Download to read offline
More Related Content
Similar to Lower GI Bleeding powerpoint presentation
Lower GI Bleeding powerpoint presentation
- 1. LOWER GASTROINTESTINAL BLEEDING IRCCS HU Naaya Proessorof Surgery/Consultant Surgeon University of Maiduguri/University of Maiduguri Teaching Hospital, Maiduguri
- 2. LEARNING OBJECTIVES • Definelower GI bleeding. • Understand the various presentations of lower GI bleeding • Consider the various classifications of lower GI bleeding • The causes of lower GI bleeding • Investigations for lower GI bleeding • Treatment of lower GI bleeding • Briefly consider the common causes of lower GI bleeding
- 3. INTRODUCTION • Lower gastrointestinaltract bleeding is defined as any bleeding in the Gl tract distal to ligament of Treitz. • Majority of the LGI Bleeding is self limiting. • Only 10-20% patients presents with massive lower GI bleeding • In 90% of the cases colon is the source of bleeding.
- 4. INTRODUCTION • LGIB: • Incidenceincreases with age, as the causes are age related • Most common causes of significant LGI bleeding are Haemorrhoids and Diverticular disease. • Most common cause of LGI bleeding in general is Haemorrhoids(rarely massive bleeding).
- 5. DEFINITION • Lower GI- bleeding is defined as abnormal haemorrhage into the lumen of the bowel from a source distal to the ligament of Treitz. • Normal faecal blood loss - 1.2 ml / day • Significant - > 10 ml / day
- 6. COMPARATIVE TYPICAL PRESENTATIONOF GI BLEEDING UPPER GI BLEED NON-SPECIFIC GI BLEED LOWER GI BLEED Haematemesis “Coffee ground” emesis Melena Relatively easier to localize the site of bleeding Haemodynamic instability Epigastric pain Fatigue/lethargy Syncope Anaemia Haematochezia Melena Localizing the site of bleeding can be challenging
- 7. PRESENTATION • Lower Glbleeding typically presents with: • Haematochezia (which can range from bright-red blood to old clots) • Melena (If the bleeding is slower or from a more proximal source) • Abdominal/Anal pain • Features of anaemia • Features of shock (In massive haemorrhage)
- 8. INCIDENCE • LGIB constituteabout 20-33% of episodes of gastrointestinal (GI) haemorrhage. • The incidence rises steeply with advancing age. • 80% may resolve spontaneously. • 25% may re-bleed.
- 9. PRINCIPLES IN THEMANAGEMENT OF LGIB • Assess and classify the amount of blood loss • Replace the blood loss volume for volume(Resuscitation) • Diagnose the cause through investigations • Treat the cause(s) adequately
- 10. CATEGORIZATION OF (LGI)BLEEDING BY INTENSITY • Massive bleeding • Moderate bleeding • Occult bleeding
- 11. MASSIVE BLEEDING • Patientpresents with passage of large volume of bright red blood PR • Bleeding > 1.5 l/ day • Hemodynamic instability & shock • Shock Index (SI) of 1 and above signifies severe haemorrhage.(SI = HR/SBP) • Normal SI ranges between 0.5 to 0.7 • Decrease in haematocrit level of 6 g / dL • Transfusion of at least 2 units of packed red blood cells • Bleeding that continues for 3 days • Common causes • Diverticulosis / Angiodysplasia/Haemorrhoids (Occasionally)
- 12. MODERATE BLEEDING • Presentsas haematochezia or Malena* • Hemodynamically stable • Shock index is near normal • Initial decrease in haematocrit level of 8 g / dL or less • Causes • Ano-rectal / Congenital / Inflammation & Neoplastic diseases
- 13. OCCULT BLOOD • Occursin the setting of a positive FOBT and/or iron deficiency anaemia. • Iron deficiency anaemia has traditionally been attributed to chronic occult GI bleeding • Detected by routine chemical tests of the stool, with or without systemic evidence of chronic blood loss.(Tiredness, Weakness, Shortness of breath, Dizziness or light-headedness). • 10 ml. of blood loss / day is necessary to have stool occult blood positive.
