Khartoum Teaching Hospital

Mr. Kailani’s Unit

By
Dr. Nada M. Ahmed
 Definition
 This is bleeding from the gastrointestinal
tract coming from a source below the
ligament of Treitz.
 Upper gastrointestinal tract causes,

however, can present with bleeding per

rectum if it is massive.
 Causes
 Haemorrhoids.
 Anal fissure.
 Colorectal cancer.
 Diverticular disease.
 Vascular anomalies (angiodysplasia).
 Meckel’s diverticulum.
 Other causes
 Colorectal polyps.
 Inflammatory bowel disease.
 Small bowel tumours.
 Ischaemic colitis.
 Infectious colitis.
 Haemorrhoids
 These are dilated veins occurring in
relation to the anus, they can be internal
or external; to the anal orifice.
 The external variety is covered by skin

while the internal variety lies beneath the

anal mucous membrane. When the two
varieties are associated, they are known
as intero-external.
 Haemorrhoids (cont.)
 The mucosal lining is gathered
prominently in three places (the anal
Cushions) which can be in the area of the
three terminal branches of the superior
haemorrhoidal artery.
 Haemorrhoids may appear as a symptom

for other conditions such as carcinoma of

the rectum.
 Haemorrhoids (cont.)
 Patients complain of bright red painless
bleeding.
 Mucous discharge, prolapce (swellings at the

anal verge), are other symptoms and may help

in the diagnosis.
 Pain is usually absent unless complications

occur.
 Severe haemorrhage complicates haemorrhoids.
 Anal fissure
 This is an elongated ulcer (canoe-shaped)
in the long axis of the lower anal canal.
 The most common site is the mid-line

posteriorly, followed by the mid-line

anteriorly.
 Anal fissure can be acute or chronic.
 Anal fissure (cont.)
Because anal fissure occur in the stratified
sensitive epithelium of the lower half of
the anal canal, pain is the most prominent
symptom.
 Patients complain of bright red bleeding.

 Usually the amount is small; it stains the

underwear and found as steaks in the
stools.
 Anal fissure (cont.)
 Sharp agonizing pain on defecation that
continue for a considerable time
afterwards, mucous discharge and
constipation are other symptoms.
 Colorectal cancer
 The commonest site for is the rectum
(28%) followed by the sigmoid (21%), the
caecum (12%) then come the
rectosigmoid junction and etc.
 Bleeding as an early symptom occurs in a
small amount and at the end of the
defecation, but can be severe.
 Other associated symptoms include
 Colorectal cancer (cont.)
 Early morning diarrhoea, sense of
incomplete defecation, alteration of bowel
habits and symptoms and signs of
anaemia are accompanying features.
 Attacks of intestinal obstruction (chronic,

sub-acute or acute on chronic) might

occur. Peritonitis due to perforation of a
malignant tumour is rarely seen.
 Diverticular disease
 A diverticulum is herniation of the mucosa
through the muscle coat of the bowel.
 Most arise in the mesenteric site as the

result of mucosal herniation through the

point of entery of blood vessels.
 In the large bowel, they are most

commonly found in the sigmoid colon.

 Diverticular disease (cont.)
The rectum is usually not affected because
of its complete muscle coat.
 They are found in 25% of patients above
40 years undergoing barium enaema.
 Haemorrhage occurs when they get
inflamed (diverticulitis). In 17% bleeding
can be very severe requiring blood
transfusion.
 Diverticular disease (cont.)
 Other features that help to differentiate
bleeding from diverticulitis include persistent
lower abdominal pain (usually in the left iliac
fossa), fever, malaise and leucocytosis. The
abdomen is especially tender in the left iliac
fossa; the sigmoid colon is often palpable,
tender and thickened.
 Patients may also present with peumaturia as
a results of a vesicocolic fistula.
 Meckel’s diverticulum
 This is a common cause of rectal bleeding
in children
 It is present in 2% of the population,
situated on the antimesenteric border of
the ileum commonly 2 feet proximal to the
ileocaecal valve and is usually 2 inches
long.
 Meckel’s diverticulum (cont.)

 Meckel’s diverticulum possesses all three

coats of the intestinal wall (mucosa, circular
& longitudinal muscles), and it has its own
blood supply.
 Meckel’s diverticulum can present with severe
haemorrhage caused by peptic ulceration.
 There is rarely any pain and some time the

bleeding precedes perforation.

 Vascular anomalies
(angiodysplasia)
This is a vascular malformation associated
with aging.
 It consists of dilated tortuous submucosal
veins. In severe cases the mucosa is
replaced massive dilated deformed
vessels.
 The lesions are only a few millimeters in
size.
 Vascular anomalies
(angiodysplasia)
 It occurs particularly in the ascending
colon and caecum of patients above 60
years of age.
 It is not associated with cutaneous lesions.
 Bleeding is usually chronic and

intermittent, but can be very severe.

 Colorectal polyps
 Polyps can occur singly, synchronously in small
numbers or as a part of the polyposis syndrome.

