This document provides an overview of lower gastrointestinal bleeding (LGIB), including its definition, etiology, clinical features, diagnostic and therapeutic approaches. It discusses how LGIB accounts for 20% of gastrointestinal bleeding cases and can be safely managed in an outpatient setting once initial resuscitation and risk evaluation is complete. Colonoscopy is highlighted as the first-line investigation, while angiography and surgery are reserved for more severe or refractory cases. The overall mortality rate of LGIB is reported to be less than 5%.

1. DR. SUCHIT KUMAR SHAH
MDGP-1st YEAR RESIDENT
APPROACH TO LOWER GI BLEED
• MODERATOR: Dr. Asraf Hussain

2. APPROACH TO LOWER GI BLEED
• IT WILL TAKE AROUND 30-45 MINUTES TO COMPLETE THE SESSION.

3. SYSTEM
• GASTRO INTESTINAL TRACT

4. GENERAL OBJECTIVES
• AT THE END OF THE SESSION PARTICIPANTS WILL KNOW ABOUT
LOWER GI BLEED AND ITS MANAGEMENT

5. SPECIFIC OBJECTIVE
• DEFINATION
• ETIOLOGY
• CLINICAL FEATURES AND APPROACH TO LOWER GI BLEED
• DIAGNOSTIC AND THERAPUTIC MODALITIES IN ACUTE
LOWER GI BLEED

6. CLINICAL SENARIO
• A 25 Year old male , resident of Birgung, occasional smoker, non
alcoholic
Low to moderate grade fever- 25 days
Bleeding per rectum- 8 hours
• Bright red
• Profuse, intermittent
• Not mixed with stool/mucus
• Not associated with abdominal pain
• No h/o significant weight loss / Loss of appetite

7. ON EXAMINATION
• GPE: Pallor++, severe dehydration+
• Pulse : 125/min
• Bp : 80/50 mmHg
• SYSTEMIC EXAMINATION
Per abdomen- soft, non tender, no organomegaly
• LAB Parameters:
Hemoglobin: 5.6 g/dl
Platelets, WBC- Normal
LFT, RFT- pre Renal AKI

8. GASTRO INTESTINAL BLEEDING
• Presents with Hematemesis, hematochezia, Melena
• Sequele of different etiologies- infection, vascular anomaly,
inflammatory disease, trauma and Malignancy
• While GI bleeding is potentially life threatening, can be safely
managed in OPD basis
• The management of GI bleed relies on prompt resuscitation, initial
risk evaluation and appropriate definitive management.

9. CATEGORIZATION OF GI BLEED

10. REVISED CATEGORIZATION

11. CLASSIFICATION OF LGI BLEED
• Based on duration
Acute – Recent duration( arbitrary<3days)
Chronic- usually over a period of several days.
• Based on presentation
Overt- Frank hematochezia
Occult-Presenting with Positive FOBT/ unexplained IDA
Obscure- Bleeding of unknown origin that persists or recurs
with negative bidirectional endoscopic procedures
Can be occult or overt

12. PROBLEM STATEMENT
• 20% of all gastro intestinal bleeding is LGIB
• Male> Female
• Incidence increases by age.
• 1-2% of Hospital Emergency
• 80% acute LGIB resolve spontaneously
• Overall mortality <5%

13. ETIOLOGY

15. PRESENTATION OF LGIB
• Hematochezia- passage of bright red blood, maroon stools, or
blood clots
Blood originating from left colon, rectum- bright red
Blood originating from right colon- dark red or maroon
color
15% hematochezia have UGIB as a source
• Malena- Black tarry, foul smelling stool
Ceacal or right colonic bleeding

16. HISTORY TAKING
• Hematochezia – painless
Blood mixed with stool- colon carcinoma
Blood streak on stool- rectal carcinoma
Blood after defecation- haemorrhoids
Blood with constipation- SRUS
Blood alone – diverticular disease
• Associated with
Abdominal pain- Crohn’s disease
Along with Fever- infective colitis.
SRUS- solitary rectal ulcer syndrome

17. HISTORY TAKING
• Changes in bowel habit
• Weight loss
Past history of
• Cardiovascular disease
• Abdominal radiation
• Diverticulosis
• Recent colonoscopy and procedure
• Steroids/ NSAIDS/ anti coagulants
• Recurrent childhood bleeding

19. EXAMINATION
• GENERAL PHYSICAL EXAMINATION
Signs of dehydration
Pallor- Severe acute GI bleed
Icterus- Liver cell failure- Rectal varices
Clubbing- IBD
Pedal edema – Liver cell failure

20. EXAMINATION

22. APPROACH TO A PATIEN WITH LGIB
• Patient presenting with hematochezia
1. Resuscitation and initial management
2. Definitive management
i. Localization of bleeding site
ii. Theraputic intervention to stop bleeding

23. RESUSCITATION

31. DIAGNOSTIC AND THERAPUTIC MODALITIES
ENDOSCOPIC METHOD
• PROCTOSCOPY
• FLEXIBLE SIGMIDOSCOPY
• COLONOSCOPY
• ENTEROSCOPY
NON ENDOSCOPIC METHODS
• CT ANGIOGRAPHY
• CATHETER ANGIOGRAPHY
• RADIO NUCLIDE IMAGING

32. COLONOSCOPY
• Colonoscopy is the investigation of choice in acute LGIB,
unless bleeding is massive and patient is hemodynamically
unstable.
• The diagnostic yield of colonoscopy in LGIB- 48%-97%
Bowel Preparation:
Inadequate bowel preparation reduces the sensitivity to
21%
1. low cecal intubation rates
2. blood or stool in the lumen

33. TIMING OF COLONOSCOPY
• Early colonoscopy with 12-24 hours of admission
associated with shorter hospital stay
• Diagnostic yield increases when performed with active
ongoing bleed
• In patient with serious co morbid condition or no ongoing
bleed delayed colonoscopy.

