LOWER GI BLEEDING

Prepared by:
ABDULLAH AL-QAHTANI AHMED AL-BAHARNA
2031040016 2031040004
Supervised by:
Prof. Lade Wosornu
Definition

It is an abnormal intraluminal blood loss

from a source distal to the trietz
ligamentum; which is the suspensory
ligament of the duodenum.
Important Defenitions

 Melena: poorly formed ,blackstool which have

offensive smell.

 Heamatochezia: the passage of bright red

blood per rectum.
 10 % of patient presnt with heamatochezia ,they
have upper GI bleeding.
Clinical presentations
 In acute cases:
 Patients present with recent passage of significant amounts of bright red blood per rectum.
 Associated with instability of vital signs (hemodynamically compromised), anemia, and/or
need for blood transfusion.
 They may have history of syncope or presyncope prior to seeking medical care.

 In chronic cases:
 Patients present with the passage of bright red blood per rectum as blood on the tissue
paper or on the outside of formed stool in the absence of other symptoms.
 General physical examination is normal.

 In most of children, the bleeding is painless, intermittent and often streaky.

 In some cases, abdominal pain may be the chief complaint but it is not always a reliable sign
b/c:
 It does not necessarily imply that there is bleeding (low specificity).
 It does not accurately localize the site of the bleeding.
Symptoms
 Acute gastrointestinal bleeding first will appear as vomiting of blood, bloody bowel
movements, or black, tarry stools. Blood may look like "coffee grounds." Symptoms
associated with blood loss can include the following:
 Fatigue
 Weakness
 Shortness of breath
 Abdominal pain
 Pale appearance
 Vomiting of blood usually originates from an upper GI source. Bright red or maroon
stool can be from either a lower GI source or from brisk bleeding at an upper GI
source.
 Long-term GI bleeding may go unnoticed or may cause fatigue, anemia, black stools,
or a positive test for microscopic blood.
Signs
 Blood per rectum occurs with any GI source.
 Hematochezia (seen in 80% of all GI Bleeding):
 Grossly bloody, maroon or dark red stool.
 Usually correlates with lower GI bleeding.
 Brisk upper GI bleeding may cause (11%).
 Melena (Black tarry stool):
 Black tarry stool requires 150 to 200 cc blood.
 Black non-tarry stool requires 60 cc blood.
 Blood must be in GI tract 8 hours to turn black.
 Stool remains black for several days in GI tract.
 Melana source:
 Present in 70% of upper GI bleeding
 Present in 33% of lower GI bleeding
 Blood in toilet (e.g. Hemorrhoids source):
 Toilet water may appear bright red from 5 cc blood
Differential Diagnosis
1- non-infective causes :
 Diverticular Disease.
 Angiodysplasia
 Haemorrhoids .
 Anal Fissure ( especially in children ) .
 Rectal Prolapse .
 Neoplasms of the anal canal and orifices , rectum , large
intestine .
Benign Malignant
Adenocarcinoma
Polyps Squamous Carcinoma
Melanoma

 Inflammatory Bowel Diseases:

 Crohn’s disease
 Ulcerative colitis
 Ischemic Colitis.
 Polyposis.
Differential Diagnosis cont.

2- infective causes :
 Enteric Fever (salmonella)
 Bilharziasis
 Amebiasis
 Diverticular disease (40%)
•Most Common Cause of lower GI bleeding.

•Diverticulum is a blind pouch leading aff the

alimentary tract, lined by mucosa, that
communicates with the lumen of the gut .

• Most of the time it is asymptomatic, exept

in case of complication:
Diverticulitis
Bleeding
Bowel obstruction
Fistula

•Symtoms:
Severe Lt. iliac fossa pain, nausea, loss
of appetite and constipation.
Angiodysplasia (30%)

 Angiodysplasia is vascular
malformation associated with
ageing.consist of dilated
tortuuous submucosal veins

 There is association with

aortic stenosis.

