Lower GI bleed, screening of colorectal cancer

Lower GI Bleed
Shumayla Aslam, MD
Internal Medicine
1st year
1dr.shumaylaaslam@gmail.com

Patient’s Data
• FS
• 80/Male
• Married
• Filipino
• Roman Catholic
• Imus, Cavite
• Admitted on 29th March, 2017 for the first
time

Chief Complaint
• Bloody stools

History of Present Illness
• 3 month PTA
• An episode of Constipation for 4 days
• Bloody stool one episode approx about 2 tsp per
bout
• No abdominal pain
• No melena
• No nausea/ vomiting
• No consultation done , no medications were taken

• In the interim patient developed
• On and off constipation 3-4 times per week
• No melena or hematochezia,
• No changes on stool caliber,
• No dizziness
• No nausea vomiting
• Self medicated with laxatives (dulcolax) suppository
with unrecalled preparations and frequency
• Provided temporary relief

• 2 HRS PTA:
• 7-10 episodes of hematochezia characterized as “
combination of soft black color stools with fresh
blood”, amounting for about one teaspoon every
bout, non mucoid.
• With dizziness characterized as light headedness
• No nausea vomiting
• This prompted consult at our institution and
hence was subsequently admitted

Past Medical History
• Hypertensive
– ~ 10yrs (HBP - ?, UBP – 130/80)
– Losartan 50mg/tab OD
– Metoprolol 50mg/tab OD
– Clopidogrel 75mg/tab OD since last 5 years
• No DM
• No asthma
• No allergy
• S/P cataract surgery (left eye – July 2013, right
eye – Feb 2015)

Family Medical History
• Unrecalled

Personal and Social History
• Previous smoker for 6 pack years
– stopped 10 years back
• Previous occasional alcoholic drinker
• Denies illicit drug use

Review Of System
• No changes in weight
• No fever
• No pallor
• No easy brusability
• With orthopnea 2 pillow
• With easy fatigability
associated with Shortness
of breath
• No chest pain
• No palpitation
• No dysphagia
• No heartburn
• No abdominal distension
• No incontinence

Physical Examination
• Vitals
– BP 150/90 mmHg
– HR 80 bpm
– RR 25/ min
– Temperature 36.4
– SpO2 97% on room air
– CBG 98 mg/dl
– Weight 51.5 kg
– Height 167 cm
– BMI 18.8

Physical Examination
• Awake, conscious and coherent, not in CP distress
• Warm to touch, with pallor
• Anicteric sclera, pale palpebral conjunctivae
• Symmetrical chest expansion, clear breath
sounds
• Adynamic precordium, normal rate regular
rhythm, no murmur
• Soft, flat, non tender abdomen, NABS
• No edema, full and equal peripheral pulses

• Digital Rectal Exam:
– No external skin tags, fissures, haemorrhoids,
perirectal lesion
– Intact external sphincter tone
– Rectal vault without masses
– Prostate smooth non tender
– Notes fresh blood with black stool per examining
finger

Salient features
• 80/ Male
• Hematochezia 7-10 episode
• Melena
• History of chronic constipation
• Pallor
• Easy fatigability and orthopnea
• Known hypertensive
• Clopidogrel intake

Initial Working Impression
• Lower Gastrointestinal Bleed probably
secondary to internal haemorrhoids vs
Diverticulosis
• t/c Upper Gastrointestinal Bleed secondary to
BPUD secondary to clopidogrel
• r/o Colonic Mass
• Anaemia secondary to GI bleed
• HCVD HF FC IIA

Differential Diagnosis
Disease Rule in Rule out
Colonic cancer 80/M
Constipation
Melena
Hematochezia
Inflammatory bowel
disease (IBD)
Melena
Hematochezia
No weight loss
Acute Proctitis
- inflammation of the
rectal mucosa

LOWER GASTROINTESTINAL BLEED
Source:
Harrison’s Internal Medicine 19th edition
ACG guidelines
Webpage

• UGIB ~1.5–2 times more common than LGIB
• incidence of GIB has decreased in recent decades and
the mortality has decreased to <5%.
• GIB presents
– overt bleeding
• Hematemesis
• melena,
• hematochezia,
– occult bleeding
• absence of overt bleeding
• anemia such as lightheadedness, syncope, angina, or dyspnea;
• or when routine diagnostic evaluation reveals iron deficiency
anemia or a positive fecal occult blood test.

Causes of lower GI bleeding
• 1. Diverticulosis (20-65%)
• 2. Angioectasia (40-50%)
• 3. Ischemic colitis
• 4. Hemorrhoids (2-5%)
• 5. Colorectal neoplasia
• 6. Postpolypectomy bleeding (2-8%)
• 7. Solitary rectal ulcer
• 8. Radiation proctopathy

Risk factors for poor outcome
• Hemodynamic instability on presentation
(tachycardia, hypotension, syncope)
• Ongoing bleeding
• Comorbid illnesses
• Age > 60
• Initial hct < 35%
• Elevated creatinine
• History of diverticulosis or angioectasia

ACG CLINICAL GUIDELINE:
MANAGEMENT OF PATIENTS WITH
ACUTE LOWER GASTROINTESTINAL
BLEEDING

Management
• Hemodynamic status should be initially
assessed with intravascular volume
resuscitation started as needed.
• Risk stratiﬁcation based on clinical parameters
should be performed to help distinguish
patients at high- and low-risk of adverse
outcomes

• Hematochezia associated with hemodynamic
instability may be indicative of an upper
gastrointestinal (GI) bleeding source and thus
warrants an upper endoscopy.
• In the majority of patients, colonoscopy
should be the initial diagnostic procedure and
should be performed within 24 h of patient
presentation after adequate colon
preparation.

