H

 Lower GI bleed refers to bleeding arising

distal to the ligament of Treitz (DJ flexure)

 Although this includes jejunum and ileum

bleeding from these sites is rare (<5%)

 Vast majority of lower GI bleeding arises from

colon/rectum/anus
 Lower GI bleeding presents as:
 Dark red blood PR – more proximal bleeding point (e.g.
Distal small bowel, colon)
 Bright red blood PR – more distal bleeding point (e.g.
rectum, anus)
 PR blood maybe:
 mixed or separate from the stool
 If separate from the stool it maybe noticed in the toilet water or on
wiping
 Passed with motion or alone

 If blood mixed with stool (as oppose to separate

from it) suggests more proximal bleeding
 If bleeding very slow and occult then can present
with iron deficiency anaemia
Colon Rectum Anus
Diverticular Disease Polyps Haemorrhoids
Polyps Malignancy Fissure
Malignancy Proctitis Malignancy
Colitis
Angiodysplasia
 Emergency resuscitation as already described

 Pharmacological
 Stop NSAIDS/anti-platelets/anti-coagulants if safe
 Tranexamic acid

 Endoscopic
 OGD (15% of patients with severe acute PR bleeding will
have an upper GI source!)
 Colonoscopy – diagnostic and therepeutic (injection,
diathermy, clipping)
 Radiological
 CT angiogram – diagnostic only (non-invasive)
 Determines site and cause of bleeding

 Mesenteric Angiogram – diagnostic and therepeutic

(but invasive)
 Determines site of bleeding and allows embolisation of
bleeding vessel
 Can result in colonic ischaemia

 Nuclear Scintigraphy – technetium labelled red blood

cells: diagnostic only
 Determines site of bleeding only (not cause)
 Surgical – Last resort in management as very
difficult to determine bleeding point at
laparotomy
 Segmental colectomy – where site of bleeding is known
 Subtotal colectomy – where site of bleeding unclear
 Beware of small bowel bleeding – always embarassing
when bleeding continues after large bowel removed!
 Resuscitate

OGD (to exclude upper GI cause for severe PR bleeding)

Colonoscopy (to identify site and cause of bleeding and to

treat bleeding by injection/diathermy/clipping) – often
unsuccesful as blood obscures views

CT angiogram (to identify Mesenteric angiogram (to identify

site and cause of site of bleeding and treat
bleeding) bleeding by embolisation of
vessel)

Surgery
 As 85% of lower GI bleeds will settle
spontaneously the interventions mentioned
on previous slide are reserved for:
 Severe/Life threatening bleeds

 In the 85% where bleeding settles

spontaneously OPD investigation is required
to determine underlying cause:
 Endoscopy: flexible sigmoidoscopy, colonoscopy
 Barium enema
 Insufficient iron in the body for haemopoeisis

 Decrease Hb and MCV

 Decreased serum iron and Ferritin
 Increased TIBC and serum transferrin
 Increased Iron demand
 Chronic Blood loss
 Think Chronic bleeding (often occult) from GI tract in men and post-menopausal females
(pre-menopause menorrhagia most common cause) e.g. Colonic polyp or cancer,
gastric/duodenal ulcer or malignancy
 Chronic haemolysis
 Pregnancy

 Insufficient Iron intake

 Diet lacking in iron
 Vegans – plant based iron poorly absorbed compared to meat based iron

 Malabsorption of iron
 Small intestinal disease e.g. Crohn’s, caeliac disease
 Lack of vitamin C (important for iron absorption)
 In adults >50yrs of age the most common
cause of Iron deficiency anaemia is chronic
occult GI bleeding
 In females <50yrs most common cause is blood loss
during menses with inadequate replacement

 In developing world intestinal parasitic infection

causing chronic blood loss from the GI tract is the
most common cause of iron deficiency anaemia
(rare in developed world)
 To confirm iron deficiency anaemia
 Hb, MCV, Ferritin, transferrin, TIBC
 Rarely bone marrow aspirate (gold standard but
invasive: rarely performed)

 OGD and colonoscopy

 Perform in males and post-menopausal females
 In pre-menopausal females menorrhagia is most
common cause and often OGD/colonoscopy not
required unless other symptoms warrant it (e.g.
dyspepsia, dysphagia, PR bleeding, change in bowel
habit, family history etc.)
 Note that iron deficiency anaemia maybe the only sign
of an occult GI malignancy
Questions