Lower gastrointestinal bleeding (LGIB) refers to blood loss originating from a site distal to the ligament of Treitz. Common causes of LGIB include hemorrhoids, diverticulosis, angiodysplasia, and anal cancers. Hematochezia is the typical presentation of LGIB. Initial workup includes examination, blood tests to check for anemia and coagulopathy, and colonoscopy for diagnosis and potential therapeutic intervention to stop bleeding. Management depends on the cause but may include conservative measures, nonsurgical options like banding or surgical procedures like hemorrhoidectomy.

2. DEFINITION
• GI bleeding can be categorized into upper and lower in origin.
The ligament of Treitz is commonly used as the point to
differentiate the two. Bleeds proximal to the ligament are upper
GI bleeds, and distal bleeds are lower GI bleeds.
• Lower gastrointestinal bleeding (LGIB) refers to blood loss of
recent onset originating from a site distal to the ligament of
Treitz

3. ETIOLOGY

5. PRESENTATION
Lower GI bleeding typically presents with :
1.Hematochezia (which can range from bright-red
blood to old clots)

6. Pain Painless
- Anal fissure
- Anal fistula
- Anorecto carcinoma
- Rupture perineal
hematoma
- Ruptured anorectal
abcess
Blood alone Polyps , diverticular disease, angiodysplasia
Blood with mucus IBD, intususseption, colitis
Blood with defecation Haemorroid
Blood mixed with stool Colon carcinoma
Blood streak on stool +
tenesmus
Rectal/anal carcinoma

7. PHYSICAL EXAMINATION
GENERAL
• Vital signs – assess for hypovolaemia.
• Urine output.
• Signs of anaemia – conjunctival pallor, tachycardia.
• Signs of dehydration – coated tongue, prolonged CRT.
• Any skin manifestations of IBD.
DIGITAL RECTAL
EXAMINATION
• To determine aetiology – potential anorectal bleeding sources, any skin fissure, prolapse,
haemorrhoid, mass.
• To determine the colour of the stool.
ABDOMINAL
EXAMINATION
• Abdominal pain – might suggest bowel perforation, infectious colitis, bowel ischaemia.

8. INITIAL INVESTIGATION
• FBC : to assess Hb level.
• Renal profile : hypovolaemia  renal hypoperfusion  renal impairment.
• Coagulation studies : TRO any coagulopathy.
• Group cross match (GXM)
• Liver function test : liver disease  portal hypertension  oesophageal
varices  UGIB.
• Stool culture, ova & parasite testing.

9. MANAGMENT
i. Initial assessment & haemodynamic resuscitation.
ii. Colonoscopy – localisation of the bleeding site.
iii. Therapeutic intervention – to stop bleeding at the site.

10. INITIAL ASSESSMENT.
• Includes thorough history, physical examination & lab tests.
• Triaging those with high risk features  requiring monitoring in an intensive care setting.
- hemodynamic instability at presentation (tachycardia, hypotension, and syncope).
- ongoing bleeding (gross blood on initial digital rectal examination and recurrent hematochezia).
- comorbid illnesses, age >60 years.
- a history of diverticulosis or angioectasia.
- an elevated creatinine, and anemia
• General supportive measures.
 Receive supplemental oxygen by nasal prong.
 2 large-bore IV access.
 Keep nil by mouth in event urgent upper endoscopy needed.

11. HAEMODYNAMIC RESUSCITATION
• Patients with hemodynamic instability/suspected ongoing bleeding  IV fluid
resuscitation.
• Packed RBCs should be transfused if
• Hb <7g/dl – young patients without any comorbid illness.
• Hb <9 g/dl – patients with massive bleeding, significant comorbid illness
(especially cardiovascular ischemia), or a possible delay in receiving therapeutic
interventions.
• Patients with active bleeding & hypovolemic despite normal Hb.

12. COLONOSCOPY

13. ANGIODYSPLASIA
• Vascular malformation consists of
dilated tortuous submucosal veins
• Most common vascular abnormality
of the gastrointestinal tract,
responsible for mosttly 6% of lower
GI bleeding cases and up to 8% of
upper GI bleeds

14. • Can occur at a multiple sites
within the GI tract,
including :
• Colon
• Small intestine
• Stomach and duodenum
Colon — Colonic lesions are found most often
in the right colon.
 Cecum – 37 %
 Ascending colon – 17 %
 Transverse colon – 7 %
 Descending colon – 7 %
 Sigmoid colon – 18 %
 Rectum – 14 %

