2. Lower gastrointestinal hemorrhage Lower gastrointestinal hemorrhage refers to a spectrum of intestinal bleeding that arises distal to the ligament of Treitz. Lower gastrointestinal hemorrhage refers to a spectrum of intestinal bleeding that arises distal to the ligament of Treitz. Incidence rate: 20/100,000/ year Incidence rate: 20/100,000/ year Disease of the elderly 200 fold increase from the 3rd to 9th decades of life Mortality 2-4 % 80 – 85 % bleeding stop spontaneously

3. BLEEDING OCCULT FRANK ANAEMIA MASSIVE BLEED (rare) SMALL BLEED ٍٍٍ SELF LIMITED ٍٍٍ NON-SELF LIMITED

4. Degrees of hemorrhage Lower gastrointestinal bleeding presents with varying degrees of hemorrhage. Lower gastrointestinal bleeding presents with varying degrees of hemorrhage. 1) Minor and self-limited, patient describe the passage of 100 – 250 mL of blood, possibly a few clots, and often mixed with mucous. patient describe the passage of 100 – 250 mL of blood, possibly a few clots, and often mixed with mucous. 2) Major and self-limited Patients experience brisk, copious bleeding Patients experience brisk, copious bleeding 3) Major and ongoing ? Patients present with massive and continuous hemorrhage associated with hypovolemia. Patients present with massive and continuous hemorrhage associated with hypovolemia.

5. Lower gastrointestinal hemorrhage Massive lower intestinal hemorrhage is difficult to define. Patients often describe massive bleeding into their commode even when a small amount of blood discolors the water. Massive lower intestinal hemorrhage is difficult to define. Patients often describe massive bleeding into their commode even when a small amount of blood discolors the water. True massive intestinal hemorrhage typically include True massive intestinal hemorrhage typically include Hematocrit less than 30%, Hematocrit less than 30%, Transfusion requirements (up to 3 – 5 units of blood/blood products), or Transfusion requirements (up to 3 – 5 units of blood/blood products), or Orthostasis requiring resuscitation. Orthostasis requiring resuscitation.

6. Etiologies Common causes for lower gastrointestinal hemorrhage include Common causes for lower gastrointestinal hemorrhage include Diverticulosis (30 - 50%) Angiodysplasia (20 - 30%) Neoplastic (10- 15%) cancer, polyp Inflammatory (15 - 20%) Inflammatory bowel disease. Inflammatory bowel disease. Ischemic colitis, and Ischemic colitis, and Anorectal diseases (5-10 %) Anorectal diseases (5-10 %) Unusual causes include Unusual causes include Hemorrhage also stems from intestinal tumors or malignancies. Hemorrhage also stems from intestinal tumors or malignancies. Nonsteroidal antiinflammatory drug (NSAID)-related nonspecific colitis, Nonsteroidal antiinflammatory drug (NSAID)-related nonspecific colitis, Meckel ’ s diverticulum, and Meckel ’ s diverticulum, and

7. LGIB Diverticulosis(30 - 50%) Prevalence of Diverticulosis 5% to 10% before age 50 30% after age of 50 50% over age 70 66% over age 85

8. Diverticular disease of the colon Pathogenesis The start is disordered colonic motility The start is disordered colonic motility leads to segmentations of the colon into (bladders) leads to segmentations of the colon into (bladders) (bladders) separated by contraction rings with pressures reaching 90 mm Hg inside these bladders (bladders) separated by contraction rings with pressures reaching 90 mm Hg inside these bladders

9. Diverticular disease of the colon Pathogenesis Segmentation causing high pressures and pulsion force responsible for diverticulosis

10. Diverticular disease of the colon Pathogenesis

11. Herniation of colonic mucosa through the circular muscle at the points where the blood vessels penetrate the colonic wall

12. Diverticular disease of the colon Pathogenesis Herniation of colonic mucosa through the circular muscle at the points where the blood vessels penetrate the colonic wall

