جامعة المعرفة ALMAAREFA UNIVERSITY

Leenah Turjoman

نرتقي مع المعرفة

جامعة المعرفة^{}[] ALMAAREFA UNIVERSITY

LOWER GIT
BLEEDING

نرتقي مع المعرفة

جامعة المعرفة ALMAAREFA UNIVERSITY

Objectives

At the end of this presentation students will be able to:

Define lower GI haemorrhage (LGIB).

Enumerate the causes of LGIB.

Describe the pathophysiology of LGIB

Describe the symptoms and signs

Describe the diagnostic work up.

Describe the resuscitative measures.

Describe the management- non-surgical & surgical.

Introduction

Definition: Bleeding distal to DJ flexure- ligament of Treitz
Frequent cause of hospital admission, morbidity & mortality.
20-33% of all gastrointestinal bleeding.
Proximal to caecum- melena
Right colon- maroon color
Left colon- bright red bleeding (hematochezia)
Brisk UGI bleeding- bright red color

Causes of Lower G I T Bleeding in Adults

Percentage of Patients

•Diverticular disease → most common

60%

•Inflammatory bowel disease

13%

•Crohn disease

•Ulcerative colitis

•Benign anorectal diseases

→ more common but not too much bleeding

11%

•Hemorrhoids

•Anal fissure

•Fistula-in-ano

•Neoplasia → less common

•Malignant neoplasia of colon, rectum, SI, anus

Coagulopathy

Arteriovenous malformations

TOTAL

100%

→ Treatment: (according to Hinchey Classification) I, II → Conservative III, IV → Surgery (hartmann Procedure) → resection of area of diverticulosis, and do end colostomy of remaining descending colon, and closure of rectum. later can do anastomosis of descending colon with rectum

Diverticular Disease

→ most common → false (true is in right colon) → mechle’s diverticulum bleeding occur in diverticulosis more than diverticulitis → present just like acute appendicitis but on left side diverticule is filled with contents and when complications occur, lead to bleeding • Greater involvement in left colon 90%. occur due to low fiber diet → Const. Pation → bulging of mucosa outside, to the entrance of bilis (mucosa only that’s why its false diverticulum) • Most bleeding from right 60-80%. → mechles diverticulum → main and major cause of GI bleeding (huge amount) • Diverticulosis - not cause of occult bleeding → its a cause of visible bleeding • Diverticulitis - rarely associated with significant bleeding

Angiodysplasia

(in research its the most common cause)

Most common A-V malformations found in the GIT
Most common site- cecum and ascending colon
Acquired lesions
Elderly >60 years
Bleeding is venocapillary in origin.
Generally, less vigorous than diverticular bleeding.
80% untreated angiodysplasia experience rebleeding.

❖ LOWER GI HEMORRHAGE IN CHILDREN & ADOLESCENTS

✓ Meckel diverticulum → → → → → → →

✓

Juvenile polyps and polyposis

✓

Peutz-Jeghers syndrome

✓ FAP + melanosis

Gardner’s syndrome GFAP + osteomas

✓

Familial adenomatous polyposis (FAP) → → → → →

✓ > 100 Polyps

✓ Premalignant → so should

✓ Should do surgery, but if refused then follow up

Crohn’s disease or Ulcerative colitis

✓ Intussusception → → → →

✓ Fred Current jelly stool

Colitis (IBD)

Massive hemorrhage-due to IBD is rare
Ulcerative colitis: Bloody diarrhea in most.

smore malignant

Mild to moderate LGIB in up to 50%.

Crohn disease: LGIB is not as common.

binhole all layers

Bleeding more common with colonic involvement.
Ischemic colitis: Elderly, pain abdomen, bloody diarrhea. Involves splenic flexure and the rectosigmoid.
❖ Not associated with significant blood loss or hematochezia.

❖ Neoplasms

Polyps and carcinoma.
Occult bleeding, Low grade and frequent bleeding- common
Massive bleeding- unusual

❖ Benign anorectal disease

Hemorrhoids, anal fissures, anorectal fistulas cause intermittent rectal bleeding.

11% of LGIB- from anorectal disease.

❖ Small intestinal conditions

Peutz-Jeghers syndrome, hemangiomas, & adenocarcinomas usually cause occult bleeding.

Pedunculated Polyp (narrow neck) → Remove by Snaring (by endoscope)

Sessile Polyp → wide base

Diagnosis

History & physical examination
Nasogastric tube →

because the cause could be upper but bleeding going down (1/3-7) eg bright red color could be from heavy ugIB or transient time (too much bowel movement → diarrhea) eg millers

Digital rectal examination, anoscopy / proctoscopy
Complete blood cell (CBC) count
Serum electrolytes levels
Coagulation profile: aPTT, PT, platelet count

End of sigmoidoscopy

Colonoscopy examines the entire length of the colon; sigmoidoscopy examines only the lower third

Diagnosis- UGIT Endoscopy

then COLONOSCOPY

4 cuz Cause could be upper GI

of but if know the patient, and sure that cause is lower then start with colonoscopy.

Flexible colonoscopy: Initial diagnostic method of choice. Hemodynamically stable.
Colonoscopy following a rapid bowel preparation.
Bowel prepared colonoscopy- higher diagnostic/therapeutic yields than unprepared colonoscopy. To see the site of bleeding
Successfully identify the origin of severe LGIB in 80-90%.

