Management Of Lower

Gastrointestinal Bleed
Megat Mohd Azman Adzmi
Khoo Yimei
Teo Yi Yan
Muhammad Hassanuddin
 Definition
• Lower gastrointestinal bleeding is blood loss
from the gastrointestinal tract of recent onset
emanating from a location distal to the
ligament of Treitz resulting in instability of vital
signs, anemia, and/or need for blood
transfusion.
Aetiology
 Aetiology
• Diverticular diseases(MC) – in elderly males.
• Angiodysplasia
• Anorectal diseases – in middle aged males.
• Carcinoma/polyps
• Colitis – ischemic, infective, radiation
• Inflammatory bowel disease (IBD)
• Meckel`s diverticulum – in childhood.
 Aetiology
• Uncommon causes
– Varices (Rectal)
– Intussusception
– Solitary rectal ulcer
– Aorto enteric fistulae
– Vasculitis
– NSAID induced ulcer, colitis
• Small intestinal causes
– Vascular ectasias
– Tumors

• UPPER GI SOURCE should always be excluded in all patients

with massive lower GI bleeding.
 Signs and symptoms
The clinical presentation of LGIB varies with the anatomical
source of the bleeding, as follows:
• Maroon stools, with LGIB from the right side of the colon
• Bright red blood per rectum with LGIB from the left side
of the colon
• Melena with cecal bleeding