13. LGIB Diverticulosis(30 - 50%) 5 – 15 % of people with diverticula will have LGIB. Bleeding is PAINLESS. The bleeding The bleeding In most cases, bleeding ceases spontaneously In most cases, bleeding ceases spontaneously In 10 to 20 % of cases, the bleeding continues unabated in the absence of intervention In 10 to 20 % of cases, the bleeding continues unabated in the absence of intervention

14. LGIB Diverticulosis(30 - 50%) The risk of rebleeding The risk of rebleeding After an episode of bleeding is approximately 25% After an episode of bleeding is approximately 25% Increases to 50% among patients who have had two or more prior episodes of diverticular bleeding. Increases to 50% among patients who have had two or more prior episodes of diverticular bleeding.

15. LGIB Angiodysplasia (20 - 30%) Angiodysplasia (20 - 30%) (or AVM, or Vascular Ectasias) arteriovenous communications Composed of ectatic, dilated, thin-walled arteriovenous communications located within the submucosa and mucosa of the intestine. located within the submucosa and mucosa of the intestine. lined by endothelium alone.

16. LGIB Angiodysplasia (20 - 30%) No one is quite certain precisely why angiodysplasias occur. No one is quite certain precisely why angiodysplasias occur. Current hypotheses suggest Current hypotheses suggest a loss of vascular integrity related to loss of transforming growth factor (TGF) β signaling cascade or a loss of vascular integrity related to loss of transforming growth factor (TGF) β signaling cascade or a deficiency in mucosal type IV collagen. a deficiency in mucosal type IV collagen.

17. Adults Angiodysplasia (20 - 30%) Risk Factors Older (65 y.o.) > Younger End stage renal disease Von Willebrand's disease (Heyde ’ s syndrome), Aortic stenosis? (Heyde ’ s syndrome), Hereditary hemorrhagic telangiectasias (Osler-Weber-Rendu) Hereditary hemorrhagic telangiectasias (Osler-Weber-Rendu) Low fiber diet Obesity

18. LGIB Angiodysplasia (20 - 30%) LGIB (VENOUS) is usually occult and PAINLESS. Located within Cecum 37%, Sigmoid 18%, Ascending 17%, Rectum 14%, Transverse and Descending 7%.

19. LGIB Neoplastic (10- 15%) Polyps Cancer

20. LGIB Inflammatory (15 - 20%) Radiation Intestinal damage due to fibrosis and ischemia. IBD Ulcerative Crohn ’ s Disease Radiation colitis Ulcerative colitis Sever Crohn ’ s Disease

21. LGIB Inflammatory (15 - 20%) Infectious (E. Coli, C. Difficile, C. Jejuni … ) Ischemic (Hypoperfusion and Vasoconstriction) Hypotension, Heart Failure, Arrhythmia Vasculitis Ischemic colitis Infective colitis

22. LGIB Inflammatory (15 - 20%) Pseudomembransous Colitis Complication of antibiotic therapy that causes severe inflammation, irritation and swelling of the colon mucosa. Almost any antibiotic can cause this condition. Clostridium difficile, which occurs normally in the intestine, overgrows when antibiotics are taken. This bacterium releases a powerful toxin which causes the symptoms.

23. LGIB Inflammatory (15 - 20%) Pseudomembransous Colitis Ampicillin is the most common cause of this condition in children. Stopping the antibiotic with rehydration therapy and metronidazole is usually used to treat the disorder.

24. LGIB Ano-rectal causes (5 – 10%) Hemorrhoids (< 50 y.o. most common) Anal fissures (most common in child) Anal fissures (most common in child) Anal fistulas Anal fistulas Proctitis Proctitis Gonorrheal or mycoplasmal infections Gonorrheal or mycoplasmal infections Rectal trauma Rectal trauma Foreign objects Foreign objects Rectal CA Rectal polyp

25. LGIB Others (5 – 10%) Small intestinal tumors, known also as gastrointestinal stromal tumors (GIST). Small intestinal tumors, known also as gastrointestinal stromal tumors (GIST). These lesions enlarge and surpass their blood supply. These lesions enlarge and surpass their blood supply. In that event, the ischemia in the tumor will ulcerate and may cause a localized hemorrhage. In that event, the ischemia in the tumor will ulcerate and may cause a localized hemorrhage. Post-polypectomy bleeding Aortoenteric fistula Coagulation deficiency