CT Angiography

Detects bleeding at rates of 1-1.5 mL/min.
Indications:
Brisk ongoing LGIB,
Hemodynamically unstable,
with or without a preceding radionuclide scan & failed colonoscopy.

Tc⁹⁹RBC scan: Detects hemorrhage at rates as low as 0.1-0.5 mL/min.
CT Angiography: Routine workup failed- contrast extravasation, bowel wall enhancement, vascular dilatation

Wireless capsule endoscopy (WCE) Technical aspects

3 components
- Capsule endoscope
- External receiving antenna with attached portable hard drive
- Computed workstation for review and interpretation of images

To know site of bleeding

3 steps

Posted after 3-5 days

Swallowed by the patient
propelled by peristaltism
Images captured at 2 frames per images. Total (50000-75000 frames) reviewed on A work station

Contra indications to WCE

Small bowel strictures
Pregnancy
Pace Maker ?
MRI
Diverticula (relative) $ capsule can go in the diverticula and not come out

Capsule Endoscopy

Diagnostic, not therapeutic
8-hr test
Risk of retained capsule
False-negative rate

THE UNIVERSITY OF CALIFORNIA LET THERE BE

THE UNIVERSITY OF CALIFORNIA 1868

WCE

small bowel angiodysplasia

Obscure GI Bleeding

(can’t find source of bleeding)

Bleeding of unknown origin that persists or recurs after negative colonoscopy and negative upper endoscopy
May be occult or overt not visible only RBCs and can’t find source visible but can’t find source
10% - 20% of GI bleeding without identifiable etiology
5% GI bleeding recurrent without identifiable etiology
Majority have small bowel source

Multiple episodes of LGIB without a known source

See: esophagus, stomach, duodenum

See: rectum, sigmoid, Descending, Transverse, ascending

Upper and lower endoscopy

So still not see the small bowel

CT angio
Elective mesenteric angiography
Meckel scanning (Tc⁹⁹)
Upper GI series with small bowel enteroclysis: is an examination of the small bowel

done in the OR under anesthesia. (Prepared for Surgery) in tertiary hospital, Push enteroscope → (it has 2 ballons) during laparotomy Push the enteroscope inside and inflate the 2 ballons. and see if filling of blood occur in that segment. (more clear than milking by hands). until reach site of bleeding

In Poor Country: take segment of jejunum and do milking, and wait, if there is bleeding in that segment, it will be filled. if not filled then go to other segment until reach segment where there is filling after milking → Then open that area, see the problem and deal accordingly

Colonoscopy	Tc^{99}RBC scan	Angiography	CT scanning (A & P)	Exploratory laparotomy
Initial diagnostic method of choice (in Hemodynamically stable). (Bowel prepared colonoscopy) Done after empty the colon. -HIGHER diagnostic and therapeutic than unprepared colonoscopy	Detects bleeding at rates as low as 0.1-0.5 mL/min.	Detects bleeding at rates of 1-1.5 mL/min. Indications -Brisk ongoing LGIB, -Hemodynamically unstable, with or without a preceding radionuclide scan -Failed colonoscopy	Routine work up failed Findings : ( contract extravasation, bowel wall enhancement, and vascular dilatation)	(Rarely) Intraoperative push enteroscopy (hemodynamically unstable)

Exploratory laparotomy (rarely): Intraoperative push enteroscopy in hemodynamically unstable patients.

*at the end, if still can’t find source of bleeding → do Subtotal colectomy

Principles of Management

Resuscitation and initial assessment
Localization of the bleeding site by: - upper endoscopy
- lower colonoscopy
- enteroscopy
Therapeutic intervention to stop bleeding

Large-bore IV access
Crystalloid infusion.
CBC, electrolytes, coagulation profile, crossmatch.
Blood loss / hemodynamic status ascertained.
Severe bleeding-invasive hemodynamic monitoring.

Localization of the bleeding site

Upper GI endoscopy
Flexible colonoscopy - hemodynamic stable patient.
RBC isotope scan
Angiography
CT scan

③

Therapeutic interventions

defend on the cause

Diverticular bleeding: Colonoscopic bipolar probe coagulation, epinephrine injection, or metallic clips. Recurrent bleeding- resection of the affected bowel segment.
Angiodysplasia: Thermal therapy (electrocoagulation, argon)
Ischemic colitis : NPO and IV hydration.
Bleeding site cannot be determined: Vasoconstrictive agents used.
Superselective embolization angiography.

Surgery

Indications :

Active persistent bleeding with hemodynamic instability refractory to aggressive resuscitation
Persistent, recurrent bleeding
Transfusion of >4 units PRBC in a 24-hours with active or recurrent bleeding
Transfusion of >6 units of PRBC during the same hospitalization

Too much blood transfusion and there is still bleeding lead to DIC

What To Do

✓ Segmental bowel resection following precise localization of the bleeding.
✓ Subtotal (total abdominal) colectomy with temporary end ileostomy is the procedure of choice in patients who are actively bleeding from an unknown source.

Then anastomosis

ترتيقي مع المعرفة

920011909

www.um.edu.sa

@in almaarefa

@almaarefa

f almaarefa.sa

🩺 MedAtlax

Explorer

Lower GIT bleeding.backup