- 14. AETIOLOGY - GENERALCAUSES • Congenital: • Polyp's / Meckel's diverticulum • Inflammatory: • Ulcerative colitis / Infective /Amoebic / Crohn's disease • Neoplastic: • Adenomas / Carcinomas / Polyps • Vascular: • Angiodysplasia / Ischaemic colitis / Vasculitis / Haemangioma • Clotting disorders: • Haemophilia / Leukaemia / Warfarin therapy / DIC • Miscellaneous: • Piles / Anal fissure / Injury to rectum
- 15. SITE - LOCALCAUSES • Small Intestine: • Polyp's / Meckel's diverticulum / Ulcers / Tumours/Intussusception • Large intestine: • Angiodysplasia / Carcinomas / Colitis / Diverticulitis • Perianal: • Injury / Rupture(Haematoma /Anorectal abscess) / Carcinoma / Condyloma • Anal: • Piles / Anal fissure / Carcinoma / Fistula-in-ano
- 16.
- 17. WITH PAIN • Fissure-in-Ano •Fistula-in-Ano • Ca. Anal Canal • Rup. perianal haematoma • Rup. Ano Rectal abscess • Endometriosis • Injury
- 18. WITHOUT PAIN • BloodAlone • Polyp • Villous Adenoma • Diverticular diseases • Blood After Defecation • Haemorrhoids • Blood with mucus • Ulcerative colitis • Intussusception • Ischaemic Colitis • Blood Streaked on stool • Ca. Rectum
- 19. MNEMONIC TO REMEMBERTHE MAJOR CAUSES OF LGIB • NADIR • N – Neoplasms (Benign or Malignant) • A – Angiodysplasias/arteriovenous malformations • D – Diverticulosis, Dyscraysias, Drugs (NSAID/Anticoagulant) • I – Inflammatory bowel diseases (Crohn’s, Ulcerative colitis), infections • R – Rhoids Haemorrhoids and/or fissure-in-Ano
- 20. CLINICAL PRESENTATIONS Bleeding Perrectum: Bright red blood Haemorrhoids (Piles) / Polyps / Fissure Altered blood Ca / Ulcer / IBD / Dysentery Maroon colour Meckel's diverticulum Streaks of blood Anal fissure Splash in pan Haemorrhoids (Piles) Red currant jelly Intussusception Blood with mucus Colitis / Ca / Dysentery Note: Ask & Look for bleeding tendency.
- 21. RELATION TO DEFECATION •Streak of fresh blood – Fissure-In-Ano • When passing stool - Bright red & Splashes over the pan - Haemorrhoids (Piles) • Other than during defecation - Polyps / PP / RP / Ca / UC • Bleeding per anum in child - Polyp
- 22. OTHERS SYMPTOMS ANDSIGNS • Pain • Altered bowel habits • Anaemia / Malnutrition / Loss of Weight I Loss of Appetite • Mass palpable PA - Rt /Lt • Per-rectal exam - Very important
- 23. LOCALIZATION OF THEBLEEDING SITE • Is a major challenge in the management of LGIB • In about 10% of patients presenting with lower gastrointestinal bleeding (LGIB), the source of bleeding is from the upper gastrointestinal (GI) tract.
- 24. LOCALIZATION OF THEBLEEDING SITE • Some patients with LGIB should have a nasogastric (NG) tube placed: • if the aspirate or lavage does not show any blood or coffee ground material, upper GI tract is unlikely. • In case of high suspicion, obtain an esophagogastroduodenoscopy (OGD) evaluation • Complete lower GI evaluation investigations should the be carried out to locate the site of bleeding
- 25. INVESTIGATIONS • Aims at: •Confirming that there is GI bleeding • Locate the site of the bleeding • Arrive at a definitive cause/diagnosis • May also serve as both investigation and treatment.
