This document discusses lower gastrointestinal (GI) bleeding, including: 1. Definitions of lower GI bleeding and what constitutes significant bleeding. Lower GI bleeding originates in the small or large intestine. 2. Presentations of lower GI bleeding ranging from hematochezia to melena to occult bleeding. Massive bleeding presents as hemodynamic instability while moderate bleeding is stable. 3. Common causes of lower GI bleeding including diverticular disease, inflammatory bowel disease, angiodysplasia, and cancers. Local causes depend on specific sites within the intestines. 4. Evaluations include blood tests, stool tests, imaging like colonoscopy, and in some cases angiography to localize the source and

1. Lower GI Bleed
Dr Vijay Kumar ; Associate Prof.

3. Definition
● Lower GI - bleeding is
defined as abnormal
hemorrhage 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

5. Presentation
● Lower GI bleeding typically presents with
1. Hematochezia (which can range from bright-red blood to old clots)
2. Melena (If the bleeding is slower or from a more proximal source)

8. Massive Bleeding
● Presents as a large volume of
bright red blood PR
● Bleeding > 1.5 l / day
● Hemodynamic instability & shock
● ↓ in hematocrit level of 6 g / dL
● Common causes – D / A
● Transfusion of at least 2 units of
packed red blood cells
● Bleeding that continues for 3 days
Moderate Bleeding
● Presents as haematochezia
or malena
● Hemodynamically stable
● Causes – Ano-rectal / Cong./
Infla.& Neoplastic diseases
● Initial ↓ in hematocrit level
of 8 g / dL or less

9. Occult Blood
● Detected by routine chemical
tests of the stool, with or
without systemic evidence of
chronic blood loss.
● 10 ml. of blood loss / day is
necessary to have stool
occult blood positive.

10. Types
Aetiology
Site of Bleeding
Pain + / -
Classification

11. Aetiology – General causes
1. Congenital -
Polyp’s / Meckel’s diverticulum
2. Infammatory -
Ulcerative colitis / Infective /Amoebic / Crohn’s disease
3. Neoplastic –
Adenomas / Carcinomas / Polyps
4. Vascular –
Angiodysplasia / Ischaemic colitis / Vasculitis / Hamangioma
5. Clotting disorders -
Haemophilia / Leukaemia / Warfarin therapy / DIC
6. Miscellaneous –
Piles / Anal fissure / Injury to rectum

13. Site – Local causes
1. Small Intestine -
Polyp’s / Meckel’s diverticulum / Ulcers / Tumours
/ Intussusception
2. Large intestine -
Angiodysplasia / Carcinomas / Colitis / Diverticulitis
3. Perianal –
Injury / Rupture(Haematoma /Anorectal abscess)
/ Carcinoma / Condyloma
4. Anal -
Piles / Anal fissure / Carcinoma / Fistula-in-ano

14. With Pain
● Fissure in Ano
● Fistula in Ano
● Ca. Anal Canal
● Rup. perianal haematoma
● Rup. Ano Rectal abscess
● Endometriosis
● Injury

15. Without Pain
1. Blood Alone
a. Polyp
b. Villous Adenoma
c. Diverticular diseases
2. Blood After Defecation
a. Hemorrhoids
3. Blood with mucus
a. Ulcerative colitis
b. Intussusception
c. Ischaemic Colon
4. Blood Streaked on stool
a. Ca. Rectum

16. Common Causes
Acute Sub-acute / Chronic
Diverticular disease Anal disease
Mesenteric ischaemia Inflammatory bowel disease
Angiodysplasia Large polyps
Ischaemic colitis Carcinoma
Meckel’s diverticulum Solitary rectal ulcer
Intussusception Radiation enteritis

17. Differential Diagnosis

21. Clinical Presentations
Bleeding Per rectum –
-
-
-
-
-
-
-
Bright red blood
Altered blood
Maroon colour
Streaks of blood
Splash in pan
Red currant jelly
Blood with mucus
Piles / Polyps / Fissure
Ca / Ulcer / IBD / Dysentery
Meckel’s diverticulum
Anal fissure
Piles
Intussusception
Colitis / Ca / Dysentery
Note : Ask & Look for bleeding tendency

25. Relation to Defecation
● Streak of fresh blood – FIA
● At the time of passing stool –
Bright red & Splashes over the pan
- Piles
● Other than during defecation -
Polyps / Ca / UC
● Bleeding per anum in child –
Polyp

26. OTHERS
● Pain
● Altered bowel habits
● Anaemia / Malnutrition / LOW / LOA
● Mass palpable PA – Rt /Lt / MOI
● Per-rectal exam – Very important

27. Investigations
1. Blood Tests –
a. Hb% / PCV / LFT
b. Coag. Profile / RFT
2. Stool examination -
a. Ova / cyst / worms
b. Occult blood – FOBT

28. Investigations - Contd
Small Bowel Enema Barium Enema

29. Investigations - Contd
Proctoscopy Sigmoidoscopy

30. Investigations - Contd
Colonoscopy – Gold Standard

31. Investigations - Contd
Colonoscopy – Gold Standard

32. Investigations - Contd
Colonoscopy – Gold Standard

33. Investigations - Contd
Colonoscopy – Gold Standard

34. Investigations - Contd
5. U/S abdomen –
6. Angiography –
Identifies bleeding rate of 0.5ml/mt
All 3 vessels – are used
Angiodysplasia / Tumours
/ Vasculitis – diagnosed
7. Radionuclear scanning –
Identifies 0.1ml / mt
Tc labelled sulphur colloid
/ tagged RBC scan

35. Investigations - Contd
Capsule Endoscopy CT / MRI - Angiography

36. TREATMENT

37. Treatment
Cause is treated
Proper exploration – lengthy midline incision – essential
Endoscopic polypectomy for polyps
Massive resection – small bowel – mesenteric ischemia
Surgical resection – colonic carcinoma
Sigmoid colectomy – sigmoid diverticula
Endoscopic fulguration / therapeutic embolization / Rt.hemicolectomy
for angiodysplasia
Drugs / Mesacol enema / Total proctocolectomy i IA anastomosis
for ulcerative colitis
Excision & ligation – piles

42. References