However, patients with upper GI bleeding and right-sided

colonic bleeding may also present with bright red blood per
rectum if the bleeding is brisk and massive.
 Signs and symptoms
The presentation of LGIB can also vary
depending on the etiology. A young patient with
infectious or noninfectious (idiopathic) colitis
may present with the following:
• Fever
• Dehydration
• Abdominal cramps
• Hematochezia
 Approach Consideration
The management of LGIB has 3 components, as
follows:
• Resuscitation and initial assessment
• Localization of the bleeding site
• Therapeutic intervention to stop bleeding at
the site
 Resuscitation and Initial Assessment
• Initial resuscitation involves establishing large-bore IV
access and administration of normal saline. Besides
ordering routine laboratory studies (eg, complete blood
cell (CBC) count, electrolyte levels, and coagulation
studies), blood should be typed and cross-matched.
• The 2008 SIGN guideline states that patients in shock
should receive fluid volume replacement without delay.
Colloid or crystalloid solutions may be used to achieve
volume restoration before administering blood products.
Red cell transfusion should be considered after loss of
30% of the circulating volume.
 Resuscitation and Initial Assessment
• Signs of hemodynamic compromise include
postural changes with dyspnea, tachypnea,
and tachycardia.
• An orthostatic drop in systolic blood pressure
of more than 10 mm Hg or an increase in
heart rate of more than 10 beats per minute is
indicative of at least 15% of blood volume
loss.
 Resuscitation and Initial Assessment
• Severe postural dizziness with a postural pulse
increase of at least 30 beats per minute is a
sensitive and specific indicator of acute blood
loss of more than 630 mL.
• Coagulopathy, such as an international
normalized ratio (INR) of greater than 1.5, may
require correction with fresh frozen plasma;
thrombocytopenia can be corrected with
platelet transfusions.
 Resuscitation and Initial Assessment
Transfer to ICU
• Patients who require admission to the intensive care
unit and early involvement of both a
gastroenterologist and a surgeon include the
following:
• Patients in shock
• Patients with continuous active bleeding
• Patients at high risk, such as patients with serious
comorbidities, those needing multiple blood
transfusions, or those with an acute abdomen
 Localization of the Bleeding Site
• In about 10% of patients presenting with LGIB, the
source of bleeding is from the upper gastrointestinal
(GI) tract.
• Some patients with LGIB should have a nasogastric
(NG) tube placed, and if the aspirate or lavage does
not show any blood or coffee ground–appearing
material but dose show bile, bleeding originating
from the upper GI tract is unlikely.
• In case of high suspicion, obtain an
esophagogastroduodenoscopy (EGD) evaluation
 Initial Approach to Hemostasis
• In patients who are hemodynamically stable
with mild to moderate bleeding or in patients
who have had a massive bleed that has
stabilized, colonoscopy should be performed
initially. Once the bleeding site is localized,
therapeutic options include coagulation and
injection with vasoconstrictors or sclerosing
agents.
 Initial Approach to Hemostasis
• For diverticular bleeding, bipolar probe
coagulation, epinephrine injection, and metallic
clips may be used. If recurrent bleeding is present,
the affected bowel segment can be resected.
• For angiodysplasia, thermal therapy, such as
electrocoagulation or argon plasma coagulation, is
generally successful. Angiodysplastic lesions may
be missed at colonoscopy if the lesions are small
or covered with blood clots.
 Initial Approach to Hemostasis
• The 2008 SIGN guideline states that
colonoscopic hemostasis is an effective way to
control hemorrhage from active diverticular or
post-polypectomy bleeding in patients with
massive LGIB.
 Therapeutic intervention
Therapeutic intervention to stop bleeding at the
site includes:
• Colonoscopy
• Vasoconstrictive Therapy
• Superselective Embolization
• Endoscopic therapies
• Emergent surgery
 Colonoscopy
• Colonoscopy is useful in radiation therapy–induced
gastrointestinal (GI) bleeding and in the treatment of
colonic polyp lesions.
• Endoscopic treatment of radiation-induced bleeding
includes topical application of formalin, Nd:YAG laser
therapy, and argon plasma coagulation.
• Neoplastic bleeding due to polyps requires
polypectomy.
• Patients diagnosed with colonic tumors may require
surgical resection.
 Vasoconstrictive Therapy
• In patients in whom the bleeding site cannot be determined
based on colonoscopy and in patients with active, brisk LGIB,
angiography with or without a preceding radionuclide scan
should be performed to locate the bleeding site as well as to
intervene therapeutically.
• Initially, vasoconstrictive agents, such as vasopressin can be
used.
• An experimental study of treatment of LGIB by selective
arterial infusion of vasoconstrictors, such as epinephrine with
propranolol and vasopressin, was reported. Although
epinephrine and propranolol drastically reduced mesenteric
blood flow, they also caused a rebound increase in blood flow
and recurrent bleeding.
 Vasoconstrictive Therapy
• Vasopressin is a pituitary hormone that causes
severe vasoconstriction in the splanchnic bed.
• Vasoconstriction reduces the blood flow and
facilitates hemostatic plug formation in the bleeding
vessel.
• Vasopressin infusions are more effective in
diverticular bleeding, which is arterial, as opposed to
angiodysplastic bleeding, which is of the
venocapillary type. The results are less than
satisfactory in patients with severe atherosclerosis
and coagulopathy.
 Vasoconstrictive Therapy
• Intra-arterial vasopressin infusions begin at a rate of 0.2
U/min, with repeat angiography performed after 20 minutes.
• The bleeding stops in about 91% of patients receiving intra-
arterial vasopressin but recurs in up to 50% of patients when
the infusion is stopped.
• If bleeding persists, the rate of the infusion is increased to
0.4-0.6 U/min.
• Once the bleeding is controlled, the infusion is continued in
an intensive care setting for 12-48 hours and then tapered
over the next 24 hours.
• In patients with rebleeding, surgery should be considered.
Complications of Vasoconstrictive Therapy