- 26. INVESTIGATIONS • Blood Tests •Hb% / PCV / LFT • Coagulation Profile / RFT • Stool examination • Ova / cyst / worms • Occult blood - FOBT
- 27. INVESTIGATIONS - CONTD •Proctoscopy • Sigmoidoscopy • Good Light source
- 28. INVESTIGATIONS - CONTD BariumEnema Small Bowel Enema Apple core deformity Diverticulosis
- 29. COLONOSCOPY • Diagnostic usesare • Visualization of the lesion • Biopsy of the lesion • Therapeutic uses are • Electro-cauterization of bleeding points • Polypectomy
- 30. COLONOSCOPY • Investigations -Contd • Colonoscopy - Gold Standard
- 31. COLONOSCOPIC PICTURES A B C D Ulcerativecolitis CA colon with bleeding Crohn's disease Diverticulosis
- 32. INVESTIGATIONS - CONTD •Colonoscopy - Gold Standard Angiodysplasia Ischaemic colitis Colonic Tumour
- 33. INVESTIGATIONS - CONTD •Abdominal USS – Tumour/Tumour Metastasis • Mesenteric Angiography • In this procedure bleeding rate of 0.5-1ml/ min can be detected. • Selective angiography is done by catheterising the arteries selectively under fluoroscopic guidance. • Therapeutic application can be achieved by embolization of the culprit vessel • Angiodysplasia / Tumours/ Vasculitis – Can be diagnosed
- 34. RADIONUCLEOTIDE SCANNING (Tc-99MLABELLED RBC SCINTIGRAPHY) • A sample of patient's blood is taken and then the RBC of the sample is labelled with Tc-99m. • Next the sample of blood is injected into the patient and serial scintigraphy scan are taken in fixed intervals. • It only has diagnostic purpose. But the advantage is that it can detect very small amount of bleeding(0.05-0.1 ml/min)
- 35. RADIONUCLEOTIDE SCANNING (Tc-99MLABELLED RBC SCINTIGRAPHY) Increasing amount of bleeding at the descending colon
- 36.
- 37. CAPSULE ENDOSCOPY • Noninvasive procedure • Done in stable patients • Duration is 8h/50000 images • Only diagnostic value • The imaging cannot be controlled from outside, thus pathological site may be missed
- 38. RESUSCITATION AND INITIALASSESSMENT • Initial evaluation and hemodynamic resuscitation: • Obtain a focused history, physical examination, and laboratory studies at the time of patient presentation (to determine severity, potential causes and site), • while concurrently performing hemodynamic resuscitation. • In the presence of haematochezia and hemodynamic instability, where an upper gastrointestinal bleeding (UGIB) site is suspected: • Perform an upper endoscopy or • Use nasogastric aspirate/lavage to help role out/determine a potential upper GI source.
- 39. RESUSCITATION AND INITIALASSESSMENT • Perform risk assessment and stratification. • Administer intravenous (IV) fluid resuscitation in patients with hemodynamic instability and/or suspicion of active bleeding. • Transfuse packed red blood cells (PRBCs) to maintain the haemoglobin level above 7 g/dL.
- 40. INITIAL RESUSCITATION -ACTION • Establish large-bore IV access and administer normal saline. • Routine laboratory studies (e.g., complete blood cell (CBC) count, electrolyte, and coagulation studies), • Blood should be typed and cross-matched. • The patient's blood loss and hemodynamic status should be ascertained, and in cases of severe bleeding, • The patient may require invasive hemodynamic monitoring (CVP, PCWP) to direct therapy.
- 41. INITIAL RESUSCITATION • Patientsin shock should receive fluid volume replacement without delay. • Colloid or crystalloid solutions may be used to achieve volume restoration before administering blood products. • PRBC transfusions should maintain the haemoglobin level above 7 g/dL, with a threshold of 9 g/dL in those with massive bleeding or • Significant comorbid conditions, or • If there may be a delay in more definitive treatment
- 42. TRANSFER TO INTENSIVECARE UNIT • Patients who may require admission to the intensive care unit and early involvement of both a gastroenterologist and a surgeon include the following: • Patients in shock • Patients with continuous active bleeding • Patients at high risk, such as patients with • Serious comorbidities, • Those needing multiple blood transfusions, or • Those with an acute abdomen
- 43. TREATMENT • Identified Causeis treated, but sometimes no definite cause/location of bleeding can be identified. • Treatment can be either endoscopic or open (Laparotomy) • Proper exploration - lengthy midline incision – essential if the bleeding site is not certain • Polyps: Endoscopic polypectomy • Mesenteric ischemia: Massive resection - small bowel • Colonic carcinoma: Surgical resection as appropriate to the location of the tumour.