26. LGIB Others (5 – 10%) Finally, NSAID-associated intestinal hemorrhage occurs most frequently in the terminal ileum and cecum. Finally, NSAID-associated intestinal hemorrhage occurs most frequently in the terminal ileum and cecum. Diaphragm-like strictures are pathognomonic for NSAID injuries and Diaphragm-like strictures are pathognomonic for NSAID injuries and may result from a healing ridge related to repeated injuries from the agents. may result from a healing ridge related to repeated injuries from the agents.

27. LGIB Others (5 – 10%) Intussusception Most common abdominal emergency to affect children under 2 years of age. Boys = 2 X Girls, in frequency Meckel ’ s Diverticulum (embryonic diverticulum) Rule of 2's: 2% of the population 2% of cases are symptomatic 2 feet from the ileocecal valve 2 inches in length Often present within 2 years of age

28. Children and Young Adults LGIB Anal Fissure Most often the result of hard stool and prolonged constipation. After forced hard bowel movement. Infectious Colitis IBD Crohn ’ s Disease Ulcerative Colitis Polyps Intussusception Meckel ’ s Diverticulum (embryonic diverticulum) Pseudomembransous Colitis

29. Management Resuscitation for major bleeds Resuscitation for major bleeds Find site (localization) Find site (localization) Treat the cause Treat the cause

30. Resuscitation for major bleeds Placement of vascular access with large bore intravenous fluids. Placement of vascular access with large bore intravenous fluids. Further hemodynamic monitoring requires Further hemodynamic monitoring requires Cardiac rhythm monitoring and Cardiac rhythm monitoring and placement of a urinary catheter. placement of a urinary catheter. A nasogastric tube placed will screen for the presence of upper gastric sources for bleeding. A nasogastric tube placed will screen for the presence of upper gastric sources for bleeding.

31. Resuscitation for major bleeds The treatment goals for resuscitation are to The treatment goals for resuscitation are to Restore volume and, Restore volume and, Replete red blood cell deficiencies and their impact on oxygen delivery. Replete red blood cell deficiencies and their impact on oxygen delivery. In addition, all coagulopathies require reversal. In addition, all coagulopathies require reversal. Patients require laboratory profiles that include a Patients require laboratory profiles that include a Complete blood count, Complete blood count, Serum electrolytes, Serum electrolytes, Coagulation profile, Coagulation profile, and a type and cross match for packed red blood cells. and a type and cross match for packed red blood cells.

32. Management Resuscitation for major bleeds Resuscitation for major bleeds Find site (localization) Find site (localization) Treat the cause Treat the cause

33. Find site (localization) The initial specific diagnostic evaluation begins with The initial specific diagnostic evaluation begins with Digital anorectal examination and anoscopy. Digital anorectal examination and anoscopy. A rigid proctosigmoidoscopy will allow the examiner A rigid proctosigmoidoscopy will allow the examiner to evacuate the rectum of blood and clots. to evacuate the rectum of blood and clots. A complete mucosal assessment serves to exclude internal hemorrhoids, anorectal solitary ulcers, neoplasms, and colitis. A complete mucosal assessment serves to exclude internal hemorrhoids, anorectal solitary ulcers, neoplasms, and colitis.

34. Find site (localization) What is the first test to evaluate the cause of bleeding ? Currently, three tests are considered for the initial evaluation. These tests include What is the first test to evaluate the cause of bleeding ? Currently, three tests are considered for the initial evaluation. These tests include Colonoscopy, Colonoscopy, Nuclear scintigraphy, and Nuclear scintigraphy, and Angiography. Angiography.

35. Find site (localization) Colonoscopy and angiography offer therapeutic intervention whereas nuclear scanning is purely diagnostic. Colonoscopy and angiography offer therapeutic intervention whereas nuclear scanning is purely diagnostic. Decisions as to which test to use depend on Decisions as to which test to use depend on The clinical judgment, The clinical judgment, Local expertise, Local expertise, Severity of the event, and Severity of the event, and The current activity of the hemorrhage. The current activity of the hemorrhage.

