This document discusses lower gastrointestinal (GI) bleeding, which originates in the small or large intestine. Lower GI bleeding accounts for 20-33% of GI hemorrhages and can present with maroon or bright red stools depending on the bleeding source. Causes of lower GI bleeding include diverticular diseases, anorectal diseases like hemorrhoids and anal fissures, colorectal neoplasms, polyps, colitis, inflammatory bowel disease, and angiodysplasias. Management involves resuscitation, diagnostic tests to localize the bleeding source like endoscopy, and potentially surgery to control or resect the bleeding area.
2. lower gastrointestinal (GI) bleed is one that
originates distal to the ligament of Treitz
Lower gastrointestinal bleeding (LGIB) accounts
for approximately 20%-33% of episodes of
gastrointestinal (GI) hemorrhage
medscape
3.
4. The clinical presentation of LGIB varies
with the anatomic source of the bleeding
as well as with the etiology
LGIB from the right side of the colon can
manifest as maroon stools
left-sided bleeding source may be evidenced by
bright red blood per rectum
medscape
5. LGIB is generally classified under three groups
according to the amount of bleeding
medscape
8. Management of patient with acute GI bleeding
1.Initial assessment
2.Resuscitation
3.History and physical examination
4.Localization
5.Risk stratification
sabiston textbook of surgery
10. Resuscitation
The more severe the bleeding, the more
aggressive the resuscitation
2 large-bore intravenous lines should be placed
Unstable patients should receive a 2-liter bolus of
crystalloid solution
Foley catheter should also be inserted for
assessment of end-organ perfusion
Frequently, these patients benefit from early
admission to and management in the intensive care
unit (ICU)
Sabiston textbook of surgery
12. A focused history and physical is essential and is
performed simultaneously with the resuscitation
Onset
Duration
Character
Relieving factor
Aggrevating factor
amount ,volume
Frequency
Previous episodes
Asks about other
colorectal/anal
symptoms:
Pain/soreness
Itching
Tenesmus
Lumps, swellings, piles
Rectal prolaps
Change of bowel habit:
Constipation ,Diarrhoea
GIT symptoms
OSCEs for medical final
14. Once resuscitation has been initiated, the first
step in the workup is to rule out anorectal
bleeding with a digital rectal examination and
anoscopy or sigmoidoscopy
With significant bleeding, it is also important to
eliminate an upper GI source
An NG aspirate that contains bile and no blood
effectively rules out upper tract bleeding in most
patients
sabiston textbook of surgery
15. Estabilish Diagnosis
1.Anoscopy or proctoscopy
2.Flexible sigmoidoscopy
3.colonoscopy
4.Capsule endoscopy
5.99M Tc-RBC Scintigraphy
6.Angiography
schwatrz's principles of surgery
21. Surgery
surgery is reserved for those who have been
localized through the aforementioned diagnostic
modalities.
In these cases, a segmental resection is appropriate
with a reasonable expectation that rebleeding will
not occur.
If localization is not obtained, a total abdominal
colectomy is the procedure of choice.
It should be additionally noted that a large majority
of bleeding stops without intervention or
localization.
common surgical diseases
23. Specific causes of lower GI bleeding
Diverticular diseases
A true diverticulum contains
all layers of the intestinal
wall and is usually
congenital.
False diverticula consist of
mucosa and submucosa
protruding through a defect
in the muscle coat and are
usually acquired defects.
sabiston textbook of surgery
24. Anorectal diseases
The major causes of anorectal outlet bleeding
1.internal hemorrhoids
2.anal fissures
3.colorectal neoplasia
25. Hemorrhoids
Hemorrhoids are
cushions of submucosal
tissue containing venules,
arterioles, and smooth
muscle fibers that are
located in the anal canal
schwartz's principle of surgery
28. Management
Exclusion of other causes of rectal bleeding,
especially colorectal malignancy, is the first
priority.
Non-operative management
1.Rubber band ligation
2.Infrared photocoagulation
3.Sclerotherapy
4.Excition of thrombosed external hemorrhoids
operative hemorrhoidectomy
schwartz's principles of surgery
29.
30. Anal fissures
is a tear in the anoderm distal to the
dentate line.
Anal fissure is extremely common.
Characteristic symptoms include
tearing pain with defecation and
hematochezia (usually described as
blood on the toilet paper)
First-line therapy to minimize anal
trauma includes bulk agents, stool
softeners, and warm sitz baths.
2% lidocaine jelly
Nitroglycerin ointment has been
used locally to improve blood flow
Both oral and topical calcium
channel block- ers (diltiazem and
nifedipine) have also been used to
heal fissures
schwartz's principle of surgery
31. Neoplasia
Colorectal carcinoma is an uncommon cause of
significant lower GI hemorrhage but is probably
the most important one to rule out
The bleeding is usually painless, intermittent,
and slow in nature. Frequently, it is associated
with iron deficiency anemia.
sabiston textbook of surgery
32. Polyps
A colorectal polyp is any
mass projecting into the
lumen of the bowel above
the surface of the
intestinal epithelium
neoplastic
hyperplastic,
hamartomatous
inflammatory
sabiston textbook of surgery
33. Colitis
inflammatory bowel disease
infectious colitis (O157:H7 Escherichia coli,
cytomegalovirus, Salmonella, Shigella,
Campylobacter spp., and Clostridium difficile),
radiation proctitis after treatment for pelvic
malignant neoplasms, and ischemia.
sabiston textbook of surgery
35. Angiodysplasia
Angiodysplasias of the
intestine, also referred to
as arteriovenous
malformations
Angiodysplasias have an
equal gender distribution
and are almost uniformly
found in patients older
than 50 years.
sabiston textbook of surgery