15. INVESTIGATION
Colonoscopy
• Lesion are only few millimeters in size
• Appear as reddish, raised area
Angiodysplasia identified on the
cecum wall during colonoscopy.
The vessel walls are thin, with little
or no smooth muscle, and the
vessels are ectatic and thin

16. Mesentric Angiography
• Assess the site and
extent of the lesion
• Indicated if bleeding
more than 1mL/min
• Show ectatic vessels
Mesenteric angiography
• Early and prolonged filling of
draining veins,
• Cluster of small arteries
• Visualisation vascular tuft

17. MANAGMENT
1. Stabilize the unstable circulation
2. Bleeding localized by colonoscopy
3. Cauterization
• By argon laser during colonoscopy after the site of bleeding confirmed
2. Surgical procedure
• If the segment of colon involved is not clear or there is massive bleeding, subtotal
colectomy may be necessary

18. HAEMORRHOIDS
• DEFINITION
 Symptomatic anal cushions
 Haemorrhoids venous cushions are normal structures of anorectum and universally present
in all person unless previous intervention has taken place
 It is a common anal pathology but many patients are embarrassed to seek attention

19. ETIOLOGY
• Straining and constipation
• Pregnancy
• Obesity
• Prolong sitting
• Portal hypertension
• And anorectal varices
• Chronic diarrhea
• Familial
• Colon malignancy
• Loss of rectal muscle tone
• Spinal cord injury
• Rectal surgery
• High socioeconomic status
• Episiotomy
• Anal intercourse
• IBD

20. • Right anterior, Right posterior and Left
lateral positions
• Those originating above the dentate line
which are termed internal
• Those originating below the dentate
linewhich are termed external
ANATOMY AMD CLASSIFICATION

21. DIFFERENCES
Internal
1. Lie above dentate line
2. Develops from embryonic
endoderm
3. Covered by columnar epithelium
of anal canal
4. Not supplied by somatic sensory
nerves so cannot cause pain
External
1. Lie below dentate line
2. Develops from embryonic ectoderm
3. Covered by squamous epithelium
4. Innervated by cutaneous nerves that
supply perianal area

23. CLASSIFICATION
• Grades:
• I- Hemorrhoids only bleed
• II- Prolapse and reduce
spontaneously
• III- Require replacement
• IV- Permanently Prolapsed

24. SYMPTOMS
• Rectal Bleeding
• Bright red blood in stool
Dripping in the toilet
On wiping after defecation
• Pain during bowel movements
• Anal Itching
• Rectal Prolapse (while walking, lifting weights)
• Thrombus
• Extreme pain, bleeding and occasionally signs of systemic illness in case of
strangulation

25. PHYSICAL EXAMINATIONS AND INVESTIGATIONS
• PR Done in Sim’s position
• ANOSCOPY
• PROCTOSCOPY
• COAGULATION PROFILE
• FBC
• FLEXIBLE SIGMOIDOSCOPY

26. TREATMENT
Treat only symptomatic haemorrhoids :
1. Conservative
2. Nonsurgical
3. Surgical

27. CONSERVATIVE
• TOC in grade 1 interbal and nonthrombosed external haemorroids
• Warm baths ( sitz bath)
• High fibre diet
• Adequate fluid intake
• Stool softeners
• Topical analgesics
• Proper anal hygiene

28. NONSURGICAL
• To destroy internal haemorrhoids
• Rubber band ligation
• Sclerotherapy
• Coagulation
• Electrocautery, electrotherapy
• Cryotherapy
• Lase therapy and radion wave ablation

29. SURGICAL
• Haemorrhoidectomy
1) Grade III & IV haemorroids with severe symptoms
2) Consevative and nonbsurgical method fails
3) Patient preference
4) Presence of anorectal conditions requiring surgery : Fistula,Fissure,large skin tags
5) Fibrosed Haemorroids
6) Intero-external haemorrhoids when external haemorroids is well defined

30. DIVERTICULOSIS
Definition
• Presence of small out-pouchings
(called diverticula) or sacs that can
develop in the wall of the
gastrointestinal tract.
Most common: Left sided of colon
(descending colon & sigmoid)
Types
1. Congenital (True)
All three layers of the bowel will be present in the
wall of diverticulum
eg: Meckel's diverticulum
2. Acquired (False/ Pseudo-diverticula)
No muscular layer present
eg: Sigmoid diverticular disease

31. Aetiology
• Older age (between 50 and 70)
• Diet in low fibre
• Most common: sigmoid colon
Pathophysiology
caused by an increase in intraluminal pressure  which leads to mucosal extrusion through the weakest
points of the muscular layer of the bowel where the blood vessels penetrate the bowel wall