 80% of the lesion occur in the

right side of the colon.
Anal carcinoma (15%)
 Hemorrhoids
 Hemorrhoids may be external
or internal to the anal orifice.
 External variety is covered by
the skin, while the internal
variety lies beneath the anal
mucous membrane.
 Usually after the age of 20
years.
 Symptoms:
 No pain in uncomplicated cases.
 Bleeding and palpable lump after
defecation.
 May cause peri-anal discomfort,
pruritis and mucous discharge.
Anal fissure
 An anal fissure is an
elongated ulcer in the long
axis of the lower anal
canal.
 It may be acute or chronic.
 Clinical features:
 Sharp pain starts during
defecation and lasts an
hour or more then ceases
suddenly.
 Slight bleeding consists
of bright streaks on the
stools or the paper.
 Slight discharge in some
cases.
Rectal ulcer

Classically, single ulcer on

the anterior wall of the
rectum.
It must be differintiated from
rectal carcinoma or
inflammatory bowel disease,
particularly Crohn’s disease.
Symptomatic relief from
bleeding and discharge may
achieved by preventing the
internal prolapse by an
abdominal rectopexy.
Crohn's disease
• presentation depends on the area of
involvement.
•It may be acute or chronic.
•In acute cases, symptoms and signs
resemble those of acute appendicitis but
there is usually diarrhea preceding the
attack.
• In chronic cases, there are mild diarrhea,
pain in the Rt. Iliac fossa, fever, secondary
anemia and loss of wieght.
• Surgical resection will not cure Crohn’s
disease.
• So, surgery is focused on complications of the
disease. Like:
1. Recurrent intestinal obstruction.
2. Bleeding.
3. Perforation.
4. Failure of medical therapy.
5. Intestinal fistula.
6. Malignant change.
Ulcerative colitis

•Symptoms:
•Watery or bloody diarrhea (1st)
•Rectal discharge: bloody or
purulent.
•Proctitis (25%)
•Left sided colitis (15%)
•Total colitis (25%)
•Early pain is unusual.
•Relapses and remission (chronic)
Polyps
 INITIAL INVESTIGATIONS
• General:
1. CBC
2. PT & PPT
3. Blood group & cross matching
4. Stool studies

• Specific:
1. Rectal examination:
• Inspection: discharge, ulceration, protruding masses, fissure, prolapse.
• Rectal digital examination: tone of sphincter, normal structures,…..etc
• Rectoscopy
2. Endoscopy: diagnostic and therapeutic procedure.
Proctoscope

Endoscopy
3. Barium enema
4. Angiography:
• It detects bleeding in GIT when it exceeds 1 – 2 ml/min.
• It is indicated when the site of Bleeding has not been detected by
endoscope.
• It is a diagnostic and therapeutic
(embolization of bleeding vessels )
procedure.
5. colonoscopy

6. Sigmoidoscopy
7. Radionucleotide scanning :
 Valuable and very sensitive to
detect slower bleeding (0.5 ml/min),
usually a complementary technique
to angiography.
 less invasive and more sensitive
than angiography.
 But less accurate than angiography
in localizing the site of bleeding.
•As a conclusion to investigations:
“for patients without contraindications to
endoscopy, colonoscopy, or both, are preferred
as first-line procedures over angiography and
radionucleotide scanning. Patients who cannot
be stabilized by these procedures should
undergo surgery to localize
and
control bleeding”
TREATMENT

A. Initial treatment:
 ABC management (Resuscitation)
• Airways
• Breathing
• Circulation
 Assessment of hemodynamic stability.
 Assessment of severity of bleeding.
TREATMENT cont.
B. Medical treatment (after stabilization)
C. Surgical treatment (according to cause of
bleeding):
 Operation is limited to segmental colonic
resection if the bleeding site has been
localized conclusively.
 Total abdomenal colectomy with iliorectal
anastomosis is only for persistent colonic
bleeding of unknown origin.
Postoperateive Complications
A. Immediate (1st 24 hours):-
 Urinary retention: Inadequate fluid replacement
intra and postoperatively.
 Primary hemorrhage: Starting during surgery
Replace blood loss and return to theatre if
necessary
 Reactive hemorrhage: Bleeding following
postoperatively increase in blood pressure
Replace blood loss and re-explore wound.
 Shock Blood loss, MI, Pulmonary Embolism or
Septicemia.
Postoperateive Complications cont.
B. Early (1st weak):-
 Nausea and vomiting: Analgesia or anesthetic related;
paralytic ileus
 Secondary Hemorrhage: Often as a result of infection
 DVT
 Acute Urinary Retention
 Urinary Tract Infection
 Postoperative Wound Infection
 Bowel Obstruction: due to fibrinous adhesions
 Paralytic ileus
Postoperateive Complications cont.

C. Late (after one weak):-

 Bowel Obstruction: due to fibrous
adhesions
 Incisional Hernia
 Recurrence of Malignancy
THANK YOU