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Dr Anshuman Aashu
1st year PGT,
Department of General Surgery,
IPGME&R
INTRODUCTION
 Bleeding distal to the ligament of Treitz.
 One of the most common symptoms to be
encountered in the out patients department.
 About 20% as common as the upper GI bleeding.
 Most often the colon is involved. Small intestine
involved in only 5% of cases.
 Male predominance.
 Incidence increases with age of the patient.
 Most of the time bleeding is intermittent with
spontaneous stoppage.
 Upto 42% of cases have multiple bleeding sites.
 Presentation ranges from intermittent mild bleeding
to severe hemorrhage with hemodynamic instability.
 Hematochezia (passage of bright red blood from
retum that may or may not be mixed with stool) is
more common presentation.
 Melena (passage of black tarry sticky stool) may
appear with lower GI bleeding when source is higher
up or the intestinal transit time is fairly slow.
 Massive upper GI bleeding may present as bleeding
P/R.
ETIOLOGY
 Diverticular diseases,
 Benign anorectal diseases,
 Fissure in ano,
 Hemorrhoids,
 Neoplasia,
 Ischemia,
 Colitis,
 Inflammatory bowel diseases,
 Infectious colitis,
 Radiation exposure,
 Angiodysplasia,
 Meckel’s diverticulum,
 Aortoenteric Fistula.
 Other systemic causes like coagulopathy.
ACUTE LOWER GI BLEEDING
 Acute lower GI bleeding should be treated as any other
surgical emergency.
 Fundamental principles of initial evaluation and
management must be followed.
 Initial management in acute lower GI bleed is the
same as acute upper GI bleed with similar approach for
initial assessment, risk stratification, resuscitation and
localization.
INITIAL ASSESSMENT
 The ABC of initial emergency management followed
here also.
 Adequacy of airway and breathing is assessed and
assured.
 Assessment of hemodynamic status:
 Obtundation, agitation, hypotension (supine SBP<90)
with cold clammy peripheries – Hemorrhagic shock
(>40% of blood volume loss)
 Resting heart rate >100, decreased pulse pressure – loss
of 20-40% of blood volume.
 Fall in BP >10 mm of Hg or elevation of heart rate >20
beats with postural changes – at least 20% blood volume
lost.
RISK STARTIFICATION
 Risk factors for morbidity and mortality on Acute GI
Hemorrhage:
 Age>60 years
 Comorbid diseases – Renal, liver, respiratory, cardiac.
 Magnitude of hemorrhage
 Persistent or recurrent hemorrhage
 Onset of hemorrhage during hospitalisation
 Need for Surgery.
 BLEED: a classification tool to predict outcome
 B: continuous Bleeding.
 L: Low blood pressure (SBP<100).
 E: Elevated prothrombin time (>1.2 times the control).
 E: Erratic mental status.
 D: comorbid Diseases.
 Presence of any one of them indicates high-risk and
increased incidence of inhospital complications.
RESUSCITATION
 More severe the bleeding, more aggressive the
resuscitation.
 Single leading cause of morbidity and mortality is
multiorgan failure related to inadequate initial or
subsequent resuscitation.
 Initial resuscitaion should be done with bolus
crystalloid solution, usually RL.
 Supplemental oxygen, monitoring of urine output.
 Assessment of the response to fluid administration.
 Administration of blood depends upon the initial
effects of crystalloid infusion and patient’s ongoing
hemodynamic parameters.
 Hematocrit >30 in older adults and >20 in young.
LOCALIZATION
 Clinical presentation, history and physical
examination.
 Urgent NG aspiration and proctoscopic examination to
rule out Upper GI bleeding and identify ano-rectal
causes resepectively.
 Unstable patients shifted to operating room and
managed accordingly with serial clamping or
intraoperative enteroscopy and guided resection.
 In stable patients, colonoscopy, tagged RBC scan or
angiography useful for localization.
