The conundrum of lower gastrointestinal bleeding Billingham RP. 1997
10-15% of patients require urgent diagnostic and therapeutic procedures 8-12 % of patients fail to have the precise origin and location of bleeding identified before an operation
In 10% of the patients with hematochezia the source of bleeding is gastroduodenal
Severe acute lower gastrointestinal bleeding(SALGIB) (15-22% of ALGIB) *significant hemodynamic compromise *significant hemodynamic compromise *decrease in hemoglobin 2-4 g/dl *transfusion requirement>/= 2-4 blood units
Mortality related to lower GI bleeding has been reported to occur in 4 to 15% of patients Bender et al.1991 Makela JT et al…1993
Undirected surgery may be necessary when: -more than 1500 ml of blood is necessary to resuscitate the patients and bleeding continues -2000 ml of blood is necessary to maintain vital signs during a 24-hour period -Bleeding continues for 72 hours -Rebleeding(significant) occurs within one week of initial cessation
Colonic origin < 60 years < 60 years Right/left diverticula IBDNeoplasm > 60 years > 60 years Angiodysplasia (right sided) Right/left diverticula Neoplasm
Diverticulosis accounts for 50% of all lower gastrointestinal bleedings 60% of bleeding episodes arise from diverticula proximal to the splenic flexure Bleeding spontaneously ceases in 80-90% of patients Risk of rebleeding is approximately 25% (Cohen J.L..1996)
Angiodysplasia (Arterovenous malformations,Vascular ectasias,Angiomas) Real or overstimated problem?? Real or overstimated problem?? Precise incidence unknown:<1-30% subjects Lower GI bleeding:2-60% Only 15% with bleeding will experience severe episodes
Rectal outlet bleeding Intermittent passage of scant to modest amounts of blood and clots,not associated(usually) with a significant drop in the hemoglobin or hematocrit and arising from anorectal conditions. Intermittent passage of scant to modest amounts of blood and clots,not associated(usually) with a significant drop in the hemoglobin or hematocrit and arising from anorectal conditions.
Chronic bleeding -In 10% of subjects aged 25-65 -80% benign anorectal diseases (Hemorroids,fissure, solitary ulcer/prolapse,radiation proctitis etc…..) -present in 70% of pts.with anorectal symptoms. but……………. ……………………….
….11% of patients(mostly of them <50 years) with significant lower gastrointestinal bleeding have a benign anorectal source of bleeding. (Hoedema R.E. et al… 2005)
Chronic bleeding (occult bleeding) Biochemical test(Guajak) Immunological test
Acute GI hemorrhages in patients with coagulopathy or under antiaggragation/anticoagulation treatment 50% of pts.with leukemia and platelet<20,000 mm 3 suffer significant GI bleeding 26-30% of geriatric patients with lower bleeding are antiaggregated/anticoagulated Spontaneous hemorrage is unlikely!!! Spontaneous hemorrage is unlikely!!! (Coon WW,1974 (Coon WW,1974 Mittal R et al..1985) Mittal R et al..1985)
The first important step,after resuscitation,is to establish whether the patient is actively bleeding or has ceased by the time of presentation.
To apply an efficient,disciplined and orderly approach in choosing among several sophisticated diagnostic tools
Moderate Lower GI bleeding When and where the admission ???
Nearly 20% of emergency department patients with a chief complaint of lower gastrointestinal bleeding will prove either to have no bleeding at all or to have bleeding from a non gastrointestinal source(eg,nose,pulmonary tree,vagina) (Law DH,1979)