- 44. TREATMENT • Sigmoid diverticula: •Sigmoid colectomy/Total colectomy may be carried depending on the extend of the disease. • Angiodysplasia: • Endoscopic fulguration / Therapeutic embolization / Hemicolectomy • Ulcerative colitis: • Drugs {Mesacol (Mesalazine)} enema / Total proctocolectomy and anastomosis • Haemorrhoids (Piles): • Appropriate haemorrhoidectomy procedure
- 45. BRIEF DISCUSSION OFFEW OF THE CAUSES OF LGIB • Anorectal dieases: Haemorrhoids • Diverticular disease • Colitis • Angiodysplasia
- 46. ANORECTAL DISEASES • Haemorrhoid:- •These are cushions of submucosal tissue containing venules, arterioles, smooth muscle fibre & elastic connective tissues • 3 anal cushions are found in 3,7&11 o'clock position in anal canal. • Caused by increased intra abdominal pressure i.e. • Obesity • Constipation • Pregnancy • Straining to pass urine
- 47. ANORECTAL DISEASES • Internalhaemorrhoids - located proximal to dentate line • Usually painless, thus banding, ligation can be done. • External haemorrhoids - located distal to dentate line • These are painful, usually self limited. • Classification of internal haemorrhoids and treatment
- 48. ANORECTAL DISEASES • Sclerotherapyis done by 5% phenol in almond or arachis oil • Operative haemorrhoidectomy are done by: • Milligan-Morgan's open haemorrhoidectomy, • Ferguson closed haemorrhoidectomy, • Whitfield submucosal haemorrhoidectomy, • Long's stapler method.
- 49. DIVERTICULAR DISEASE OFLGI TRACT • Next most common cause of significant LGI bleeding after haemorrhoid. • Incidence increases with age • Prevalent in western countries and developing countries where the dietary fibres in the food is less in amount. • Less dietary fibre causes increased duration of transit time followed by increased intraluminal pressure. • This results in diverticulum (pulsion type)
- 50. DIVERTICULAR DISEASE OFLGI TRACT • Caused by mucosal outpouching at the site of entrance of vessel i.e. Appendices epiploicae of the colon. • Present on the anti mesenteric border of LGI tract • Bleeding occurs in 3-15% of patient with diverticulosis • More than 75% of bleeding stops spontaneously with 10% rebleeds in 1year and 50% in 10 years.
- 51. DIVERTICULAR DISEASE OFLGI TRACT
- 52. DIVERTICULAR DISEASE OFLGI TRACT • Diverticulitis - is infected diverticula due to impaction of faecal material at neck and result into perforation/intraperitoneal abscess/peritonitis/LGI bleeding/ fistula. • Best method of diagnosis-Full length colonoscopy/Ba enema • Indication of surgery in Diverticulitis are • No improvement in medical therapy • At least 2 documented attacks of diverticulitis • Complicated diverticulitis • Recurrent or persistent haemorrhage.
- 53. DIVERTICULAR DISEASE OFLGI TRACT • Therapeutic use of colonoscopy is done to control bleeding by • Epinephrine injection • Electrocautery • Endoscopic clips. • If haemorrhage recurs then colonic resection is indicated. Surgical Specimen of Diverticulosis Barium Enema showing Diverticuli
- 54. COLITIS • An inflammatoryreaction in the colon, often auto-immune or infectious. • Most common types • Ulcerative colitis • A chronic, inflammatory bowel disease that causes inflammation in the digestive tract • Crohn's disease • A chronic inflammatory bowel disease that affects the lining of the digestive tract. • C. Diff. Colitis • Inflammation of the colon caused by the bacteria Clostridium difficile.
- 55. COLITIS • Both infective/inflammatorycolitis present as LGI bleeding, mostly haematochezia, pus may also be present. • DIAGNOSIS • The diagnosis of Ulcerative colitis and Crohn's disease is usually confirmed by biopsies on colonoscopy. • Although colonoscopy and sigmoidoscopy are still employed, now stool testing for the presence of C. difficile toxins is frequently the first-line diagnostic approach with history of prior antibiotic use or hospitalization.
- 56. ANGIODYSPLASIA • Angiodysplasia isa small vascular malformation of the gut. • It is a common cause of otherwise unexplained gastrointestinal bleeding and anaemia. • Cases present with black, tarry stool (melena), the blood loss can be subtle, with the anaemia symptoms predominating
- 57. ANGIODYSPLASIA • Diagnosis ofangiodysplasia is often accomplished with colonoscopy or esophagogastroduodenoscopy (EGD). • Treatment may be with: • Colonoscopic interventions, • Angiography and embolization, • Medication, or • Occasionally surgery.
- 58. APPROACH TO APATIENT WITH LGIB 1 2 3 4 5 6 +ve
- 59. CONCLUSION • Lower gastrointestinalbleeding (LGIB) • 10-20% may present with massive bleeding. • In 90% of cases, the source of the bleeding is the colon. • Incidence increases with age. • Majority of the cases are self-limiting. • Resuscitation is paramount in massive LGIB, before diagnosis and any definitive treatment. • Outcome of management will depend on the cause of the bleeding, but generally, the outcome is good.