 Capsule endoscopy, double balloon endoscopy helpful
in obscure bleeding.
COLONOSCOPY
 Most appropriate in the setting of minimal to
moderate bleeding.
 Urgent colonoscopy in major bleeding is usually less
revealing as bleeding itself obscures vision.
 Gentle preparation of the bowel is helpful.
 Helpful in identifying source of bleeding in upto 95%
cases.
 Beneficial as has got therapeutic role as well.
 May identify diverticula, angiodysplasia, colitis or
neoplastic lesions as source of bleeding.
RADIONUCLIDE SCANNING
 Technitium-99m labeled RBCs.
 Most sensitive but least accurate.
 Patients own red cells are labeled and reinjected.
 Can detect bleeding as slow as 0.1 ml/min and is >90%
sensitive.
 Reported acuracy is 40-60%.
 Not useful as definitive study before surgery but useful
as guide to the usefulness of angiography.
 Negative RBC scan indicates that angiography will be
unrevealing.
MESENTRIC ANGIOGRAPHY
 Used for diagnosis of ongoing hemorrhage.
 Can detect hemorrhage in the range of 0.5-1.0 ml/min.
 Less sensitive but more accurate than RBC scan.
 Particularly useful in diagnosing AVMs such as
angiodysplasia.
 Major advantage being the therapeutic potential.
 Local injection of vasopressin or other
vasoconstrictors, or embolization that may be
temporary (gelfoam) or permanent (coils).
TREATMENT
 Pharmacologic,
 Endoscopic,
 Angiographic,
 Surgical:
 Hemodynamic instability despite vigourous
resuscitation (>6U transfusion).
 Failure of endoscopic techniques.
 Recurrent Hemorrhage (with upto 2 attempts at
obtaining endoscopic hemostasis.
 Shock.
 Continued slow bleeding with tenasfusion requirement
>3U/day.
SURGICAL THERAPY
 First objective in surgery focuses on the location of the
intraluminal blood with the goal of segmentally
isolating the possible sources of bleeding.
 If no source appears obvious, may consider intestinal
enteroscopy.
 If the source of bleeding cannot be found, and it
appears to arise from the colon, the surgeon should
perform a subtotal or total colectomy
 Stable patients will tolerate a primary ileosigmoid or
ileorectal anastomosis
 Unstable patients require an end ileostomy with closure
of the rectal stump or a mucous fistula
DIVERTICULAR CAUSES
 Outpuching of the mucosa and submucosa through
defects in the muscular layer of the bowel at sites of
penetration of the vasa recta.
 Sigmoid colon most common site.
 Most significant cause of significant lower GI bleeding
in the western world, upto 55%.
 Bleeding generally occurs at the neck of the
diverticulum.
 In upto 75% of cases bleeding stops spontaneously
with upto 10% risk of rebleeding within 5 years.
 Best method of diagnosis and treatment is
colonoscopy.
 Endoscopic injection of
epinehrine,
electrocoagulation, endoscopic
clips successfully employed.
 Failure of these maneuvres
lead to consideration of
angiographic embolization.
(success rate >90%)
 Failure of all these techniques
warrant surgical treatment in
the form of segmental
resection (if source defined) or
subtotal colectomy (source
unidentified).
ANGIODYSPLASIA
 Arterio-venous malformation (AVM) of the GI tract.
 Cecum is the most common site.
 Unlike hemangiomas and other true congenital AVMs,
these are acquired degenerative lesions secondary to
progressive dilation of normal blood vessels within the
submucosa of the intestine.
 Presentation with chronic bleeding more common but
may present as acute severe bleeding.
 Can be diagnosed by either colonoscopy or
angiography.
 On colonoscopy, seen as red
stellate lesion with
surrounding pale mucosa.
 In unstable patients with
mesentric casoconstriction,
visualisation in colonosopy is
particularly difficult.
 Managed usually with
endosopic and angiographic
techniques.