35. ADVANTAGES
• Direct visualization of bleeding site
• Precisely localizes the site of bleeding
• To obtain biopsy specimens
• Stigmata of recent bleeding
1.Active bleeding
2.Visible bleeding
3. Adherent clots
• Therapeutic intervention

36. COMPLICATIONS
• Fluid overload
• Aspiration pneumonia
• Bowel perforation
• Sepsis

37. ENDOSCOPIC THERAPY
• Injection
• Thermal coagulation
• Mechanical devices

40. MECHANICAL DEVICES
• Used for active bleeding
• Secure definitive bleeding control
1. Clips
Placed either over or side of the bleeding source
Clip retention time 2-4 week
2. Bands
Mainly used for hemorrhoidal bleed
Ligated at the neck of the lesion.

42. ENTEROSCOPY
• Balloon enteroscopy
• Capsule enteroscopy
• Sound enterocopy

43. BALLOON- ASSISTED ENTEROSCOPY
• Two forms of balloon-assisted enteroscopy:
1. Double- balloon enteroscopy
2.Single balloon enteroscopy
The enteroscopes – working length of 200 cm.
Push-and Pull method, inflation and deflation of balloons
and telescoping of the intestine onto the overtube.
Balloon-assisted enteroscopy can be performed via the
oral(anterograde) and aboral(retrograde) approach.

45. ADVANTAGES
It allows deeper access to the small bowel than push enteroscopy
The diagnostic yield- 60-80%
Therapeutic intervention- 40-70%
Total enteroscopy, success rate- 16-86%

46. 2. CAPSULE ENDOSCOPY
• 26 mm capsule containing a camera, transmitter and other accessories
• 2 images per second and around 60000 images generated in 8 hours
• Diagnostic yield of capsule endoscopy in LGIB is 40-80%
• It is non invasive and patient friendly with low complication rate
• Capsule retention can occur in 1.4% case mainly with stenosis.
• Main drawbacks: No therapeutic intervention, process is passive.

47. CT ANGIOGRAPHY
• Diagnostic accuracy 0.3 mL/min
• Sensitivity of 50-60% and Specificity of 92-95%
• Identify site of bleeding and etiology of LGIB
• Oral contrast not recommended
• Diagnostic tool; no therapeutic intervention
• It provides information about vascular anatomy endovascular
intervention or surgical planning

49. CATHETER ANGIOGRAPHY
• Recommended for patients- massive bleed and hemodynamically
unstable, persistent or recurrent bleeding
• Detects the bleed at the rate of 0.5-1 ml/min
• High specificity-95-100%
• Low sensitivity- 30-47%

53. EMBOLIZATION
• Using coils, gel foam, poly vinyl alcohol particles-
Success of 44-86%,
Re- bleeding in about 15% of case
High incidence of bowel ischemia- 20%

54. SUPER SELECTIVE EMBOLIZATION
• Target artery- the vasa –recta
Along the marginal arteries and the distal intestinal arcades

55. RADIONUCLIDE SCANNING
• Radio labelled substances into patient blood stream and performing
serial scintigraphy
• Two methods exist- Tc99m sulfur colloid, Tc99m labelled RBC(latter is
better)
• The rate of bleeding detection is a low as 0.1-0.5 ml/min
• PPV-45%, Diagnostic accuracy to localize the bleeding site-78%
• Highly helpful in obscure bleeding.

59. ROLE OF SURGERY
• Indicated as an emergency life saving procedure
1. Inability to maintain hemodynamically stability
2. Failure of available therapeutic modalities
3. Requiring blood transfusion more than 6 units within 24 hours
4. Recurrence of severe bleeding after initial control.

63. RE- BLEEDING IN ACUTE LGIB
• Mean rate of acute re- bleeding- 22%
late re-bleedin-16%
• Factors predisposing rebleeding in LGIB
1. source of index bleeding
2. Initial hemostasis modality
3.Medication use
4. Co morbid condition
• Increased mortality risk

64. PROGNOSIS
• Most of LGIB will stop spontaneously (80%)
• Continued bleeding occurred in 10-40% of cases
• About 5% of cases required surgical homeostasis
• Mortality <5%
• Patient who bleeds while hospitalized for separate disease- higher risk
of death than admitted for LGIB

65. TAKE HOME MESSAGE
• Prompt resuscitation is the first step in the management of LGIB
• Colonoscopy is the investigation of choice in the evaluation
• Angiography to be considered in patient hemodynamically unstable.
• Timely surgical consultation.

66. •THANK YOU