 These include adenomatous, inflammatory,

neoplastic and hamartomous polyps.
 A localized submucosal haemangioma is often a
cause of bleeding which may be severe.
Small bowel tumours
 These can be benign or malignant.
 They include adenoma, sub-mucous

lipoma, liomyoma and lymphoma.

 Bleeding, intussusception, perforation,

anorexia, weight loss are the presenting

features.
 Per rectal examination
 In haemorrhoids it shows nothing unless they
are thrombosed.
 In anal fissure it is painful and should not be

done (EUA is better). An ulcer is seen with skin

tag.
 Rectal carcinoma, in 90% of cases the tumour is
felt digitally as a plateau or a nodule with
indurated base. The gloved finger may be blood
stained.
 Proctoscopy
 This is diagnostic for haemorrhoids and it
shows the bulging of the internal
haemorrhoids into the lumen of the
proctoscope.
 In rectal cancer, it may show the tumour.
Sigmoidoscopy & Colonoscopy

 Angiodysplasia appear as reddish raised

areas that are oozing blood provided that
the bleeding is not too brisk.
 It also shows the tumour in colorectal

cancer and detects synchronous tumours.

 It is also helpful in the diagnosis of

diverticular disease.
 Barium enaema
 Barium enaema shows the tumour in
colorectal cancer as a constant irregular
filling defect, also it detects synchronous
tumours.
 Colonic diverticula are diagnosed by

barium enaema.
 Small bowel enaema
 This is the most accurate method for the
diagnosis of Meckel’s diverticulum.
 Small bowel tumours can be shown.
 Others
 Selective superior and inferior mesenteric
angiography shows the site and extends
of the angiodyplasia. It also demonstrates
haemangiomata.
 Technetium-99m (99mTc)- labelled red

cells may confirm and localize the source

of haemorrhage in angiodyplasia.
 General management
 The first step in an acute case is to check the
haemodynamic state of the patient (this is by
checking the pulse).
 Venous access should be established be a
canula.
 Blood is taken for haemoglobin, haematocrit and
grouping.
 Transfusion may be considered in cases with
massive bleeding.
General management (cont.)

 A nasogastric tube is inserted to exclude

upper gastrointestinal causes that bleed
profusely. If the aspirate is bilious, the
examiner can be fairly sure that the
source is distal to the ligament of Treitz.
However, if the aspirate reveals no bilious
fluid, the patient may have a bleeding
source in the duodenum with a competent
pylorus.
General management (cont.)

 Most cases settle spontaneously and most

patients are treated electively. 75% of
patients with angiodysplasia and 90% of
those with diverticular disease resolve
spontaneously.
Treatment of haemorrhoids
 Many modalities of treatment are found
depending on the degree of the haemorrhoids;
 Injection of sclerosant agent (e.g. 5%

phenol in almond oil) is used for 1st degree

and early stage of the 2nd degree.
 Banding is applied for 2nd degree piles.

 Photocoagulation (infra-red) for 1st & 2nd

degree piles
Treatment of haemorrhoids
(cont.)
Operative haemorrhoidectomy (commonly the
open Milligan-Morgan operation) is indicated in:
 3rd degree piles

 Fibrosed piles

 Intero-external

 Failure of non- operative treatment.

Treatment of anal fissure
 This can be conservative or operative
 Conservative management;
 Avoidance of constipation by the use of high
residue diet, laxatives (lactulose) and most
importantly a local pain killer (Xylocaine
ointment).
 Chemical sphincterotomy by GTN 0.2%
ointment. When applied to anal canal
produces sufficient relaxation of the internal
sphincter and improves the blood flow to the
area, and this aids in healing.
Treatment of anal fissure
(cont.)
 Operative management;
 These measures are indicated in chronic
fissure or ineffective conservative
management.
 Anal dilatation.

 Lateral sphincterotomy.

 Dorsal fissurectomy and sphincterotomy.

Treatment of colorectal cancer

The treatment in these cases is mostly

surgical.
 Curative resection is considered in early
operable cases
 The best palliation is resection of late

cases.
 Treatment bleeding
diverticulitis
 Initially:
 Bed rest.
 IV antibiotics (cefuroxime & metronidazole).
 Treatment bleeding
diverticulitis (cont.)
 Treatment of the bleeding:
 This usually responds to conservative
management.
 Blood transfusion may be considered if the

bleeding was massive

 Only occasionally, it may require resection.

 On-table lavage and colonoscopy may be

necessary to localize the bleeding site.

Treatment of Angiodysplasia
Colonoscopic diathermy.
 Surgery will be necessary if the bleeding is
brisk and the patient is seriously ill;
 Bleedingpoint is demonstrated by on table
colonoscopy after colonic irrigation with
water and saline or by transillumination
through the colonic wall.
 Surgery may range from partial to total
colectomy with ileorectal anastomosis.
 Treatment of Meckel’s
diverticulum
 Bleeding usually stops spontaneously.
 Operation for resection of the diverticulum
is done for serious progressive bleeding.
Thanks a lot