 Surgery reserved for cases
that don’t respond or rebleed.
Segmental resection is
sufficient.
NEOPLASIA
 Colorectal carcinoma is the most important cause to
rule out.
 Bleeding is usually painless, intermittent and slow in
nature.
 Benign polyps are unusual causes of lower GI bleeding
in elderly but Juvenile polyp is the 2nd most common
cause in patients <20 years of age.
 Diagnosed by colonoscopy and treated accodingly after
proper staging and workup.
HEMORRHOIDS
 One of the most common causes of bleeding p/r in our
part of the world.
 Usually low volume, fresh bleeding seen in toilet as
splash in the pan or on toilet papers.
 Unless complicated, are usually painless.
 Patients often present with iron deficiency anemia.
 Managed conservatively with dietary modifications.
 Minimally invasive techniques like sclerotheraphy,
infrared coagulation, band ligation etc may be used.
 Surgical treatment is hemorrhoidectomy or stapled
hemorrhoidopexy for unresponsive cases.
FISSURE IN ANO
 Presents with painful defecation with streak of fresh
blood over the stool.
 Usually associated with constipation.
 Canoe shaped ulcer seen, most commonly, in posterior
midline at anal verge.
 Bleeding is seldom massive.
 Dietary modification with bulk forming agents and
stool softeners often used.
 Topical muscle relaxant ointment relieves sphincteric
spasm and helps in ulcer healing.
 Lateral sphincterotomy is the surgical option in
unresolving cases.
INFLAMMATORY BOWEL DISEASES
 IBD is a common cause of lower GI bleed with UC
involved more often than CD.
 Crampy abdominal pain, tenesmus with sometimes
over 20 episodes of bloody diarrhea in a day.
 Diagnosis is usually done with colonoscopy and guided
biopsy from the lesion.
 Medical management with steroids, 5-ASA and
immunomodulators are quite effective.
 Surgery indicated in acute cases with toxic megacolon
or hemorrhage refractory to medical management.
MESENTERIC ISCHEMIA
 Predisposing factors include pre-existing
cardiovascular disease, recent abdominal vascular
surgery, hypercoagulable states and vascuiltis.
 Acute colonic ischemia is the most common type of
mesenteric ischemia.
 Tends to occur in watershed areas of splenic flexure
and recto-sigmoid junction.
 Patient presents as pain with bloody diarrhea.
 Diagnosis confirmed by flexible endoscopy.
 Treatment consists of supportive therapy with bowel
rest, IV antibiotics, cardiovascular support.
 Features of peritonitis indicate surgical management.
OBSCURE GI BLEEDING
 Bleeding that persists or recurs after an initial negative
evaluation with an EGD and colonoscopy.
 Further subdivided into obscured-occult or overt
bleeding.
 Occult bleeding presents with iron deficiency anemia
and guaiac positive stool without visible bleeding.
 Often treated with iron supplementation only.
 Obscured-overt bleeding is usually due to small
intestinal lesions.
 Crohn’s disease, Meckel’s diverticulum, small bowel
erosions or NSAIDs use and radiation exposure are the
common causes.
 Very frustrating for both the physician and the patient
as the cause is most often not identified.
 Repeat endoscopy is are helpful in identifying missed
lesion in upto 35% patients.
 Small bowel enteroclysis was a commonly used
diagnostic technique that is now rarely used as yield
was too low and test is poorly tolerated.
 Video capsule endoscopy and small bowel endoscopy
with pediatric colonoscope (push endoscope) or
double balloon endoscopy are useful techniques of
localisation of bleeding.
 Intraoperative endoscopy is useful in those patients in
whom exhaustive search has failed to identify a source.
 Endoscope is usually introduced through an
enterotomy in the small bowel.
 Upto 25% cases remain undiagnosed and 33-50% of
patients have rebleeding within 3-5 years.
 Management strategy is planned as and according to
the cause identified.