36. Colonoscopy

37. Colonoscopy

38. Colonoscopy Advantages Ability to provide a definitive localization of ongoing active bleeding the region of the intestine requires a tattoo to mark the site with India ink Ability to provide a definitive localization of ongoing active bleeding the region of the intestine requires a tattoo to mark the site with India ink The potential for therapy. The potential for therapy. Thermal agents such as heater probes, bipolar coagulation, argon beam, and laser therapy Thermal agents such as heater probes, bipolar coagulation, argon beam, and laser therapy Injection therapy primarily uses topical and intramucosal epinephrine. Injection therapy primarily uses topical and intramucosal epinephrine. Mechanical therapy includes endoscopically applied clips. Mechanical therapy includes endoscopically applied clips.

39. Colonoscopy Disadvantages Disadvantages Colon must be preparation is for visualization which require 24 hour Risks of sedation and anesthesia

40. Argon beam arrest of AVM

41. Radionuclide imaging

42. The more frequently preferred agent for lower gastrointestinal hemorrhage radionuclide scanning is the 99mTc pertechnetate-tagged RBC scans. The more frequently preferred agent for lower gastrointestinal hemorrhage radionuclide scanning is the 99mTc pertechnetate-tagged RBC scans. The tagged RBC scans may cover a period of hours and allow for re-imaging within 24 hours. The tagged RBC scans may cover a period of hours and allow for re-imaging within 24 hours.

43. Radionuclide imaging Advantages Noninvasive Radionuclide imaging detects the slowest bleeding rates. It is able to detect rates of 0.1 – 0.5 mL/min. Thus, it is a technique that is more sensitive than angiography. Radionuclide imaging detects the slowest bleeding rates. It is able to detect rates of 0.1 – 0.5 mL/min. Thus, it is a technique that is more sensitive than angiography. Disadvantages the nuclear scanning cannot reliably localize the site of hemorrhage precisely. the nuclear scanning cannot reliably localize the site of hemorrhage precisely. Requires active bleeding of > 0.1 ml/min Nuclear scintigraphy has variable results, suggesting that scan timing, technical skills, and experience may increase accuracy. Nuclear scintigraphy has variable results, suggesting that scan timing, technical skills, and experience may increase accuracy. Current reports suggest accuracies ranging from 24% to 91%. Current reports suggest accuracies ranging from 24% to 91%.

44. Selected images from a 99mTc-labeled RBC gastrointestinal bleeding study in a patient with known diureticulosis.Images acquired at 1 minute (A) and 14 minutes (B). Abnormal increased isotopic activity developed in the proximal transverse colon, which progressed antegrade to the descending colon.

45. Technetium labelled RBC scan showing extravasation of radiolabelled blood in a loop of ileum (arrow(

47. Angiography

48. Angiography Angiography is diagnostic and therapeutic in the treatment of intestinal hemorrhage. Angiography is diagnostic and therapeutic in the treatment of intestinal hemorrhage. The clinical judgment for choosing angiography involves three different types of hemorrhage. The clinical judgment for choosing angiography involves three different types of hemorrhage. First, acute, major hemorrhage with ongoing bleeding requires emergency angiography. First, acute, major hemorrhage with ongoing bleeding requires emergency angiography. Second, patients with an early blush during nuclear scintigraphy may benefit from therapeutic angiography. Second, patients with an early blush during nuclear scintigraphy may benefit from therapeutic angiography. Finally, angiograms may define a potential source for hemorrhage in occult and recurrent gastrointestinal hemorrhage. Finally, angiograms may define a potential source for hemorrhage in occult and recurrent gastrointestinal hemorrhage.

