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Lower gi bleed
The document discusses lower gastrointestinal (GI) bleeding, focusing on its causes, clinical features, and management principles. It emphasizes diverticular bleeding as the most common cause, with potential complications and recurrence rates, and outlines various diagnostic and treatment approaches including endoscopy, imaging, and surgical interventions. Key management strategies involve resuscitation, identifying the cause of bleeding, and implementing definitive treatment based on the patient's condition.
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Lower gi bleed
- 1. Lower GI bleed CheaChan Hooi Surgeon Sibu Hospital
- 2. Content • Introduction • Definition •Classification • Clinical features • Principles of management • Special discussion – Diverticular bleed
- 3. Introduction • 20 –33% of GI bleed cases • Wide spectrum of presentation • Potentially life-threatening
- 4. Definition • Bleeding withinGI tract distal to ligament of Trietz
- 5. Classification by etiology •Infective amoebic, typhoid, dysentery, TB • Neoplasm polyps, tumour • Degenerative diverticulosis, angiodysplasia • Inflammatory IBD • Autoimmune SLE • Trauma blunt, penetrating • Iatrogenic radiation, scope ± intervention • Vascular AVM, haemangioma, ischaemia
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- 7. Clinical features • Haematochezia •Melaena • Fresh rectal bleed • Anaemic symptoms • Localising symptoms • Red flags • Coagulation disorders, antiplatelets
- 9. Principles of management •Resuscitation – IVF challenge – Blood product transfusion – Majority stop spontaneously • Identify cause of bleed + haemostasis • Definitive treatment
- 10. Investigations • Endoscopy – Anoscopy –Proctoscopy – Sigmoidoscopy – Colonoscopy • Initial diagnostic method of choice • IDs cause up to 90% – Enteroscopy – Capsule endoscopy
- 11. • Imaging – Angiography •Bleed rate ≥1.0ml/min • Pros : therapeutic in same setting • Cons : invasive, high dose radiation – CT angiography of mesentery • Bleed rate ≥0.5ml/min • Pros : anatomically detailed, relatively easily available • Cons : non-therapeutic – RBC-tagged scintigraphy • Bleed rate ≥0.1ml/min • Pros : detect minute amount of bleeding • Cons : poor anatomical correlation, time consuming, now widely available
- 13. Enteroscopy • Push enteroscopy –An extra-long upper endoscope with an average reach of proximal 70cm of small bowel • Balloon –assisted enteroscopy – Single & double balloon – Inflatable balloons to grip the intestine to facilitate deep enteroscopy – Largest body of evidence on enteroscopy is based on double-balloon enteroscopy • Spiral enteroscopy – A specialised overtube with a compliant spiral located at the distal tip
- 19. Definitive treatment • Dependson etiology, severity of bleed, patient’s haemodynamic & premorbid status • Options – Medical – Intervention radiology – Surgery • Discuss common etiologies – Tumour – Angiodysplasia – Diverticular – Haemorrhoids
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- 21. Introduction • Most commoncause of LGIB • Bleeding complicates 5 – 15% of patients with diverticulosis • 80% will cease spontaneously • 30 – 40% will have recurrent bleed • Bleeding tends to complicate right sided diverticuli
- 22. Pathogenesis of colonicdiverticular bleed • At sites of weaknesses in the colonic wall – where vasa recta penetrates • Mucosa herniates thru pseudodiverticulum • Vasa recta draped over the dome of the diverticulum susceptible to trauma and disruption • Intimal damages eccentric thickening wall weakening rupture
- 23. Other contributory factors •Atherosclerosis • NSAIDs • Hyperuricaemia oxidised LDL oxygen free radicals • Faecoliths
- 26. Principles of management •Resuscitation • Endoscopy for localisation & haemostasis • Angioembolisation • Surgery
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