• During vasopressin infusion, monitor patients for recurrent

hemorrhage, myocardial ischemia, arrhythmias, hypertension,
and volume overload with hyponatremia.
• Nitroglycerine paste or drip can be used to overcome cardiac
complications.
• Selective mesenteric infusion induces bowel wall contraction
and spasms.
• Do not administer vasopressin into systemic circulation
intravenously, because this causes coronary vasoconstriction,
diminished cardiac output, and tachyphylaxis.
• Vasopressin infusions are contraindicated in patients with
severe coronary artery disease and peripheral artery disease.
 Superselective Embolization
• An alternative to vasopressin infusion is embolization with agents
such as gelatin sponge, coil springs, polyvinyl alcohol, and oxidized
cellulose.
• Embolization involves superselective catheterization of the bleeding
vessel to minimize necrosis, the most feared complication of
ischemic colitis.
• This therapeutic modality is useful in patients in whom vasopressin
is unsuccessful or contraindicated.
• Initial experience with embolization suggested that complications of
intestinal infarction were as high as 20%.
• With the advent of superselective catheterization and embolization
of the vasa recta, successful embolization has been performed
without intestinal infarction.
 Superselective Embolization
• Embolization is performed using a 3 French (F)
microcatheter placed coaxially through the
diagnostic 5F catheter.
• The therapeutic catheter is advanced as far as
the vasa recta over a 0.018-inch guidewire so
as to decrease the risk of infarction.
 Superselective Embolization
• Once the bleeding vessel is identified, microcoils
are used to occlude the bleeding vessel and to
achieve hemostasis.
• Although microcoils are most commonly used,
polyvinyl alcohol and Gelfoam are also used
alone or in conjunction with microcoils.
• However, if terminal mural branches of the
bleeding vessel cannot be catheterized, abort
the procedure and immediately perform surgery.
 Superselective Embolization
• Kuo et al concluded superselective microcoil
embolization for the treatment of LGIB is safe
and effective.
• They reported complete clinical success in
86% of patients with a rebleeding rate of 14%.
Minor ischemic complication rates were noted
as 4.5%, and major ischemic complication
rates were reported as 0%.
 Superselective Embolization
• Rossetti at al reviewed 11 years of experience in
transarterial embolization of acute colonic bleeding
in Switzerland.
• Twenty-four patients underwent colonic
embolization for diverticular, post-polypectomy,
bleeding, and bleeding from cancer, angiodysplasia,
and hemorrhoids.
• All bleeding stopped except hemorrhoidal bleeding,
requiring hemorrhoidal ligature.
• The risk of bowel ischemia was 21%.
 Superselective Embolization
• In another study by Yap et al, 95 patients underwent
embolization for acute GI hemorrhage; 80% of the patients
had upper GI hemorrhage and the rest had lower GI
hemorrhage.
• Vessels embolized included gastroduodenal (39%),
pancreatoduodenal (20%), gastric (19%), superior mesenteric
(11%), inferior mesenteric (11%), and splenic artery (4%).
• Immediate hemostasis was obtained in 98% of patients.
Complications included bowel ischemia in 4% and coil
migration in 3% of patients.
• The overall 30-day mortality rate was 18%.
 Complications of Superselective
Embolization
• Rosenkrantz et al reported 3 cases of colonic
infarction.
• One patient died following segmental colectomy, and
the other patients revealed full-thickness bowel wall
injury in the resected specimen.
• Intestinal ischemia and infarction have also been
reported.
• To prevent this complication, perform embolization
beyond the marginal artery as close as possible to
the bleeding point in the terminal mural arteries.
 Complications of Superselective
Embolization
• The relevance of surgery after embolization of gastrointestinal
and abdominal surgery was also studied in 2014.
• In a retrospective study, a total of 54 patients with 55 bleeding
events were identified; only 25 patients (45%) had LGIB.
• The rebleeding rate was 24% (n=6), and 50% of those with
recurrent LGIB required surgery.
• The study revealed a primary clinical embolization success rate of
82%, the rate of early recurrent bleeding (< 30 d) was 18%, and
the rate of delayed bleeding (>30 days) was 3.6%.
• Surgery after embolization was required in 20% of patients
(n=11). The investigators concluded that surgery has an important
role after successful embolization.
 Endoscopic therapies
• Advantages of upper or lower endoscopic evaluation is that it
provides access to therapy in patients with GI bleeding.

• Endoscopic control of bleeding can be achieved using the

thermal modalities or sclerosing agents. Absolute alcohol,
morrhuate sodium, and sodium tetradecyl sulfate can be used
for sclerotherapy of upper and lower GI lesions.

• Endoscopic epinephrine injection is commonly used because

of its low cost, easy accessibility and low risk of complications.
An additional hemostatic method such as clips or
thermoregulation is needed to prevent subsequent bleeding.
 Endoscopic therapies
• Endoscopic thermal modalities such as laser
photocoagulation, electrocoagulation, heater probe can also
be used to arrest hemorrhage.

• Endoscopic control of hemorrhage is suitable for GI polyps and

cancers, arteriovenous malformations, mucosal lesions,
postpolypectomy hemorrhage, endometriosis, and colonic and
rectal varices.

