ONLY DISCUSSION OF CAUSES

1. LOWER GI BLEEDING
-MANOJIT SARKAR
JR,NRSMCH
-DEPT OF SURGERY

2. Clinical types
• Occult LGI bleeding:>10ml/day but not revealed
• Overt LGI bleeding: bledding which revealed
 Overt acute
Overt acute massive(1.5 lits/day)
Overt chronic
• Obscure LGI bleeding:It is the intermittent GI bleed for which no
source has been found radiologically or endoscopically

4. Discussion of causes of Lower GI Bleeding

5. Anorectal diseases(benign)
• Hemorrhoids
• Fissure in ano

6. Hemorrhoids/Piles
Clinical types:
 Internal-above the dentate line and covered by mucous membrane
 External-below the dentate line and covered by skin
 Intero-external-both together
Anatomical classification:
 Primary:located at 3,7,11 o clock position
 Secondary: between the primary sites

7. Grading/degree of internal hemorrhoides

8. Treatment
• 1st degree & 2nd degree:
Medical:
Fibre diet(35gm/day),plenty of water,sitz bath(20mins/2s-
3times/day),laxatives(lactulose),local anesthetics to reduce pain,anti infammatory and
antibiotics
Interventional:
Sclerotherapy:scleoscent(polidocanol) causes fibrosis in the submucosal plane-95% cure
rate.C/I:thrombosed piles or prolapsed piles,in presence of proctitis,pregnancy
Infrared coagulation:It coagulates tissue proteins which heals to form scar & reduces blood
flow through hemorrhoids therby shirnking it.
C/I:external piles,proctitis
Barron’s banding:
It causes ischemic necrosis.Band should be placed above the dentate
line.C/I:fissure,fistula,proctitis.
Surgical:
Failure of non operative methods-Hemorrohoidectomy

9. 3rd degree:
Barron’s banding
Infrared coagulation
Cryosurgery:use of nitrous oxide(-98 deg) to coagulate & necrosis of
the piles
Operative:hemorrhoidectomy

10. • 4th degree:
Stapled hemorrhoidopexy:( Minimally invasive procedure)
It is circumferential excision of the mucosa & submucosa 4cm above
the dentate line
Adv:less painful,less blood loss & faster recovery
D/a:may cause full thickness excision of rectal wall,may injure anal
sphincter,incomplete purse string leads to hemorrhage
c/I:a/w fissure & fistula
Hemorrhoidectomy:Milligan morgan(commonly done),submucosal
hemorrhoidectomy of park,Hill ferguson closed method

11. Anal fissure
• Acute :deep tear in the lower anal skin with severe sphinteric spasm
without edema & inflammation
• Chronic:inflamed,indurated with scar tissue.lower part of fissure appears
like guarding of fissure-sentinel piles
• Treatment:
General measures:adequate fluid intake(6-8 glasses of water),fibre rich
diet,stool softners,sitz bath
Acute fissure:stretching of anal sphincter 4 fingers method or lord’s
dilatation under (GA)oint.nifedipine/diltiazem(2%)
Chronic fissure:lateral anal sphincterotomy,dorsal fissurectomy with
sphincterotomy

12. Inflammatory causes
• Crohn’s disease
• Ulcerative colitis
• Amoebic colitis
• Diverticulitis

15. • Crohn’s disease:
Indication of surgery:
Failure of medical treatment
Intestinal obstruction(m/c indication)
Stricture formation
Malignant change
Fistula formation
Perforation
Surgical procedure:
Ileocecal resection(commonly done),stricturoplasty,segmental
resection,temporary ileostomy,total colectomy with ileorectal anastomosis in
extensive colonic crohn’s.definitive procedure for internal
fistulas(ileovesical,ileocolic with fecal & urinary diversions)

16. Surgery for IBD
• Ulcerative colitis:
Indication of surgery:
Intractibility-commonest indication
Toxic dilatation
Perforation
Risk of malignant transformation
Progressive disease with stricture,fistula & abscess
Surgical procedure:total proctocolectomy with ileo-anal anastomosis with
reservior pouches(J/c or w pouch),total colectomy with ileostomy or
ileorectal anastomosis

17. Amoebic colitis
• Presentation:
Amoebic dysentery-diarrhea,pain & tenderness in lt iliac fossa
Amoebic typhlitis/amoeboma-in rt iliac fossa pain/tenderness
Acute fulminant amoebic colitis:severe type which cause torrential bleeding
Treatment:
 Mild cases-tab metronidazole thrice daily for 10days or diloxanide furoate
500 mg thrice daily for 10days
 Moderative-severe-iv metronidazole or metronidazole
 Indication of surgery:stricture,perforation & obstruction

20. Diverticulitis
• Surgical procedure:
Proximal colostomy-In case of perforation(in ER)later RA(Elective)
Multiples fistulas-Resection of the diseased bowel & closure of
fistula along with diversion procedures
(colostomy/cystostomy/ureterostomy)

21. Vascular causes
• Ischemic colitis
• Angiodysplasia
• Mesenteric ischemia

22. Ischemic colitis
• Occurs in splenic flexure most commonly
• Griffith critical point-poor perfusion in arterial diseases-
atherosclerosis,embolism,vasculitis,T2DM,CRF,autoimmune diseases
• Types: Gangrenous type(full thickness),stricture type(ischemia of
muscularis propria),transient type(only mucosa)
Ix:plain dxray-thumb printing sign,ct scan, & in chronic case-
colonoscopy & contrast study
Rx-in 80% cases-conservative mgmt,in case of perforation gangrene or
stricture resection anastomosis or diversion colostomy needed

