Management of lower GI

bleeding

M K Alam MS; FRCS

ALMAAREFA COLLEGE
 Learning objectives (ILOs)
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

• Brisk UGI bleeding- bright red color

Causes of LGIB
 Lower Gastrointestinal Bleeding in Percentage of Patients
Adults
•Diverticular disease 60%

•Inflammatory bowel disease 13%

•Crohn disease
•Ulcerative colitis

•Benign anorectal diseases 11%

•Hemorrhoids
•Anal fissure
•Fistula-in-ano

•Neoplasia 9%
•Malignant neoplasia of colon, rectum, SI, anus

Coagulopathy 4%
Arteriovenous malformations 3%
TOTAL 100%
Source: Vernava AM, Longo WE, Virgo KS. A nationwide study of the incidence and etiology of lower gastrointestinal bleeding. Surg Res
Commun. 1996;18:113-20.[8]
 Diverticulosis
• Dominant cause of LGIB
• Saclike protrusion through the circular muscle fibers at a point
where the vessel has perforated.
• Vessel becomes draped over the dome of the diverticulum
• Most commonly located in the sigmoid and descending colon
• Bleeding originates from vasa rectae in the submucosa
• Risk factors: Lack of dietary fiber, constipation, advanced age, and
use of NSAIDs and aspirin.
 Angiodysplasia
• 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.

 Colitis (IBD)

• Massive hemorrhage-due to IBD is rare

• Ulcerative colitis: Bloody diarrhea in most.
Mild to moderate LGIB in up to 50%.
• Crohn disease: LGIB is not as common.
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.
 Neoplasm

• Polyps and carcinoma

• Occult bleeding

• Low grade and frequent bleeding- common

• Massive bleeding- unusual

 Other diseases

• Benign anorectal disease- hemorrhoids, anal

fissures, anorectal fistulas cause intermittent rectal
bleeding. 11% of LGIB- from anorectal disease.[8]

• Small intestinal conditions- Peutz-Jeghers

syndrome, hemangiomas, & adenocarcinomas
usually cause occult bleeding.
 Symptoms & signs of LGIB

• Variable- depending on the etiology

• Mild and intermittent- colon carcinoma, colitis

• Colon carcinoma rarely causes significant LGIB.

• Moderate/ severe: Diverticulosis, angiodysplasia.

 Symptoms & signs

• Young patients with infectious or noninfectious (idiopathic) colitis :

• Fever
• Dehydration
• Abdominal cramps
• Hematochezia

• Older patients with diverticular bleeding or angiodysplasia:

Painless bleeding and minimal symptoms.
• Ischemic colitis: Abdominal pain, and varying degrees of bleeding

• Massive lower GI bleeding usually in ≥65 years.

 Massive LGIB

• Age > 65

• Hematochezia or bright red blood PR

• Hemodynamically unstable
• 1. Diverticulosis 2. Angiodysplasia
 Lower GI bleeding rate
• Moderate bleeding: Hematochezia or melena.
Hemodynamically stable.
Benign anorectal conditions, IBD, neoplasia.

• Occult bleeding: Microcytic hypochromic anemia.

Benign anorectal conditions, IBD, neoplasia.
 Diagnosis
• History & physical examination

• Nasogastric tube

• Digital rectal examination, anoscopy /proctoscopy

• Complete blood cell (CBC) count

• Serum electrolytes levels

• Coagulation profile: aPTT, PT, platelet count

 Diagnosis- COLONOSCOPY

• Flexible colonoscopy: Initial diagnostic method of choice.

• Hemodynamically stable.

• Colonoscopy following a rapid bowel preparation.

• Bowel prepared colonoscopy- higher diagnostic/

therapeutic yields than unprepped colonoscopy.

• Successfully identify the origin of severe LGIB in 80-90% .

Colonoscopy- Bleeding polyp in colon
Bleeding rectal ulcer
 Colonoscopy
Carcinoma colon Vascular malformation in sigmoid
Ulcerative Colitis
Ulcerative colitis Crohn’s disease
Colonic Diverticulosis
 Other diagnostic modalities
• Tc⁹⁹RBC scan: Detects hemorrhage at rates as low as 0.1-0.5 mL/min.

• 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.

• CT scanning (A & P): Routine workup failed- contrast extravasation, bowel

wall enhancement, vascular dilatation

• Exploratory laparotomy (rarely): Intraoperative push enteroscopy in

hemodynamically unstable patients.

 Multiple episodes of LGIB without a known source

• Elective mesenteric angiography

• Upper and lower endoscopy

• Meckel scanning (Tc⁹⁹)

• Upper GI series with small bowel

• Enteroclysis
Tc⁹⁹RBC scan
Meckel's (Tc⁹⁹) scan
ANGIOGRAPHY
Haemorrhoids Anal fistula
 Principles of Management

• Resuscitation and initial assessment

• Localization of the bleeding site

• Therapeutic intervention to stop bleeding

 Resuscitation and initial assessment

• 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

• Flexible colonoscopy - hemodynamic stable patient

• RBC isotope scan

• Angiography
• CT scan
• Upper GI endoscopy
 Therapeutic interventions
• 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- vasopressin (Pitressin) used.
Vasopressin unsuccessful/contraindicated- superselective
embolization.
Superselective angiographic embolization

• The most feared complication of embolization

of the mesenteric vessels- ischemic colitis.

• Limited use for GI bleeding.

 SURGERY
Indications for surgery:

• 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
 Surgery
• Segmental bowel resection following precise localization of
the bleeding. Low morbidity & mortality when compared
with subtotal colectomy.

• Subtotal (total abdominal) colectomy with temporary end

ileostomy is the procedure of choice in patients who are
actively bleeding from an unknown source.

• Blind segmental resection should not be performed.

Associated with high rebleeding rate, morbidity & mortality.

Thank you!