Lower GI Bleed T R Wilson Doncaster Royal Infirmary

Case 1 67 year old male PMHx – AF, IHD on Warfarin, Atenolol, Statin 24 hour history of fresh blood PR – 4 Episodes, No stool, No pain – BP 90/40, Pulse 60, Temp 35.5 – After 1L crystaloid → BP up to 105/60 – Hb 9.5 (was 13 2 weeks ago), INR 3.1

Aspects to consider in initial management Reversal of anticoagulation – Beriplex / Vit K Cross match – Keep Hb at around 10 and have 4 units is reserve – If > 6 units then consider FFP/platelets Tranexamic acid? CT angiogram ? – >80% will settle with supportive care Once stable consider OGD

After admission In next 24 hours 4 further bleeds BP drops intermittently to 95 systolic After 4 units of blood Hb is still 9.0 Day 2: Bleeding less Day 3: 2 further episodes bleeding → 2 units RBC CTA and angiogram negative Where to go next??

Further management Patient remains stable but transfusion dependent Consider further investigations – OGD if not done – Consider preping and performing colonoscopy – CTA or angiogram asap if shock index <1 Leave in angiocatheter Administration of tPA at time of angiogram

What next Patient continues to be transfusion dependent OGD negative 2 negative CTAs and an angiogram Colonoscopy – Diverticulosis in left colon – Some fresh blood and clots predominantly in right colon Where next? – More investigations? – Surgery ?

Investigation vs Surgery Further investigations – Capsular endoscopy – Red cell scan – Repeat all previous investigations Surgical options – On table investigation Colonoscopy/enteroscopy Irrigate bowel and soft clamps – Segmental colectomy (left or right?) – Subtotal colectomy

Approach to massive lower GI Bleed If lower bleed in doubt consider OGD If shock index < 1 then consider CT angiogram → proceed to interventional radiology if required If settles (80%) → Colonoscopy If continues – Angiography → If source not identified (and patient remains stable) → – Colonoscopy → If source not identified (and patient remains stable) → – Radionucleotide scan If patient is unstable then surgery is necessary

Surgical approach to lower GI bleed If source identified → Segmental resection – Recurrent bleed 15%, Mortality <10% If source cannot be identified – Examine small and large bowel Blood in upper SB suggests UGI bleed Blood in lower SB may occur in right colonic bleed Blood in right colon may come from left colonic bleed Ensure there is no anorectal cause – Consider on table lavage + colonoscopy +/- enteroscopy Difficult and time consuming – If in doubt → subtotal colectomy is safest option Recurrent bleed low if rectal bleed excluded (risk small bowel source) Mortality usually >10% (10-30%) – Segmental colectomies carry Risk of rebleeding 35-75% Mortality 20-50%

Case 2 38 year old female – no PMHx Intermittant PR bleeding for 3 days – Up to 6 times a day – small volume – No pain – Not opening bowels O/E – looks well – Normal pulse and blood pressure – Normal abdominal and rectal examination Hb 9.7 (usually ), WCC/CRP normal Differential diagnosis and invesigation?

Investigations Rigid sigmoidoscopy - a bit of blood in lower rectum with contact bleeding Proctoscopy – partially prolapsing piles Flexible sigmoidoscopy – Pools of liquid stool and blood – Proctosigmoiditis – Possible pseudomembranes Where next?

Further management Stool MC+S/c-diff Biopsy of mucosa Started PO metronidazole pending Ix

Case 3 69 year old lady PMHx: MI/IHD, IBS/diverticulitis 2/7 of low abdominal pain → 2 large episodes of fresh Pr bleeding and some lose stool o/e – Temp 38, Pulse 112 (sinus) – Markedly tender left side abdomen WCC 25, CRP 170, Hb 137 Differential diagnosis and investigation

CT scan – 6.5 cm AAA – Marked diverticulosis – no inflammation – Thick walled colon on left side – No active bleeding Next management

Suspected ischaemic colitis Start antibiotics (Cef and Met) Close observations Consider – Stool MC+S – Flexible sigmoidoscopy (distribution / biopsy)

PR bleeding - classification 1. Massive PR bleeding – Diverticular – painless – Angiodysplasia – painless – Ischaemic colitis – pain 2. Bloody Diarrhoea – IBD: Crohns or UC – Infective – Ischaemic 3. Anal canal bleeding – Piles – Fissure – Protrusion 4. Higher bleeding (mixed with stool) – rarely seen

Management Massive Bleed Present as acutes If pain and tenderness – consider CT ? Ischaemia Otherwise observation – Settles → OP colonoscopy – Unstable → CTA → Angio if bleeding point – Try and avoid surgery unless source of bleed known

Management Colitis Acute / unwell – Stool cultures – Flexy sig and biopsy – Empirical antibiotics and steroids – DVT prophylaxis – Calcium Outpatient – Rigid sigmoidoscopy – Well → colonoscopy – Unwell – consider empirical steroids/ASA

Management – Anal canal bleeding Outpatients Diagnosis depends on history and examination All patients >30 should have a more proximal lesion excluded – Full colonoscopy for all 2 week waits – ?Most cancers will be picked up incidentally