• Endoscopic hemostasis therapy should be
provided to patients with high-risk endoscopic
stigmata of bleeding
• Radiographic interventions (tagged RBC
scintigraphy, CT angiography, and angiography)
should be considered in high-risk patients with
ongoing bleeding who do not respond
adequately to resuscitation and who are unlikely
to tolerate bowel preparation and colonoscopy.

• NSAIDs use should be avoided in patients with
a history of acute lower GI bleeding,
particularly if secondary to diverticulosis or
angioectasia.
• Patients with established cardiovascular
disease who require aspirin (secondary
prophylaxis) should generally resume aspirin
as soon as possible after bleeding ceases and
at least within 7 days.

COLONOSCOPY
• Colonoscopy as a diagnostic tool
• Colonoscopy should be the initial diagnostic
procedure for nearly all patients presenting with
acute LGIB
• The colonic mucosa should be carefully inspected
during both colonoscope insertion and
withdrawal, with aggressive attempts made to
wash residual stool and blood in order to identify
the bleeding site. should also include the terminal
ileum to rule out proximal blood suggestive of a
small bowel lesion

Bowel preparation
• Once the patient is hemodynamically stable,
– colonoscopy should be performed after adequate colon
cleansing.
– Four to six liters of a polyethylene glycol (PEG)-based
solution or the equivalent should be administered over 3–
4 h until the rectal efﬂuent is clear of blood and stool.
– Unprepped colonoscopy/sigmoidoscopy is not
recommended
• A nasogastric tube can be considered to facilitate
colon preparation in high-risk patients with ongoing
bleeding who are intolerant to oral intake and are at
low risk of aspiration

Timing of colonoscopy
• In patients with high-risk clinical features and signs or
symptoms of ongoing bleeding, a rapid bowel purge should
be initiated following hemodynamic resuscitation and a
colonoscopy performed within 24 h of patient presentation
after adequate colon preparation to potentially improve
diagnostic and therapeutic yield
• In patients without high-risk clinical features or serious
comorbid disease or those with high-risk clinical features
without signs or symptoms of ongoing bleeding,
colonoscopy should be performed next available after a
colon purge

Endoscopic hemostasis therapy
• Endoscopic therapy should be provided to
patients with high-risk endoscopic stigmata of
bleeding: active bleeding (spurting and
oozing); non-bleeding visible vessel; or
adherent clot

• Diverticular bleeding: through-the-scope endoscopic
clips are recommended as clips may be safer in the
colon than contact thermal therapy and are generally
easier to perform than band ligation, particularly for
right-sided colon lesions

• Angioectasia bleeding:
noncontact thermal
therapy using argon
plasma coagulation is
recommended

• Post-polypectomy bleeding: mechanical (clip)
or contact thermal endotherapy, with or
without the combined use of dilute
epinephrine injection, is recommended

Role of repeat colonoscopy in the setting of
early recurrent bleeding
• Repeat colonoscopy, with endoscopic
hemostasis if indicated, should be considered
for patients with evidence of recurrent
bleeding

Non-colonoscopy interventions
• A surgical consultation should be requested in patients
with high-risk clinical features and ongoing bleeding.
• In general, surgery for acute LGIB should be considered
after other therapeutic options have failed and should
take into consideration the extent and success of prior
bleeding control measures, severity and source of
bleeding, and the level of comorbid disease.
• It is important to very carefully localize the source of
bleeding whenever possible before surgical resection
to avoid continued or recurrent bleeding from an
unresected culprit lesion

• Radiographic interventions should be
considered in patients with high-risk clinical
features and ongoing bleeding who have a
negative upper endoscopy and do not respond
adequately to hemodynamic resuscitation
efforts and are therefore unlikely to tolerate
bowel preparation and urgent colonoscopy

Prevention of recurrent LGIB
• Non-aspirin NSAID use should be avoided in
patients with a history of acute LGIB, particularly if
secondary to diverticulosis or angioectasia
• In patients with established high-risk
cardiovascular disease and a history of LGIB,
aspirin used for secondary prevention should not
be discontinued. Aspirin for primary prevention of
cardiovascular events should be avoided in most
patients with LGIB

• In patients on dual antiplatelet therapy or
monotherapy with non-aspirin antiplatelet agents
(thienopyridine), non-aspirin antiplatelet therapy
should be resumed as soon as possible and at
least within 7 days based on multidisciplinary
assessment of cardiovascular and GI risk and the
adequacy of endoscopic therapy.
• However, dual antiplatelet therapy should not be
discontinued in patients with an acute coronary
syndrome within the past 90 days or coronary
stenting within the past 30 days.

COLORECTAL CANCER SCREENING

American Cancer Society
Recommendations for Colorectal
Cancer Early Detection
If you are at an increased or high risk of colorectal cancer,
you might need to start colorectal cancer screening
before age 50 and/or be screened more often.
The following conditions make your risk higher than
average:
• A personal history of adenomatous polyps
• A personal history of inflammatory bowel disease
(ulcerative colitis or Crohn’s disease)
• A strong family history of colorectal cancer or polyps
• A known family history of a hereditary colorectal cancer
syndrome such as familial adenomatous polyposis (FAP)
or Lynch syndrome (hereditary non-polyposis colon
cancer or HNPCC) 53dr.shumaylaaslam@gmail.com

THANK YOU

Lower GI bleed, screening of colorectal cancer

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