23. Angiodysplasia
• Vascular ectasia commonly seen in rt sided colon
• Commonly seen in elderly >70yrs
• It is due to degeneration mucosal & submucosal vessels of the colon
• Diagnosis: mesenteric angiography
• Rx:therapeutic embolization,colonic fulgaration or resection

24. Mesenteric ischemia
• SMA commonly involved
• causes:Embolism(50%),thrombosis,non-occlusive-due to hypotension or shock
• Presentation:
Acute:severe abdominal pain,recurrent vomiting,bloody diarrhea
Chronic-post prandial pain,diffuse recurrent colicky pain
• IX:CT scan,CT angiogram
• Rx:exp.lap f/b resection & anastomosis (in case of gangrene)
NOMI-selective infusion of papavrine
Chronic mesenteric arterial ischemia-surgical revascularization using
aortomesenterc bypass graft
Chronic mesenteric vein thrombosis:anticoagulation

25. Congenital
• Meckel’s diverticulum
• Polyp

26. Meckel’s diverticulum
• It is a congenital diverticulum arising from the terminal ileum & is a part of
unobliterated proximal portion of vitellointestinal duct
• Rule of 2:
Common 2%
2 feet from ic valve
2cm in length
2% will be symptomatic
2 type of epithelial tissue
• p/w:asymptomatic(mostly),severe he,perforation,diverticulitis,littre’s
hernia,carcinoid
• Dx:Tc99 SCAN very usefull(90-95%)accuracy
• Rx:resection & anastomosis,Meckelian diverticulectomy

27. polyp
• Classification:
Inflammatory
Hyper/metaplastic
Hamartomatous(peutz-jegher syndrome,cronkhite-Canada syndrome)
Neoplastic(Adenomatous,carcinomatous)
Familial Adenomatous Polyp(FAP)-
• AD
• Presents in younger age group(15-20yr)
• High potential to malignant transformation
• Gardner’s syndrome & Turcot’s syndrome
• Ix:double contrast barium enema,colonoscopy,screening of all family members
• Rx:proctocolectomy

28. Intussusception(ISS)
• Telescoping/invagination of one portion of bowel into the adjacent segment
• It can be ileocolic(m/c),colocolic(m/c elderly),retrograde(jejunogastric in GJ
stoma)
• Commonest cause of intestinal obstruction in children of 6-18months of age
• c/p:red current jelly stool(usually not found in adult),colicky abdominal
pain,sausage shaped mass ,f/o intestinal obstruction,empty rt iliac fossa(sign of
Dance)
• Ix-USG-Target sign/bull’s eye sign(diagnostic),Barium enema(claw sign)dxr
abd(multiple air fluids level)
• Rx-non-operative(in child & presentation within 24hrs):reduction by hydrostatic
pressure or by microbarium sulfate soltn->failed->cope’s method(by laparotomy)
->failed->RA
Adult ISS->RA

29. Neoplastic
• Adenoma-small bowel, Large bowel
• Carcinoma-Small bowel, Large bowel

30. Adenoma of small bowel
• It is 15% of all benign small bowel tumor
• 50% in ileum,30% in jejunum & 20% in duodenum
• Types:
Brunner gland adenoma-it never turns into malignancy,treated by
endoscopic resection
Villous adenoma-malignant potential high(>50%),transduodenal
excison, pancreaticoduodenectomy are the surgical options.
Tubular-It is usually single,endoscopic excision,
pancreaticoduodenectomy are the surgical options

31. Adenocarcinoma of small bowel
• m/c primary malignant tumor of small intestine
• In 80% cases it is in the duodenum & jejunum
• Adenoca in crohn’s disease occurs in younger age,commonly in ileum
• Ix-CT scan,capsule endoscopy
• Rx-duodenal adenoca-Pancraticoduodenectomy,ileal/jejunal tumor –
radical resection with 10cm clear margin with mesenteric
cleareance.Adenoca of terminal ileum-Rt hemicolectomy
• Poor prognosis

32. Carcinoma of colon
• m/c Adenocarcinoma-90%,others-sq cell CA,signet ring cell CA,small/oat cell CA-extreamly
poor prognosis
• AdenoCA-rectum(40%)>sigmoid>cecum>Tr.colon>As.colon>ds.colon>flexures
• Pathogenesis-
80% arises from loss of heterozygocity(LOH)pathway due to APC gene defect-poor prognosis
20% arises from mutation of RER pathway-microsatellite instability.-better prognosis
• Colonic ca-
Hereditary-FAP,HNPCC,peutz-jeghers syndrome
Non-hereditary-sporadic(60%) & familial(30%)
• Stenosing/annular type of growth-lt colon:often p/w Intestinal obstruction
• Ulceroproliferative-fleshy,bulky polypoidal mass:common in rt sided
• Presentation:
Rt sided growth-anemia
Lt sided growth-altered bowel habits/distension of abdomen due subacute or chronic
obstruction

33. Treatment
• Mainly surgical
Rt sided growth->Rt radical hemicolectomy
Inoperable rt sided growth->ileo-transverse bypass surgery
Hepatic flexure growth-extended Rt hemicolectomy
Mid-transverse growth-excision of tranverse colon with both flexure
Lt sided growth->lt hemicolectomy
Splenic flexure growth-extended lt hemicolectomy
Inoperable lt sided growth-colocolic bypass surgery
Multiple synchronous primary-total colectomy
Surgical treatment of liver secondaries-solitary->segmental hepatic reection,multiple in single lobe-
>hemihepatectomy
Rectal Ca-Mid & upper part rectum/well diff/small sized-Anterior Resection,APR- poorly diff tumor &
nodes are involved
 Adjuvant therapy:
chemotherapy(+ve nodes,T4 lesions,poorly differentiated,microscopic venous spread)
EGFR & VEGF blockers-Cetuximab,Bevacizumab are used as single agent in combination with
chemotherapy