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

2. 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.

3. 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

5. Causes of LGIB

6. 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: [8]

7. 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.

8. 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.

9. 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.

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

11. 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.

12. 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.

13. 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.

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

15. 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.

16. 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

17. 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% .

18. Colonoscopy- Bleeding polyp in colon

19. Bleeding rectal ulcer

20. Colonoscopy Carcinoma colon Vascular malformation in sigmoid

21. Ulcerative Colitis

22. Ulcerative colitis
Crohn’s disease

23. Colonic Diverticulosis

24. Other diagnostic modalities
Tc⁹⁹RBC scan: Detects hemorrhage at rates as low as mL/min.
Angiography: Detects bleeding at rates of 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.

25. 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

26. Tc⁹⁹RBC scan

27. Meckel's (Tc⁹⁹) scan

28. ANGIOGRAPHY

29. Haemorrhoids Anal fistula

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

31. 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.

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

33. 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.

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

35. 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

36. 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.

37. Thank you!