lower g.i.t bleed

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lower g.i.t bleed

  1. 1. LOWER G.I.T BLEED
  2. 2. G.I.BLEEDING DEFINITIONS       Acute versus chronic Upper (proximal to ligament of treitz) Lower(distal to ligament of treitz) Overt-clinical signs/symptoms present Occult-not clinically evident(FOBT + or iron def anemia) Obscure-routine evaluation
  3. 3. INTRODUCTION    Bleeding arising below the Ligament Of Treitz Either from the small intestine or from the colon Majority of the cases arise from colon specially the ANORECTAL region
  4. 4. HEMATOCHEZIA   Related term meaning FRESH BRIGHT RED BLOOD PER RECTUM
  5. 5. LOWER GI BLEED     Accounts for 24% of all GI bleeding Presentation can be malena(19%)or hematochezia(81%) Usually less severe than upper GI bleeding Mortality of 2-3.6%
  6. 6. TYPES (Depending upon patients age)     PATIENTS BELOW 50years OF AGE Inflammatory bowel diseases Infectious colitis due to Shigella,E.coli Anorectal diseases like Hemorrhoids, Anal fissures      PATIENTS ABOVE 50years OF AGE Diverticulosis Angiodysplasias Neoplasms Ischemic colitis
  7. 7. TYPES BASED ON BLEEDING     BLEEDING WITH PAIN Anal fissures Ischemic colitis Inflammatory bowel diseases     PAINLESS BLEEDING Internal hemorrhoids Diverticulosis Angiodysplasias
  8. 8. EPIDEMIOLOGY   Mortality is usually due to co-morbid conditions(like organ failure,AMI,aspiration,sepsis) Bleeding stops spontaneously>80% of the time.
  9. 9. SYMPTOMOLOGY AND EVALUATION     DIVERTICULOSIS Presents as MAROON or BRIGHT RED hematochezia Bleeding stops spontaneously Common in patients over 50 years of age
  10. 10. ANGIODYSPLASIA  Patient presents with painless bleeding  Common after 70 years of age
  11. 11. NEOPLASMS    Both benign polyps and carcinoma can cause bleeding Usually chronic occult bleeding May cause mild intermittent hematochezia
  12. 12. INFLAMATORY BOWEL DISEASE    Most commonly ulcerative colitis presents with diarrhea with occult blood or recurrent hematochezia,abdominal pain,tenesmus and urgency
  13. 13. ANORECTAL DISEASE Hemorrhoids present as painless bleeding mixed with stool or dipping into toilet bowl Painless small bleeding can occur in case of small fissure
  14. 14. ISCHEMIC COLITIS Seen in elderly especially those who have atherosclerosis presenting as bloody diarrhea with mild abdominal pain
  15. 15. DIAGNOSTIC PROTOCOLS       1.Rectal examination 2.Anoscopy and sigmoidoscopy 3.Nasogastric intubation 4.Technetium scan 5.Angiography 6.Colonoscopy
  16. 16.  RECTAL EXAM,SIGMOIDOSCOPY AND ANOSCOPY Digital examination anoscopy and sigmoidoscopy to look for anorectal diseases,inflammatory bowel disease or infectious colitis.
  17. 17. TECHNETIUM-99mRBC scan   Performed in active bleeding to detect source of bleeding Can also be performed for intermittent bleeding
  18. 18. ANGIOGRAPHY       In active bleeding it is the investigation of choice Selective angiography indicated for massive ongoing lower G.I bleeding or with recurrent bleeding and negative colonoscopy. Can detect rates of 0.5ml/min Can be used as therapy-coil embolization,alcohols,vasoconstrictors. 70-100%effective if positive Low rebleeding rate-12%
  19. 19. COLONOSCOPY    Performed if bleeding stops or occurs at slow rate Allows identification of angiodysplasia,tissue biopsy and therapeutic intervention with electrocautery heater probe or laser therapy of active bleeding Not helpful during massive bleeding
  20. 20. ASSESMENT      Includes history and examination Age Attention to vitals, volume status, oxygen saturation, urine output Evidence of liver disease Risk factors, use of NSAIDs,anticoagulation,co-morbidities,
  21. 21. LABORATORY ASSESMENT       Complete blood count Blood type and cross-match Coagulation factors PT,APTT Chemistry panel BUN/Cr ratio Bilirubin,albumin,INR to asses for hepatic synthetic dysfunctions
  22. 22. INITIAL MANAGEMENT      ABC management Oxygen I/v access FLUIDS ETT
  23. 23. MANAGEMENT If the patient has massive ongoing bleeding with homodynamic instability, urgent angiography is indicated If colonoscopy does not reveal a source, but bleeding continues-tagged RBC scan should be done to localize bleeding If colonoscopy doesn't reveal a source,but bleeding stops, observe patient.
  24. 24. SURGERY    Done on patients who have failed medical,colonoscopic,angiographic intervention Ongoing bleeding>4U of PRBC per 24h Effort should be made to localize the source prior to surgery.
  25. 25. SURGICAL PROCEDURES    Targeted subtotal colectomy Blind subtotal colectomy(high mortality) Blind segmental colectomy(high mortality and 54%re-bleeding rate-not preferred)
  26. 26. OCCULT LOWER GI BLEED     Loss of small blood that can not be seen Detected in 2 settings FOBT + Iron def anemia
  27. 27. CONCLUSION      Always remember to treat the patient Resuscitate-ABC Correct coagulopathy Patient die from co-morbidities Gi bleeding requires a multidisciplinary approach-critical care,medicine,G.I radiology and surgery.
  28. 28. THANK YOU

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