49. Angiography Advantages Advantages Used with major sever bleeding the study requires a hemorrhage rate of > 1 mL/min. Used with major sever bleeding the study requires a hemorrhage rate of > 1 mL/min. Highly accurate localization of the site of bleeding. Highly accurate localization of the site of bleeding. Angiographic blush may suggest a specific etiology, but it lacks the accuracy of colonoscopy. Angiographic blush may suggest a specific etiology, but it lacks the accuracy of colonoscopy. Angiography could used for treatment by either Angiography could used for treatment by either Intra-arterial vasopressin infusion Intra-arterial vasopressin infusion Arterial embolization Arterial embolization

50. Extravasation hge in the caecum AVM Diverticular hge in the caecum

51. Angiography vasopressin infusion Hemorrhagic site may receive highly selective, intra-arterial vasopressin infusion. Hemorrhagic site may receive highly selective, intra-arterial vasopressin infusion. Vasopressin controls bleeding in as many as 91% of patients. Vasopressin controls bleeding in as many as 91% of patients. Bleeding may recur in as many as 50% of patients once the vasopressin is tapered. Bleeding may recur in as many as 50% of patients once the vasopressin is tapered.

52. Angiography Arterial embolization Angiographic technology also allows for arterial embolization to control hemorrhage. Angiographic technology also allows for arterial embolization to control hemorrhage. Superselective mesenteric angiography with current microcatheters allows for embolization of the vasa recta of the intestine, vessels as small as 1 mm. Superselective mesenteric angiography with current microcatheters allows for embolization of the vasa recta of the intestine, vessels as small as 1 mm. In the past, arterial embolization of larger vessels risked intestinal ischemia or infarction. The risk of intestinal infarctions of larger selective vessels may exceed 20%. In the past, arterial embolization of larger vessels risked intestinal ischemia or infarction. The risk of intestinal infarctions of larger selective vessels may exceed 20%. Embolization uses a combination of agents to control bleeding including Embolization uses a combination of agents to control bleeding including Gelfoam pledgets, Gelfoam pledgets, Coils, and Coils, and Polyvinyl alcohol particles Polyvinyl alcohol particles

53. Angiography Arterial embolization Arteriography also has complication rates related to angiography, separate from the therapy delivered at the site of bleeding. Arteriography also has complication rates related to angiography, separate from the therapy delivered at the site of bleeding. These include arterial thrombosis, distant arterial emboli, and renal toxicity from the angiographic dye. These include arterial thrombosis, distant arterial emboli, and renal toxicity from the angiographic dye. Requires active bleeding of 1 – 1.5 ml/min

54. Find site (localization) Minor, self-limited may undergo a colonic lavage and colonoscopy within 24 hours. Minor, self-limited may undergo a colonic lavage and colonoscopy within 24 hours. Major ongoing hemorrhage requires prompt intervention with Major ongoing hemorrhage requires prompt intervention with Angiography or Angiography or Surgery. Surgery. Major, self-limited may be more difficult to define create the current controversy. Major, self-limited may be more difficult to define create the current controversy. Should these patients undergo Should these patients undergo nuclear imaging or nuclear imaging or colonoscopy? colonoscopy?

55. Occult Hemorrhage The traditional tests of Colonoscopy, and Nuclear scintigraphy, and Angiography provide no solution The traditional tests of Colonoscopy, and Nuclear scintigraphy, and Angiography provide no solution Occult bleeding noted in no more than 5% of all patients admitted with lower gastrointestinal massive hemorrhage. Occult bleeding noted in no more than 5% of all patients admitted with lower gastrointestinal massive hemorrhage. Patients in this situation may benefit from Patients in this situation may benefit from Small bowel contrast radiography or Small bowel contrast radiography or Capsule endoscopy. Capsule endoscopy. Additionally, elective angiography with cecal magnification may reveal small angiodysplasias. Additionally, elective angiography with cecal magnification may reveal small angiodysplasias.

