Lower gi bleed

1. Lower GI bleed
Dr nawin kumar

2. • as any bleed that occurs distal to the ligament
of Treitz and superior to the anus
• 20-33% of episodes of gastrointestinal (GI)
hemorrhage
– 85% from colon
– 10% from UGI
– 5% from SB
• The mortality rate for LGIB is between 2–4%

4. • marginal artery of Drummond -
Connects the inferior mesenteric
artery (IMA) with the superior
mesenteric artery (SMA)
• The Arc of Riolan (Riolan's arcade,
Haller's anastomosis or'meandering
mesenteric artery) -connect the
proximal middle colic artery with a
branch of the left colic artery. This
artery is found low in the mesentery,
near the root. It is a poor
anastomosis.

5. Aetiology
angiodysplasia
carcinoma
Meckel’s diverticulum
intussusception enteritis
Crohn’s disease
carcinoma
proctitis
colitis
carcinoma
polyps
Diverticular
disease
solitary ulcer
haemorrhoids
fissure
carcinoma
warts
Perianal Crohn’s disease

6. Rule out- Coagulopathy
1. SB
2. Colon
3. Benign anorectal
DANI

7. Gastrointestinal Hemorrhage
% SMALL BOWEL BLEEDING (5%)
0-40 Angiodysplasias
-10 Erosions or ulcers (potassium, NSAIDs)
-15 Crohn's disease
-10 Radiation
-8 Meckel's diverticulum
-7 Neoplasia
-4 Aortoenteric fistula
-3

8. • infectious colitis
– E. coli O157:H7
– Shigella
– Salmonella
– Campylobacter
jejuni
• Pseudomembranous
colitis
DANI

9. • Rectal polyps
• Haemorrhoids
• Anal fissures
• Anal fistulas
• Proctitis
• Gonorrheal or mycoplasmal infections
• Rectal trauma
• Foreign objects
BENIGN ANORECTAL CAUSES

10. Lower Gastrointestinal Bleeding in Children and
Adolescents
• Intussusception
• Polyps and polyposis syndromes
 Juvenile polyps and polyposis
 Peutz-Jeghers syndrome
 Familial adenomatous polyposis (FAP)
• Inflammatory
 Crohn disease
 Ulcerative colitis
 Indeterminate colitis
• Meckel diverticulum

11. Clinical Approach
• History
• Physical Examination
• Investigation
• Diagnosis
• Management

12. History
• Presenting complaint(s)
• History of presenting illness
• Systemic review
• Past medical and surgical history
• Medication history (iatrogenic factors)
• Family history
• Social history

13. Information about bleeding
• Volume and frequency (amount)of bleeding
• Colour of blood?
• Relationship of bleeding to defecation?
[before, during (mixed into faeces or coating surface?) or after]
• Associatiated symptoms eg, Painful
defecation?, abdominal pain?

14. amount
• trivial hematochezia to massive hemorrhage
with shock.

15. BLEEDING
FRANK OCCULT
ANAEMIA
SMALL
BLEED
MASSIVE
BLEED
(rare)

16. 3 groups

17. Stools may appear red in some patients
after ingestion of beers

18. Colour- indicate the site
• occult, microscopic bleeding
• Black tarry -melena - usually indicates blood
that has been in the GI tract for at least 8
hours. likely to come UGI
• Maroon color suggests rt. Sided lesion
• Bright red stool- called hematochezia- sign of
a fast moving active GI bleed

19. Relationship of bleeding to
defecation?
• minor blood on toilet paper
• streaks of bright red blood
• Blood mixed stools
• Slash in pan
• Mixed with mucus

20. Associated symptoms
• Bloody diarrhoea:
– acute inflammation of the colon; amoebic
colitis; ulcerative colitis; ischaemic colitis;
rectal and colonic carcinoma; shigellosis

21. •Abdominal pain?
–Carcinoma of the colon; ischaemic colitis (in
elderly(; ulcerative colitis; amoebic colitis
•No abdominal pain?
–Painless bleeding from colonic diverticula,
colonic angiodysplastic lesion; malignant lesion
arising in the rectal ampulla

22. • anal pain?
– External haemorrhoids; anal fissure, anal ulcer

23. • Fever?
– Infectious colitis (amoebiasis, shigellosis); ulcerative colitis

24. • Vomiting of blood
– Bleeding above ligament of Treitz

25. •A change in your bowel habits?
•A change in the caliber of the stools?
• colo-rectal Carcinoma

26. • Hypovolaemia
– due to haemorrhage (e.g. pallor, dizziness
hypotension, tachycardia, angina, syncope,
weakness, confusion, stroke, myocardial
infarction/heart attack, and shock)