32. CLINICAL FEATURES
1. Mainly asymptomatic
2. Mild intermittent lower abdominal pain shifts to left iliac fossa & become more constant pain
3. Colicky pain if large bowel becomes obstructed
4. Loss of appetite
5. Change in bowel habits
6. Distension and flatulence
7. Increased frequency of micturition

33. COMPLICATIONS
Uncomplicated Diverticulitis (Inflammtion)
• Present as persistent lower abdominal pain usually at left iliac fossa
• May accompanied by diarrhea or constipation
Complicated Diverticulitis (Perforation)
• Often leads to pericolic abscess, generalized peritonitis, fistulas between the
colon and adjacent structures
• Distension, flatulence and heaviness sensation
• Acute: persistent LIF pain, fever, malaise, may be accompanied by diarrhea or
constipation and urinary symptoms
• Hinchey Classification

34. HINCHEY
CLASSIFICATION

35. Intestinal Obstruction Haemorrhage Fistula formation
Progressive fibrosis can cause
stenosis of the colon
Loop of small intestine can
adhere to an inflamed sigmoid -
> small bowel obstruction
Rare
Usually due to angiodyplasia
May present with painless,
profuse and recurrent colonic
hemorrhage due to erosion of
vessel adjacent to diverticulum
Bleeding from the sigmoid
Types: colovesical (most
common), colovaginal

36. INVESTIGATIONS
1. CT Scan
• Pericolic soft tissue stranding, colonic wall
thickening, and/or phlegmo
2. Barium enema
• Demonstrate diverticula as barium-filled
outpouchings.
• Distinguished from the polyps by the presence of
contrast pooling within the diverticulum
3. Colonoscopy
• Diverticula as well as polyps and other
abnormalities can be seen with this instrument.
MANAGEMENT
-The majority of patients remain asymptomatic
throughout life and no treatment is required.
-Treatment is usually reserved for diverticulitis or
diverticular hemorrhage.

37. DIVERTICULOSIS -High fibre diet
-Syrup lactulose to keep stool soft hence avoid constipation
Uncomplicated Diverticulitis -Intravenous antibiotics (to cover Gram-negative bacilli and anaerobes)
-Appropriate resuscitation and analgesia.
-Nil by mouth to ‘rest the bowel’ and catheterisation to reduce the risk of
colovesical fistulation
Complicated Diverticulitis (Perforated/Abscess) -Small abscesses (<2cm)  IV antibiotics
-Larger abscess  percutaneous drainage
-Perforated  Laparotomy and thorough washout of contamination + Hartmann’s
procedure
Hemorrhage in Diverticulum -Resuscitation if needed.
-colonoscopy is needed to localise the bleeding site and treat the bleeding
-If fail, subtotal colectomy and ileostomy may be the safest option
Diverticular fistulae
-Definitive treatment of colovesical fistula will require resection of the affected
bowel

38. HARTMANN’S PROCEDURE
Surgical resection of the rectosigmoid colon with closure of the
anorectal stump and formation of an end colostomy

39. MECKEL’S DIVERTICULUM
• Contains all three layers of the small intestines
• Caused by incomplete obliteration of the vitelline duct
• Rule of two :
Occurs in 2% of patients,
2 inches in length (5 cm long)
2 feet (60 cm) from the ileocaecal valve,
• Obstruction can occur and is usually caused by intussusception,
volvulus or hernia

40. ANAL CANCER
1. Rare
2. Squamous cell carcinoma is the common one
3. Those arising below dentate line are usually squamous cell carcinoma while above are
adenocarcinoma
4. High incidence in :
• Female
• Human papillomavirus (HPV) infection
• Genital warts infection
• Human immunodeficiency virus (HIV)
• Multiple sexual partner
• Cigarette smoking
• Receptive anal intercourse

41. CLINICAL FEATURES
• Bleeding
• Pain
• Presence of mass
• Pruritus ani
• Fecal incontinence

42. ANAL CANCER
1. Rare
2. Squamous cell carcinoma is the common one
3. Those arising below dentate line are usually squamous cell carcinoma while above are
adenocarcinoma
4. High incidence in :
• Female
• Human papillomavirus (HPV) infection
• Genital warts infection
• Human immunodeficiency virus (HIV)
• Multiple sexual partner
• Cigarette smoking
• Receptive anal intercourse

43. CLINICAL FEATURES
• Bleeding
• Pain
• Presence of mass
• Pruritus ani
• Fecal incontinence

44. MANAGEMENT
Depends on histological type
Squamous Cell Carcinoma
1. Concurrent chemotherapy (5-fluoroucil + mitomycin) & radiotherapy -
for non metastatic anal cancer
2. If failed & disease become progressive : proceed to surgical method
• Wide local incision with 1cm margin of normal tissue
• Abdominoperineal resection with colostomy (if tumour >50% of
anal canal)
Adenocarcinoma
1. Surgical - Abdominoperineal resection (APR)
2. Chemoradiotherapy as adjunct pre and post operative