56. Capsule Endoscopy

57. Bleeding Celiac Disease Tumors Suspected Crohn’s

58. Occult Hemorrhage If the occult hemorrhage recurs and investigations fail to reveal the source a variety of provocative diagnostic angiographic studies have been described. If the occult hemorrhage recurs and investigations fail to reveal the source a variety of provocative diagnostic angiographic studies have been described. Most studies prefer to incite bleeding using either heparin or thrombolytics. Once the site of bleeding is identified, it may be difficult to control without an operation. Most studies prefer to incite bleeding using either heparin or thrombolytics. Once the site of bleeding is identified, it may be difficult to control without an operation. In these instances, the surgeon should prepare and hold an operating room. In these instances, the surgeon should prepare and hold an operating room. Once the location is identified, a superselective catheter is left in the distal artery. Once the location is identified, a superselective catheter is left in the distal artery. During the conduct of surgery, the surgeon can palpate the catheter within the vessel and direct the surgical resection. During the conduct of surgery, the surgeon can palpate the catheter within the vessel and direct the surgical resection.

59. Operative Therapy Surgical therapy for massive lower intestinal bleeding is Surgical therapy for massive lower intestinal bleeding is Rare, Rare, Often definitive, and Often definitive, and Associated with significant mortality. Associated with significant mortality. Most sources of bleeding spontaneously resolve or are controlled with the current therapeutic interventions. Most sources of bleeding spontaneously resolve or are controlled with the current therapeutic interventions.

60. Operative Therapy Few patients currently require surgical treatment. Few patients currently require surgical treatment. If the patient is hemodynamically unresponsive to the initial resuscitation, then radiographic, radionuclide, and endoscopic evaluations are usurped by the need for urgent surgery. If the patient is hemodynamically unresponsive to the initial resuscitation, then radiographic, radionuclide, and endoscopic evaluations are usurped by the need for urgent surgery. Other patients may have the site of hemorrhage localized, yet the available therapeutic interventions fail to control the bleeding. Other patients may have the site of hemorrhage localized, yet the available therapeutic interventions fail to control the bleeding.

61. Operative Therapy Patient mortality increases with their transfusion requirements Patient mortality increases with their transfusion requirements Mortality of (7%) for patients requiring < 10 units of blood. Mortality of (7%) for patients requiring < 10 units of blood. Mortality increased to (27%) for patients > 10 units. Mortality increased to (27%) for patients > 10 units. Therefore, once a patient reaches 6 – 7 units during the resuscitation and the hemorrhage remains ongoing, surgical intervention becomes eminent. Therefore, once a patient reaches 6 – 7 units during the resuscitation and the hemorrhage remains ongoing, surgical intervention becomes eminent.

62. Operative Therapy The surgeon tailors the approach to the patient and depends on the diagnostic information gathered before the operation. The surgeon tailors the approach to the patient and depends on the diagnostic information gathered before the operation. All patients require All patients require Open laparotomy Open laparotomy Thorough examination of the entire intestine. Thorough examination of the entire intestine. The first objective in surgery focuses on the location of the intraluminal blood with the hope of segmentally isolating the possible sources of bleeding. The first objective in surgery focuses on the location of the intraluminal blood with the hope of segmentally isolating the possible sources of bleeding.

63. Operative Therapy Once the surgeon completes the initial visual inspection, a complete exploration ensues. Once the surgeon completes the initial visual inspection, a complete exploration ensues. The exploration begins in the stomach, duodenum, and considers possible missed upper gastrointestinal sources. The exploration begins in the stomach, duodenum, and considers possible missed upper gastrointestinal sources. Next, the small intestine must undergo examination from the ligament of Treitz to the ileocecal valve. Next, the small intestine must undergo examination from the ligament of Treitz to the ileocecal valve. Palpation of the intestine may demonstrate such etiologies as a Meckel ’ s diverticulum, ileitis, colitis, or a GIST. Palpation of the intestine may demonstrate such etiologies as a Meckel ’ s diverticulum, ileitis, colitis, or a GIST.

