Management of lower GI bleeding Abdul Aziz Alsaigh. FRCS, FACS. Prof of surgery

Learning objectives (ILOs) At the end of this presentation students will be able to: Define lower GI haemorrhage (LGIB). Enumerate the causes of LGIB. Describe the pathophysiology of LGIB Describe the symptoms and signs Describe the diagnostic work up. Describe the resuscitative measures. Describe the management- non-surgical & surgical.

Introduction Definition: Bleeding distal to DJ flexure- ligament of Treitz Frequent cause of hospital admission, morbidity & mortality. 20-33% of all gastrointestinal bleeding. Proximal to caecum- melena Right colon- maroon color Left colon- bright red bleeding Brisk UGI bleeding- bright red color

Causes of LGIB

Lower Gastrointestinal Bleeding in Adults Percentage of Patients Diverticular disease 60% Inflammatory bowel disease Crohn disease Ulcerative colitis 13% Benign anorectal diseases Hemorrhoids Anal fissure Fistula-in-ano 11% Neoplasia Malignant neoplasia of colon, rectum, SI, anus 9% Coagulopathy 4% Arteriovenous malformations 3% TOTAL 100% Source: Vernava AM, Longo WE, Virgo KS. A nationwide study of the incidence and etiology of lower gastrointestinal bleeding. Surg Res Commun. 1996;18:113-20.[8]

Diverticulosis Dominant cause of LGIB Saclike protrusion through the circular muscle fibers at a point where the vessel has perforated. Vessel becomes draped over the dome of the diverticulum Most commonly located in the sigmoid and descending colon Bleeding originates from vasa rectae in the submucosa Risk factors: Lack of dietary fiber, constipation, advanced age, and use of NSAIDs and aspirin.

Angiodysplasia Most common A-V malformations found in the GIT Most common site- cecum and ascending colon Acquired lesions Elderly >60 years Bleeding is venocapillary in origin. Generally less vigorous than diverticular bleeding. 80% untreated angiodysplasia experience rebleeding.

Colitis (IBD) Massive hemorrhage-due to IBD is rare Ulcerative colitis: Bloody diarrhea in most. Mild to moderate LGIB in up to 50%. Crohn disease: LGIB is not as common. Bleeding more common with colonic involvement. Ischemic colitis: Elderly, pain abdomen, bloody diarrhea. Involves splenic flexure and the rectosigmoid. Not associated with significant blood loss or hematochezia.

Neoplasm Polyps and carcinoma Occult bleeding Low grade and frequent bleeding- common Massive bleeding- unusual

Other diseases Benign anorectal disease- hemorrhoids, anal fissures, anorectal fistulas cause intermittent rectal bleeding. 11% of LGIB- from anorectal disease.[8] Small intestinal conditions- Peutz-Jeghers syndrome, hemangiomas, & adenocarcinomas usually cause occult bleeding.

Symptoms & signs of LGIB Variable- depending on the etiology Mild and intermittent- colon carcinoma, colitis Colon carcinoma rarely causes significant LGIB. Moderate/ severe: Diverticulosis, angiodysplasia.

Symptoms & signs Young patients with infectious or noninfectious (idiopathic) colitis : Fever Dehydration Abdominal cramps Hematochezia Older patients with diverticular bleeding or angiodysplasia: Painless bleeding and minimal symptoms. Ischemic colitis: Abdominal pain, and varying degrees of bleeding Massive lower GI bleeding usually in ≥65 years.

Massive LGIB Age > 65 Hematochezia or bright red blood PR Hemodynamically unstable 1. Diverticulosis 2. Angiodysplasia

Lower GI bleeding rate Moderate bleeding: Hematochezia or melena. Hemodynamically stable. Benign anorectal conditions, IBD, neoplasia. Occult bleeding: Microcytic hypochromic anemia. Benign anorectal conditions, IBD, neoplasia.

Diagnosis History & physical examination Nasogastric tube Digital rectal examination, anoscopy /proctoscopy Complete blood cell (CBC) count Serum electrolytes levels Coagulation profile: aPTT, PT, platelet count

Diagnosis- COLONOSCOPY Flexible colonoscopy: Initial diagnostic method of choice. Hemodynamically stable. Colonoscopy following a rapid bowel preparation. Bowel prepared colonoscopy- higher diagnostic/ therapeutic yields than unprepped colonoscopy. Successfully identify the origin of severe LGIB in 80-90% .

Colonoscopy- Bleeding polyp in colon

Bleeding rectal ulcer

Colonoscopy Carcinoma colon Vascular malformation in sigmoid

Ulcerative Colitis

Ulcerative colitis Crohn’s disease

Colonic Diverticulosis

Other diagnostic modalities Tc⁹⁹RBC scan: Detects hemorrhage at rates as low as 0.1-0.5 mL/min. Angiography: Detects bleeding at rates of 1-1.5 mL/min. Indications: Brisk ongoing LGIB, hemodynamically unstable, with or without a preceding radionuclide scan & failed colonoscopy. CT scanning (A & P): Routine workup failed- contrast extravasation, bowel wall enhancement, vascular dilatation Exploratory laparotomy (rarely): Intraoperative push enteroscopy in hemodynamically unstable patients.

Multiple episodes of LGIB without a known source Elective mesenteric angiography Upper and lower endoscopy Meckel scanning (Tc⁹⁹) Upper GI series with small bowel Enteroclysis

Tc⁹⁹RBC scan

Meckel's (Tc⁹⁹) scan

ANGIOGRAPHY

Haemorrhoids Anal fistula

Principles of Management Resuscitation and initial assessment Localization of the bleeding site Therapeutic intervention to stop bleeding

Resuscitation and initial assessment Large-bore IV access Crystalloid infusion. CBC, electrolytes, coagulation profile, crossmatch. Blood loss / hemodynamic status ascertained. Severe bleeding-invasive hemodynamic monitoring.

Localization of the bleeding site Flexible colonoscopy - hemodynamic stable patient RBC isotope scan Angiography CT scan Upper GI endoscopy

Therapeutic interventions Diverticular bleeding: Colonoscopic bipolar probe coagulation, epinephrine injection, or metallic clips. Recurrent bleeding- resection of the affected bowel segment. Angiodysplasia: Thermal therapy (electrocoagulation, argon) Ischemic colitis : NPO and IV hydration. Bleeding site cannot be determined: Vasoconstrictive agents- vasopressin (Pitressin) used. Vasopressin unsuccessful/contraindicated- superselective embolization.

Superselective angiographic embolization The most feared complication of embolization of the mesenteric vessels- ischemic colitis. Limited use for GI bleeding.

SURGERY Indications for surgery: Active persistent bleeding with hemodynamic instability refractory to aggressive resuscitation Persistent, recurrent bleeding Transfusion of >4 units PRBC in a 24-hours with active or recurrent bleeding Transfusion of >6 units of PRBC during the same hospitalization

Surgery Segmental bowel resection following precise localization of the bleeding. Low morbidity & mortality when compared with subtotal colectomy. Subtotal (total abdominal) colectomy with temporary end ileostomy is the procedure of choice in patients who are actively bleeding from an unknown source. Blind segmental resection should not be performed. Associated with high rebleeding rate, morbidity & mortality.

Thank you!