 Long term iron supplementation with intermittent
blood transfusion is occasionally necessary in
undiagnosed cases, though this approach is not
appealing.
Lower Gastro-Intestinal Bleed
Lower Gastro-Intestinal Bleed

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Lower Gastro-Intestinal Bleed

  • 1. Dr Anshuman Aashu 1st year PGT, Department of General Surgery, IPGME&R
  • 2. INTRODUCTION  Bleeding distal to the ligament of Treitz.  One of the most common symptoms to be encountered in the out patients department.  About 20% as common as the upper GI bleeding.  Most often the colon is involved. Small intestine involved in only 5% of cases.  Male predominance.  Incidence increases with age of the patient.
  • 3.  Most of the time bleeding is intermittent with spontaneous stoppage.  Upto 42% of cases have multiple bleeding sites.  Presentation ranges from intermittent mild bleeding to severe hemorrhage with hemodynamic instability.  Hematochezia (passage of bright red blood from retum that may or may not be mixed with stool) is more common presentation.  Melena (passage of black tarry sticky stool) may appear with lower GI bleeding when source is higher up or the intestinal transit time is fairly slow.  Massive upper GI bleeding may present as bleeding P/R.
  • 5.  Diverticular diseases,  Benign anorectal diseases,  Fissure in ano,  Hemorrhoids,  Neoplasia,  Ischemia,  Colitis,  Inflammatory bowel diseases,  Infectious colitis,  Radiation exposure,  Angiodysplasia,  Meckel’s diverticulum,  Aortoenteric Fistula.  Other systemic causes like coagulopathy.
  • 6. ACUTE LOWER GI BLEEDING  Acute lower GI bleeding should be treated as any other surgical emergency.  Fundamental principles of initial evaluation and management must be followed.  Initial management in acute lower GI bleed is the same as acute upper GI bleed with similar approach for initial assessment, risk stratification, resuscitation and localization.
  • 7.
  • 8. INITIAL ASSESSMENT  The ABC of initial emergency management followed here also.  Adequacy of airway and breathing is assessed and assured.  Assessment of hemodynamic status:  Obtundation, agitation, hypotension (supine SBP<90) with cold clammy peripheries – Hemorrhagic shock (>40% of blood volume loss)  Resting heart rate >100, decreased pulse pressure – loss of 20-40% of blood volume.  Fall in BP >10 mm of Hg or elevation of heart rate >20 beats with postural changes – at least 20% blood volume lost.
  • 9. RISK STARTIFICATION  Risk factors for morbidity and mortality on Acute GI Hemorrhage:  Age>60 years  Comorbid diseases – Renal, liver, respiratory, cardiac.  Magnitude of hemorrhage  Persistent or recurrent hemorrhage  Onset of hemorrhage during hospitalisation  Need for Surgery.
  • 10.  BLEED: a classification tool to predict outcome  B: continuous Bleeding.  L: Low blood pressure (SBP<100).  E: Elevated prothrombin time (>1.2 times the control).  E: Erratic mental status.  D: comorbid Diseases.  Presence of any one of them indicates high-risk and increased incidence of inhospital complications.
  • 11. RESUSCITATION  More severe the bleeding, more aggressive the resuscitation.  Single leading cause of morbidity and mortality is multiorgan failure related to inadequate initial or subsequent resuscitation.  Initial resuscitaion should be done with bolus crystalloid solution, usually RL.  Supplemental oxygen, monitoring of urine output.  Assessment of the response to fluid administration.  Administration of blood depends upon the initial effects of crystalloid infusion and patient’s ongoing hemodynamic parameters.  Hematocrit >30 in older adults and >20 in young.
  • 12. LOCALIZATION  Clinical presentation, history and physical examination.  Urgent NG aspiration and proctoscopic examination to rule out Upper GI bleeding and identify ano-rectal causes resepectively.  Unstable patients shifted to operating room and managed accordingly with serial clamping or intraoperative enteroscopy and guided resection.  In stable patients, colonoscopy, tagged RBC scan or angiography useful for localization.  Capsule endoscopy, double balloon endoscopy helpful in obscure bleeding.