• Postpolypectomy hemorrhage can be managed by

electrocoagulation of the polypectomy site bleeding with
either snare or hot biopsy forceps or by epinephrine injection.
 Endoscopic therapies
• Photocoagulation using lasers such as argon laser
or Nd:YAG laser.

• Argon laser treatment is recommended for mucosal

or superficial lesions, because the energy
penetrates only 1 mm. Nd:YAG lasers are more
useful for deeper lesions, because they penetrate
3-4 mm.

• Endoscopic therapy for LGIB is a minimally invasive.

 Emergent surgery
• Emergency surgery is required in about 10-25% of patients
with lower gastrointestinal bleeding (LGIB) in whom non-
operative management is unsuccessful or unavailable.

Surgical indications:
• Persistent hemodynamic instability with active bleeding
• Persistent, recurrent bleeding
• Transfusion of more than 4 units packed red bloods cells in
a 24-hour period, with active or recurrent bleeding
 Segmental bowel resection and subtotal
colectomy
• Segmental bowel resection following precise
localization of the bleeding point is a well-accepted
surgical practice in hemodynamically stable patients.

• The procedure of choice in patients who are actively

bleeding from an unknown source.

• Intraoperative esophagogastroduodenoscopy (EGD),

surgeon-guided enteroscopy, and colonoscopy may be
helpful in diagnosing undiagnosed massive GI bleeding.
• Patients who are hemodynamically stable should have
preoperative localization of the bleeding whereas
patients who are hemodynamically unstable with
active bleeding may undergo emergency exploratory
laparotomy with intraoperative endoscopy.

• In patients who are hemodynamically stable, once the

bleeding site is preoperatively localized, intra-arterial
vasopressin is used as a temporizing measure to
reduce the bleeding before patients undergo
segmental colectomy. Using this approach the
operative morbidity rate is approximately 8.6%, the
mortality rate is around 10%, and the rate of rebleed
ranges from 0-14%.
• In patients undergoing emergency laparotomy,
every attempt should be made to localize the
bleeding intraoperatively, because a segmental
colectomy is preferred. If the bleeding site is not
localized, a subtotal colectomy is performed with an
inherent morbidity rate of around 37% and a
mortality rate of about 11%-33%. In unstable
patients, a two-stage procedure is preferred:
temporary end ileostomy and delayed
ileoproctostomy.

• postoperative diarrhea can be a significant problem

in elderly patients who undergo subtotal colectomy
and ileoproctostomy.
 Pre-operative details
• Acute LGIB is a common clinical entity and is
associated with significant morbidity and
mortality (10-20%).

• These factors are dependent on the patient

age (>60 y), the presence of multi-organ
system disease, transfusion requirements (>4
units), need for operation, and recent stress
(eg, surgery, trauma, sepsis).
3 major aspects involved in managing LGIB:
• Treat shock
• Localization of the source of bleeding
• Formulating and interventional plan

• Insert a nasogastric (NG) tube in all patients. A clear bile-

stained aspirate generally excludes bleeding proximal to the
Treitz ligamentum. After initial resuscitation, undertake a
search for the cause of the bleeding to precisely locate the
bleeding point.

• Following accurate localization by angiogram, bleeding can be

temporarily controlled with either angiographic embolization
or vasopressin infusion to stabilize the patient in anticipation
of semi-urgent segmental bowel resection.
• Segmental bowel resection is performed in the next 24-48 hours
following correction of the patient's physiologic parameters, which
include hypotension, hypothermia, acute hemorrhagic anemia, and
deficient coagulation factors.

• Use selective mesenteric embolization in high-risk patients for

whom the operative management is associated with prohibitive risk
of morbidity and mortality. If mesenteric embolization is used,
these patients must be carefully monitored for bowel ischemia and
perforation. Any evidence of ongoing bowel ischemia and/or
unexplained sepsis following mesenteric embolization requires
exploratory laparotomy to resect the affected bowel segment.

• Perform subtotal colectomy with ileoproctostomy in patients with

multiple episodes of non-localized LGIB or bilateral sources of
colonic hemorrhage.
 Intra-operative details
• Surgical intervention is required in only a small percentage of patients
with LGIB. The surgical option depends on whether the bleeding source
has been accurately identified preoperatively; if so, it is then possible to
perform segmental intestinal resection.

