hemodynamically stable
 Causes – Ano-rectal / Cong./
Infla.& Neoplastic diseases
 Initial ↓ in hematocrit level
of 8 g / dL or less

7. Occult Blood
 Detected by routine chemical
tests of the stool, with or
without systemic evidence of
chronic blood loss.
 10 ml. of blood loss / day is
necessary to have stool
occult blood positive.

8. Types
Aetiology
Site of Bleeding
Pain + / -
Classification

9. Aetiology – General causes
1. Congenital -
Polyp’s / Meckel’s diverticulum / HHT
2. Infammatory -
Ulcerative colitis / Infective /Amoebic / Crohn’s disease
3. Neoplastic –
Adenomas / Carcinomas / Polyps
4. Vascular –
Angiodysplasia / Ischaemic colitis / Vasculitis / Hamangioma
5. Clotting disorders -
Haemophilia / Leukaemia / Warfarin therapy / DIC
6. Miscellaneous –
Piles / Anal fissure / Injury to rectum

10. Site – Local causes
1. Small Intestine -
Polyp’s / Meckel’s diverticulum / Ulcers / Tumours
/ Intussusception
2. Large intestine -
Angiodysplasia / Carcinomas / Colitis / Diverticulitis
3. Perianal –
Injury / Rupture(Haematoma /Anorectal abscess)
/ Carcinoma / Condyloma
4. Anal -
Piles / Anal fissure / Carcinoma / Fistula-in-ano

11. With Pain
 Fissure in Ano
 Fistula in Ano
 Ca. Anal Canal
 Rup. perianal haematoma
 Rup. Ano Rectal abscess
 Endometriosis
 Injury

12. Without Pain
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. Ischaemic Colon
4. Blood Streaked on stool
a. Ca. Rectum

13. Common Causes
Acute Sub-acute / Chronic
Diverticular disease Anal disease
Mesenteric ischaemia Inflammatory bowel disease
Angiodysplasia Large polyps
Ischaemic colitis Carcinoma
Meckel’s diverticulum Solitary rectal ulcer
Intussusception Radiation enteritis

14. Differential Diagnosis

15. 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
Note : Ask & Look for bleeding tendency

16. Relation to Defecation
 Streak of fresh blood – FIA
 At the time of passing stool –
Bright red & Splashes over the pan
- Piles
 Other than during defecation -
Polyps / PP / RP / Ca / UC
 Bleeding per anum in child –
Polyp

17. OTHERS
 Pain
 Altered bowel habits
 Anaemia / Malnutrition / LOW / LOA
 Mass palpable PA – Rt /Lt / MOI
 Per-rectal exam – Very important

18. Investigations
1. Blood Tests –
a. Hb% / PCV / LFT
b. Coag. Profile / RFT
2. Stool examination -
a. Ova / cyst / worms
b. Occult blood – FOBT

19. Investigations - Contd
Small Bowel Enema Barium Enema

20. Investigations - Contd
Proctoscopy Sigmoidoscopy

21. Investigations - Contd
Colonoscopy – Gold Standard

22. Investigations - Contd
Colonoscopy – Gold Standard

23. Investigations - Contd
Colonoscopy – Gold Standard

24. Investigations - Contd
Colonoscopy – Gold Standard

25. Investigations - Contd
5. U/S abdomen –
6. Angiography –
Identifies bleeding rate of 0.5ml/mt
All 3 vessels – are used
Angiodysplasia / Tumours
/ Vasculitis – diagnosed
7. Radionuclear scanning –
Identifies 0.1ml / mt
Tc labelled sulphur colloid
/ tagged RBC scan

26. Investigations - Contd
Capsule Endoscopy CT / MRI - Angiography

27. Treatment
Cause is treated
Proper exploration – lengthy midline incision – essential
Endoscopic polypectomy for polyps
Massive resection – small bowel – mesenteric ischemia
Surgical resection – colonic carcinoma
Sigmoid colectomy – sigmoid diverticula
Endoscopic fulguration / therapeutic embolization / Rt.hemicolectomy
for angiodysplasia
Drugs / Mesacol enema / Total proctocolectomy i IA anastomosis
for ulcerative colitis
Excision & ligation – piles

29. References