  • 13. COLONOSCOPY  Most appropriate in the setting of minimal to moderate bleeding.  Urgent colonoscopy in major bleeding is usually less revealing as bleeding itself obscures vision.  Gentle preparation of the bowel is helpful.  Helpful in identifying source of bleeding in upto 95% cases.  Beneficial as has got therapeutic role as well.  May identify diverticula, angiodysplasia, colitis or neoplastic lesions as source of bleeding.
  • 14. RADIONUCLIDE SCANNING  Technitium-99m labeled RBCs.  Most sensitive but least accurate.  Patients own red cells are labeled and reinjected.  Can detect bleeding as slow as 0.1 ml/min and is >90% sensitive.  Reported acuracy is 40-60%.  Not useful as definitive study before surgery but useful as guide to the usefulness of angiography.  Negative RBC scan indicates that angiography will be unrevealing.
  • 15.
  • 16. MESENTRIC ANGIOGRAPHY  Used for diagnosis of ongoing hemorrhage.  Can detect hemorrhage in the range of 0.5-1.0 ml/min.  Less sensitive but more accurate than RBC scan.  Particularly useful in diagnosing AVMs such as angiodysplasia.  Major advantage being the therapeutic potential.  Local injection of vasopressin or other vasoconstrictors, or embolization that may be temporary (gelfoam) or permanent (coils).
  • 17. TREATMENT  Pharmacologic,  Endoscopic,  Angiographic,  Surgical:  Hemodynamic instability despite vigourous resuscitation (>6U transfusion).  Failure of endoscopic techniques.  Recurrent Hemorrhage (with upto 2 attempts at obtaining endoscopic hemostasis.  Shock.  Continued slow bleeding with tenasfusion requirement >3U/day.
  • 18. SURGICAL THERAPY  First objective in surgery focuses on the location of the intraluminal blood with the goal of segmentally isolating the possible sources of bleeding.  If no source appears obvious, may consider intestinal enteroscopy.  If the source of bleeding cannot be found, and it appears to arise from the colon, the surgeon should perform a subtotal or total colectomy  Stable patients will tolerate a primary ileosigmoid or ileorectal anastomosis  Unstable patients require an end ileostomy with closure of the rectal stump or a mucous fistula
  • 19.
  • 20. DIVERTICULAR CAUSES  Outpuching of the mucosa and submucosa through defects in the muscular layer of the bowel at sites of penetration of the vasa recta.  Sigmoid colon most common site.  Most significant cause of significant lower GI bleeding in the western world, upto 55%.  Bleeding generally occurs at the neck of the diverticulum.  In upto 75% of cases bleeding stops spontaneously with upto 10% risk of rebleeding within 5 years.  Best method of diagnosis and treatment is colonoscopy.
  • 21.  Endoscopic injection of epinehrine, electrocoagulation, endoscopic clips successfully employed.  Failure of these maneuvres lead to consideration of angiographic embolization. (success rate >90%)  Failure of all these techniques warrant surgical treatment in the form of segmental resection (if source defined) or subtotal colectomy (source unidentified).
  • 22. ANGIODYSPLASIA  Arterio-venous malformation (AVM) of the GI tract.  Cecum is the most common site.  Unlike hemangiomas and other true congenital AVMs, these are acquired degenerative lesions secondary to progressive dilation of normal blood vessels within the submucosa of the intestine.  Presentation with chronic bleeding more common but may present as acute severe bleeding.  Can be diagnosed by either colonoscopy or angiography.
  • 23.  On colonoscopy, seen as red stellate lesion with surrounding pale mucosa.  In unstable patients with mesentric casoconstriction, visualisation in colonosopy is particularly difficult.  Managed usually with endosopic and angiographic techniques.  Surgery reserved for cases that don’t respond or rebleed. Segmental resection is sufficient.