• If the bleeding source is unknown, an upper gastrointestinal endoscopy

should be performed before any surgical exploration.

• The abdominal cavity is explored through a midline vertical incision. The

assistance of a gastroenterologist or another surgical endoscopist or
surgeon is required for intraoperative endoscopic evaluation. The
colonoscope is introduced, and the surgeon assists its passage. On-table
colonic lavage and colonoscopy may identify the colonic source of
bleeding. Surgeon-guided intraoperative small bowel enteroscopy is also
performed when no colonic source of bleeding is identified.
• Colonoscopic manipulation of the small bowel may
cause iatrogenic mucosal tears and hematomas, which
may be mistakenly identified as a source of bleeding.

• Another intraoperative strategy is to clamp segments

of the bowel with non-crushing intestinal clamps to
identify the segment that fills with blood.

• If the bleeding point cannot be diagnosed through

intraoperative pan-intestinal endoscopy and
examination, and if evidence points to a colonic
bleeding, perform a subtotal colectomy with end
ileostomy.
 Post-operative details
• Hypotension and shock are the eventual
consequences of blood loss, but this depends on
the rate of bleeding and the patient's response.

• Clinical development of shock may precipitate

myocardial infarction, cerebrovascular accident,
and renal or hepatic failure. Azotemia occurs in
patients with gastrointestinal blood loss.
 COMPLICATION OF LOWER
GASTROINTESTINAL BLEED
• Anemia
• Shock
• Kidney failure
• Complications of blood transfusions
⮚ Complications related to massive blood
transfusions (greater than one blood volume in
24 hour) are hypothermia, hypocalcemia,
hyperkalemia, dilutional thrombocytopenia,
and coagulation factor deficiencies.
 Complication of surgery

• The most common early postoperative complications

are
▪ intra-abdominal or anastomotic bleeding,
▪ mechanical small bowel obstruction (SBO),
▪ intra-abdominal sepsis,
▪ localized or generalized peritonitis,
▪ wound infection and/or dehiscence,
▪ Clostridium difficile colitis
▪ deep venous thrombosis (DVT),
▪ pulmonary embolus (PE).
 TRANSFUSION FREE MANAGEMENT
• The management of lower GI bleeding (LGIB) can be challenging in
patients who refuse transfusions of blood or blood products.
However, transfusion-free management of GI bleeding may be
effective with an acceptable mortality rate.
• Studied has been done in Englewood Hospital in which they
experience in managing patients with gastrointestinal bleeding who
do not accept blood-derived products – most of them survived
• These results suggest that transfusion-free management of
gastrointestinal hemorrhage can be effective with mortality
comparable with the general population accepting medically
indicated transfusion.
• Management of these patients is challenging and requires a
dedicated multidisciplinary team approach knowledgeable in
techniques of blood conservation.
• Surviving patients were treated with epoetin alfa
(Procrit) – stimulate erythropoesis - once daily for 5
days, IV iron dextran(plasa vol expender) infusion
once daily for 10 days, IV folic acid daily, vitamin C
twice daily, as well as IM vitamin B12 injection once.
These patients also received beta-blockers (to reduce
the cardiac workload) and supplemental oxygen
(100%) with intubation (to improve the oxygen
delivery as much as possible without blood
transfusions).
• The overall mortality rate was 10%.
 LONG TERM MONITORING
• Postoperative office visits every 2 weeks are essential to ensure proper
wound healing.
• Upon discharge, a general diet abundant in fruits and vegetables is
recommended.
• Patients are instructed to drink 6-8 glasses of fluid per day.
• Psyllium seed preparationsa(dietary fibre) should also be started.
• Increased levels of physical activity may prevent the progression of
diverticular disease
• Aspirin and NSAID use is associated with increased risk of diverticular
bleeding.
• The need for a follow-up colonoscopy is determined by a recurrence of
symptoms.
• Angiodysplasia is more likely to rebleed if untreated and may require
follow-up intervention to localize and treat recurrent bleeding.
• Colonoscopic electrocoagulation is generally successful in such situations.