Transcript Lower GI Bleeding

BY
Dr. Waleed M. Abdel Maksoud
MBBCh, MS, MD, MRCS (England)
 Melena
is passage of digested blood (mainly
mixed with bile and intestinal secretions),
which is characteristically described as black
tarry soft sticky offensive stools. It may
cause a red halo around the soft fecal mass if
mixed with water or urine.
 Bleeding
per rectum or hematochezia is
passage of altered maroon colored or reddish
dark brown colored offensive fluidy stool
motions with possible clots. The nature of
blood is evident to the patient.
 Fresh
bleeding per rectum is passage of fresh
blood during passing a stool motion, and it
takes several forms as splashing, drippling,
streaking of stools or as terminal drops.
Sometimes it stains the underwear after
defecation. May be associated with mucus
and /or pus
•
Lower gastrointestinal bleeding is defined as
abnormal hemorrhage into the lumen of the bowel
from a source distal to the ligament of Treitz.
The ligament of Treitz is
a musculofibrous band
that extends from the
upper aspect of the
ascending part of the
duodenum to the right
crus of the diaphragm
and tissue around the
celiac artery.
Etiology
COLONIC BLEEDING (95%)
Diverticular disease
Ischemia
%
30-40
5-10
SMALL BOWEL BLEEDING (5%)
Angiodysplasias
Erosions or ulcers
(potassium, NSAIDs)
Anorectal disease
Neoplasia
Infectious colitis
5-15
5-10
3-8
Crohn's disease
Radiation
Meckel's diverticulum
polyps
3-7
Inflammatory bowel disease 3-4
Angiodysplasia
Radiation colitis/proctitis
3
1-3
Other
Unknown
1-5
10-25
Neoplasia
Aortoenteric fistula
Age
Common causes
Adolescents and young adults
-
Meckel’s diverticulum
Inflammatory bowel disease
Polyps
Adults to 60 years of age
-
Diverticulae
Inflammatory bowel disease
Neoplasms
Adults older than 60 years
-
Angiodysplasia
Diverticulae
neoplasms
 Lower
GIT bleeding is considered massive
and serious if:
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3-5 units of blood are needed over 24 hours to
maintain stability.
if hematocrit is less than 30%.
if orthostatic changes in blood pressure occur.
 Evaluation
is difficult for the following
reasons:
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Bleeding can originate from any area of the GIT.
Bleeding is often intermittent and source may be
difficult to clarify if it is not actively bleeding.
This is a condition in which emergency surgery with
significant morbidity and mortality may be required
before specific diagnosis or even specific site of
bleeding is identified.
Even radical types of surgery cannot prevent
rebleeding.
There is no universal applicable sequence of
investigations or treatments.
(1)
(2)
(3)
initial hemodynamic stabilization,
localization of the bleeding site,
site-specific therapeutic intervention
We should assess the chronicity of bleeding and
medication use, particularly regarding:
 anti coagulants such as


warfarin
low molecular weight heparin.
inhibitors of platelet aggregation such as
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NSAIDs.
Clopidrogrel, this can associated with
mesenteric ischemia.
 Use of digitalis should be documented because
this can associated with mesentric ischemia.

(1) Resuscitation:
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with crystalloid solutions, preparing for blood
transfusion.
diagnostic nasogastric intubation are important step to
exclude Upper GI causes. The presence of bile in the
aspirate is the only sure sign that there is no active
upper GIT source of bleeding. (Upper endoscopy can
diagnose more accurately the upper GIT source)
It should be recognized that about 85% of bleeding
from lower GI sources stops spontaneously, however,
the presence of large amounts of blood in the colon
can give the impression of a continuous bleeding
process. That is why in monitoring the bleeding, one
should depend more on the hemodynamic figures
rather than frequent passage of bloody motions.
(2) Per rectal examination, anoscopy, and
possibly rigid sigmoidoscopy:
 are imperative to rule out palpable
neoplasms and other anal and rectal
conditions.
 It is important, even if detection of a lesion
is not possible due to bad preparation, to
ascertain a healthy lower 15 or 20 cm for a
possible use of subtotal colectomy.
 Treatment of a simple visible cause like piles
can be done at the same setting by injection
or Baron band ligation.
(3)Colonoscopy:
 It offers the chance for proper diagnosis and
sometimes-non-surgical stoppage of
bleeding.
 Mechanical preparation can be done and
sometimes because the blood is very good
laxative to the gut it is unnecessary.
 It should be done as soon as the patient is
stabilized and better to be done under
intravenous general anesthesia.
(3)Colonoscopy:
 Diverticulosis, inflammatory bowel disease, polyps and
neoplasms are confidently diagnosed, however
arteriovenous malformations are sometimes difficult to
diagnose, but if seen can be treated with injection of
diluted adrenaline or photocoagulated by laser therapy.

The average detected lesions is in the range of 75%, about
85% of these are in the left colon, 10% in the right one.

Colonoscopy can also diagnose the source of bleeding as
small bowel if the cecum is reached and more fresh blood
is coming out of the ileocecal valve. This will indicate
small bowel site, which is most propably ulcers, IBD,
benign or malignant small bowel neoplasms (leiomyoma,
leiomyosarcoma or lymphoma) Meckel’s diverticulum, or
arteriovenous malformation are also other possibilities.
 Colon
Carcinoma

Capsule endoscopy uses a small capsule with a
video camera that is swallowed and acquires
video images as it passes through the GI tract.

This modality permits visualization of the
entire GI tract, but offers no interventional
capability.

It is also very time consuming because
someone has to watch the video to identify the
bleeding source, and then a means to deal
with the pathology has to be developed.
(4) Arteriography:
 By selective catheterization of all mesenteric
vessels, and technetium labeled RBC scanning
are only of use if active bleeding is present
with a high rate (2ml/minute or higher), which
is not usually the case on admission of the
patient.
 Selective vasopressin infusion or embolization
with thrombin or gel foam can help to stop
bleeding.
Angiographic study documents
extravasation of contrast into
small bowel.
Intraoperative examination
of bowel is aided by injection
of methlyene blue dye,
which facilitates localization
of bleeding site and thereby
helps direct surgical
resection.
(5) Surgical intervention:
 Indications:
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 In
Failure of all preveuos measures to stop bleeding.
When the bleeding is massive (blood loss more than
2.5 litres over 48 hrs).
these situation, surgical intervention
will have a lower morbidity than
continued conservative management.
(5) Surgical intervention:
 Procedure:
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If the source of bleeding could be localized
preoperatively or intra-operatively, segmental
resection would be performed.
If the source of bleeding could not be localized
preoperatively or intra-operatively:
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Intraoperative enteroscopy is reserved for patients who
have transfusion-dependent obscure-overt bleeding in
whom an exhaustive search has failed to identify a
bleeding source.
Segmentation of the colon is done by means of non
crushing clamps and observation of the segment that will
collect blood.
If all measures fail to localize the source of bleeding,
sub-total colectomy may be indicated.