  • 24. NEOPLASIA  Colorectal carcinoma is the most important cause to rule out.  Bleeding is usually painless, intermittent and slow in nature.  Benign polyps are unusual causes of lower GI bleeding in elderly but Juvenile polyp is the 2nd most common cause in patients <20 years of age.  Diagnosed by colonoscopy and treated accodingly after proper staging and workup.
  • 25. HEMORRHOIDS  One of the most common causes of bleeding p/r in our part of the world.  Usually low volume, fresh bleeding seen in toilet as splash in the pan or on toilet papers.  Unless complicated, are usually painless.  Patients often present with iron deficiency anemia.  Managed conservatively with dietary modifications.  Minimally invasive techniques like sclerotheraphy, infrared coagulation, band ligation etc may be used.  Surgical treatment is hemorrhoidectomy or stapled hemorrhoidopexy for unresponsive cases.
  • 26.
  • 27. FISSURE IN ANO  Presents with painful defecation with streak of fresh blood over the stool.  Usually associated with constipation.  Canoe shaped ulcer seen, most commonly, in posterior midline at anal verge.  Bleeding is seldom massive.  Dietary modification with bulk forming agents and stool softeners often used.  Topical muscle relaxant ointment relieves sphincteric spasm and helps in ulcer healing.  Lateral sphincterotomy is the surgical option in unresolving cases.
  • 28. INFLAMMATORY BOWEL DISEASES  IBD is a common cause of lower GI bleed with UC involved more often than CD.  Crampy abdominal pain, tenesmus with sometimes over 20 episodes of bloody diarrhea in a day.  Diagnosis is usually done with colonoscopy and guided biopsy from the lesion.  Medical management with steroids, 5-ASA and immunomodulators are quite effective.  Surgery indicated in acute cases with toxic megacolon or hemorrhage refractory to medical management.
  • 29. MESENTERIC ISCHEMIA  Predisposing factors include pre-existing cardiovascular disease, recent abdominal vascular surgery, hypercoagulable states and vascuiltis.  Acute colonic ischemia is the most common type of mesenteric ischemia.  Tends to occur in watershed areas of splenic flexure and recto-sigmoid junction.  Patient presents as pain with bloody diarrhea.  Diagnosis confirmed by flexible endoscopy.  Treatment consists of supportive therapy with bowel rest, IV antibiotics, cardiovascular support.  Features of peritonitis indicate surgical management.
  • 30. OBSCURE GI BLEEDING  Bleeding that persists or recurs after an initial negative evaluation with an EGD and colonoscopy.  Further subdivided into obscured-occult or overt bleeding.  Occult bleeding presents with iron deficiency anemia and guaiac positive stool without visible bleeding.  Often treated with iron supplementation only.  Obscured-overt bleeding is usually due to small intestinal lesions.
  • 31.  Crohn’s disease, Meckel’s diverticulum, small bowel erosions or NSAIDs use and radiation exposure are the common causes.  Very frustrating for both the physician and the patient as the cause is most often not identified.  Repeat endoscopy is are helpful in identifying missed lesion in upto 35% patients.  Small bowel enteroclysis was a commonly used diagnostic technique that is now rarely used as yield was too low and test is poorly tolerated.  Video capsule endoscopy and small bowel endoscopy with pediatric colonoscope (push endoscope) or double balloon endoscopy are useful techniques of localisation of bleeding.
  • 32.  Intraoperative endoscopy is useful in those patients in whom exhaustive search has failed to identify a source.  Endoscope is usually introduced through an enterotomy in the small bowel.  Upto 25% cases remain undiagnosed and 33-50% of patients have rebleeding within 3-5 years.  Management strategy is planned as and according to the cause identified.  Long term iron supplementation with intermittent blood transfusion is occasionally necessary in undiagnosed cases, though this approach is not appealing.