64. Operative Therapy Upon completion of the exploration phase, if no source appears obvious, the surgeon may consider intestinal enteroscopy. Upon completion of the exploration phase, if no source appears obvious, the surgeon may consider intestinal enteroscopy. The enteroscope or colonoscope will expose the luminal surface and transilluminate the intestinal wall for occult lesions. The enteroscope or colonoscope will expose the luminal surface and transilluminate the intestinal wall for occult lesions. Transillumination may identify vascular anomalies, small ulcers or tumors. Transillumination may identify vascular anomalies, small ulcers or tumors. Endoscopic access to the intestine may require Endoscopic access to the intestine may require Upper enteroscope, Upper enteroscope, Transgastric approach, Transgastric approach, Transcolonic approach, or Transcolonic approach, or Insertion through the anus. Insertion through the anus.

65. Operative Therapy Once a hemorrhage site is identified, the surgeon can perform an appropriate segmental resection. Once a hemorrhage site is identified, the surgeon can perform an appropriate segmental resection. Intra-operative endoscopy is a technically difficult endeavor. Intra-operative endoscopy is a technically difficult endeavor. A team approach with two surgeons or A team approach with two surgeons or The availability of an experienced endoscopist is important to identify the elusive lesions causing the hemorrhage. The availability of an experienced endoscopist is important to identify the elusive lesions causing the hemorrhage.

66. Operative Therapy If the source of bleeding cannot be found, and it appears to arise from the colon, If the source of bleeding cannot be found, and it appears to arise from the colon, the surgeon should perform a subtotal or total colectomy. the surgeon should perform a subtotal or total colectomy. Stable patients will tolerate a primary ileosigmoid or ileorectal anastomosis in this circumstance. Stable patients will tolerate a primary ileosigmoid or ileorectal anastomosis in this circumstance. Unstable patients require an end ileostomy with closure of the rectal stump or a mucous fistula. Unstable patients require an end ileostomy with closure of the rectal stump or a mucous fistula. Once stable, the patient may return for ileostomy closure. Once stable, the patient may return for ileostomy closure. The rectum and sigmoid colon require reexamination endoscopically to assure no bleeding persists. The rectum and sigmoid colon require reexamination endoscopically to assure no bleeding persists.

67. Operative Therapy The key concerns with operative management are, The key concerns with operative management are, first, a delay in the decision to operate until the hemorrhage reaches a critical point beyond 10 units of blood. This seems to contribute to the high mortality rate. first, a delay in the decision to operate until the hemorrhage reaches a critical point beyond 10 units of blood. This seems to contribute to the high mortality rate. Second, mortality rates for patients requiring urgent surgery consistently reach a range between 10% and 35%. Second, mortality rates for patients requiring urgent surgery consistently reach a range between 10% and 35%. Third, notable recurrence rates of 10% are attributable to the limits of isolating the precise cause of the bleeding. Third, notable recurrence rates of 10% are attributable to the limits of isolating the precise cause of the bleeding.

68. Operative Therapy The key concerns with operative management are, The key concerns with operative management are, The rates of recurrence increase if a surgeon The rates of recurrence increase if a surgeon Elects to perform a limited right or left colectomy without precise localization of the hemorrhage excessive persistent bleed rates of 20%, and still have high mortalitiy Elects to perform a limited right or left colectomy without precise localization of the hemorrhage excessive persistent bleed rates of 20%, and still have high mortalitiy A total colectomy offers the same mortality with a lower chance of recurrent or persistent hemorrhage. A total colectomy offers the same mortality with a lower chance of recurrent or persistent hemorrhage.

69. Massive lower GIT bleeding Hypotension and shock Resuscitation Nasogastric tube or upper GIT endoscopy Yes Bleeding source could be localized Yes Endoscopic therapy No Digital rectal examination and ano-proctoscopy Treat pathology Positive Negative Colonoscopy Bleeding source detected Endoscopic treatment or other Bleeding source not detected HematocheziaMassive bleeding

70. Colonoscopy Bleeding source not detected Hematochezia with negative UGIE Small bowel contrast radiographySmall bowel contrast radiography Capsule endoscopy.Capsule endoscopy. elective angiographyelective angiography with cecal magnification. Massive bleeding Active bleeding of 1 – 1.5 ml/min Active bleeding of > 0.1 ml/min Angiography diagnostic and therapeutic Surgery RBC radionucleotide scan success failed