27. • Nonspecific complaints
• may include dyspnoea, abdominal pain, chest
pain, fatigue

28. • past medical history
– constipation or diarrhea- (hemorrhoids, colitis),
– the presence of diverticulosis (diverticular
bleeding),
– receipt of radiation therapy (radiation enteritis),
– recent polypectomy (postpolypectomy bleeding),
and
– vascular disease/hypotension (ischemic colitis).
– anticoagulant
– A family history of colon cancer - colorectal
neoplasm

29. Investigations &Management
• Resuscitation for major bleeds
• Find site
• Treat the cause

30. Initial steps in the management of upper gastrointestinal bleeding
Airway protection
Airway monitoring
Endotracheal intubation (if indicated)
Hemodynamic stabilization
Large bore intravenous access
Intravenous fluids
Red cell transfusion (for symptomatic anemia)
Fresh-frozen plasma, platelets (if indicated)
Consider erythropoeitin
Nasogastric oral administration
Large bore orogastric tube/lavage
Clinical and laboratory monitoring
Serial vital signs
Serial hemograms, coagulation profiles, and chemistries (as clinically indicated)
Electrocardiographic monitoring
Hemodynamic monitoring (if indicated in high-risk patients)
Endoscopic examination and therapy

31. localization

32. Colour- indicate the site
• occult, microscopic bleeding
• Black tarry -melena - usually indicates blood
that has been in the GI tract for at least 8
hours. likely to come UGI
• Maroon color suggests rt. Sided lesion
• Bright red stool- called hematochezia- sign of
a fast moving active GI bleed

33. LOCALIZATION
• past medical history
– constipation or diarrhea- (hemorrhoids, colitis),
– the presence of diverticulosis (diverticular
bleeding),
– receipt of radiation therapy (radiation enteritis),
– recent polypectomy (postpolypectomy bleeding),
and
– vascular disease/hypotension (ischemic colitis).
– anticoagulant
– A family history of colon cancer - colorectal
neoplasm

34. localization
nasogastric
tube
Blood
UGI bleed
bile
UGI bleed-
unlikely
nondiagnostic
(no blood or
bile
LGI bleed

37. COLONOSCOPY
• Identifies lesion in 75 % or more
• Can provide endoscopic therapyand disadvantages of common diagnostic procedures used in the evaluation of lower
gastrointestinal bleeding
Advantages Disadvantages
• Therapeutic possibilities • Bowel preparation required
• Diagnostic for all sources of
bleeding
• Can be difficult to orchestrate without on-
call endoscopy facilities or staff
• Needed to confirm diagnosis in
most patients regardless of initial
testing
• Invasive
• Efficient/cost-effective
• No bowel preparation needed • Requires active bleeding at the time of the
exam
• Therapeutic possibilities • Less sensitive to venous bleeding

38. MESENTERIC ANGIOGRAM
• Selective embolization initially controls
hemorrhage in up to 100% of patients, but
rebleeding rates are 15% to 40%
and disadvantages of common diagnostic procedures used in the evaluation of lower
gastrointestinal bleeding
Advantages Disadvantages
• Therapeutic possibilities • Bowel preparation required
• Diagnostic for all sources of
bleeding
• Can be difficult to orchestrate without on-
call endoscopy facilities or staff
• Needed to confirm diagnosis in
most patients regardless of initial
testing
• Invasive
• Efficient/cost-effective
y • No bowel preparation needed • Requires active bleeding at the time of the
exam
• Therapeutic possibilities • Less sensitive to venous bleeding
• May be superior for patients with
severe bleeding
• Diagnosis must be confirmed with
endoscopy/surgery
• Serious complications are possible
e • Noninvasive • Variable accuracy (false positives)
• Sensitive to low rates of bleeding • Not therapeutic
• No bowel preparation • May delay therapeutic intervention

39. RADIONUCLIDE SCAN
•May be superior for patients with
severe bleeding
•Diagnosis must be confirmed with
endoscopy/surgery
• Seriouscomplications are possible
e •Noninvasive • Variable accuracy(false positives)
• Sensitive to lowratesof bleeding •Nottherapeutic
•No bowel preparation •May delaytherapeutic intervention
•Easilyrepeated if bleeding recurs •Diagnosis must be confirmed with
endoscopy/surgery
py
•Diagnostic andtherapeutic • Visualizesonlythe left colon

40. Treatment
Lower GI bleed
Small volume Large volume
Investigate cause
Manage cause
Resuscitate
Bleeding
stops
Bleeding
persists
? Surgical
intervention

41. SURGERY
• two settings: massive or recurrent bleeding.
• Try to localize
– Localisation- segmental rather
– Not localise- blind subtotal colectomy.