45. COLITIS
Refers to inflammation of the inner lining
of the colon

46. COLITIS
Inflammatory bowel
diseases
Ischaemic colitis Infectious colitis
Ulcerative colitis Crohn’s Diseases

47. Ulcerative colitis
a chronic inflammatory condition characterized by relapsing and remitting
episodes of inflammation limited to the mucosal layer of the colon.
Crohn’s disease
characterized by transmural inflammation and by skip areas of involvement
(segments of normal-appearing bowel interrupted by areas of disease)
INFLAMMATORY BOWEL DISEASE (IBD)

49. ULCERATIVE COLITIS
• First symptoms: Watery or bloody diarrhoea. (lasted for weeks to months)
• May associated with rectal discharge of mucus that is either blood-stained or purulent.
• Colicky abdominal pain, urgency, tenesmus.
• Systemic symptoms: fever, fatigue, and weight loss as well as anemic symptoms due to chronic blood
loss.
• Physical examination:
• Anaemic signs
• Abdominal tenderness
• rectal examination may reveal evidence of blood.

50. EXTRAINTESTINAL MANIFESTATIONS
• Musculoskeletal : Arthritis (large joints)
• Eye : Uveitis and episcleritis (most common)
• Skin : erythema nodosum & pyoderma gangrenosum
• Hepatobiliary : primary sclerosing cholangitis, fatty liver, autoimmune liver
disease
• Hematopoietic/coagulation : high risk for venous & arterial
thromboembolism

51. INVESTIGATION
• Lab findings :
• FBC: ↓Hb (anemia),
• ESR: Increase
• BUSE: electrolyte abnormalities due to chronic diarrhoea and dehydration.
• LFT: hypoalbuminaemia – due to poor nutritional intake

52. ENDOSCOPY
Extensive
ulceration
Irregular, friable,
erythematous and loss of
vascular markings and
pseudopolyps
Extensive lesion

53. BIOPSY
• Crypt abscesses
• Crypt branching
• Crypt atrophy
• Epithelial cell abnormalities
• Inflammatory features of ulcerative colitis include increased lamina propria
cellularity, basal plasmacytosis, basal lymphoid aggregates, and lamina propria
eosinophils
*Although none of these features are specific for ulcerative colitis, the presence of
two or more histologic features is highly suggestive of ulcerative colitis

54. CROHN’S DISEASE
• Patients can have symptoms for many years prior to diagnosis.
• The cardinal symptoms of CD include abdominal pain, diarrhea (with or without gross bleeding), fatigue, and
weight loss.
• Oral : aphthous ulcers or pain in the mouth and gums.
• Esophageal : odynophagia or dysphagia
• Gastroduodenal : nausea or postprandial vomiting
• Fistulas : Transmural bowel inflammation is associated with the development of sinus tracts. Sinus tracts that
penetrate the serosa can give rise to fistulas.
• Perianal disease : These include perianal pain and drainage from large skin tags, anal fissures, perirectal
abscesses, and anorectal fistulas.
• Malabsorption.
• Extraintestinal manifestations.

55. INVESTIGATION
1. Full blood count (anemia, increase white cell count)
2. ESR & CRP
3. Renal profile (electrolyte abnormalities)
4. Serum Vitamin B12 and Vitamin D (deficient)
5. Barium study
6. Colonoscopy

56. BARIUM STUDY

57. COLONOSCOPY
Aphthous ulcers interspersed of large ulcers
Cobblestone appearance Intraluminal narrowing
(stricture)

58. MANAGEMENT
• Ulcerative colitis
1) Multidisciplinary approach
2) Maintenance therapy : corticosteroids and 5-Aminosalycylic acid
3) Mild : oral prednisolone or rectal steroids 20-40mg/day for 3-4 weeks.
4) Moderate : oral prednisolone 40mg/day, 2times/day steroid enema, and 5- ASA
5) Severe : medical emergency  surgical intervention

59. Crohn’s disease
1. Steroids with Aminosalicylates (5-ASA -if colonic involvement)
2. Antibiotics (Metronidazole and ciprofloxacin) – those with abscess
3. Immunomodulatory agents (Azathioprine & 6-mercaptopurine (6-
MP) )
A. Nutritional support
B. Lifestyle advice : Increase physical activity & Dietary advice

60. THANK YOU