Lower Gastrointestinal Bleeding

Dr. Naser El-Hammuri

Definition
Abnormal Hemorrhage into the lumen of the bowel from source distal to ligament of Treitz - Majority of cases are colonic - Small intestine 1/3rd - Upper GIT 11%

Epidemiology
Men > Women Incidence rises steeply with age Incidence about 20 27 / 100,000 adults 24 % of all GIT bleeding events

Can be - Acute & life threatening - Chronic - Occult

Initial Evaluation & Resuscitation

Resuscitation simultaneously with focused history & examination - Nature & duration of bleeding - Stool colour & frequency - Associated symptoms ( abd pain, change of bowel habits, fever, urgency, tenesmus or wt. loss) - Past medical history (previous episodes, injuries, surgical procedure, PUD, inflammatory bowel disease & exposure to pelvic or abd radiation) - Complicating comorbid condition (heart, liver disease, coagulation disorders) - Drugs (NSAID, anti plt, anticoagulant)

Initial Evaluation & Resuscitation

Physical Examination - V/S (postural drop) - Tachycardia, Tachypnea, hypotension & depressed mental state) > 1500 ml of blood (about 30%) - Complete abdominal examination - PR - Proctoscopy

Initial Evaluation & Resuscitation

Lab - CBC - Electrolytes - Coagulation Profile - Blood typing & Crossmatching

Initial Evaluation & Resuscitation

NG tube & Gastric lavage Positive esophagogastroduodenoscopy Bile lower GIT source Clear cant R/O source of bleeding Two large-bore cannulas Foley catheter ? ICU

Diagnostic testing
Accurate localization of bleeding site SO Definitive therapy can be properly directed

Diagnostic testing
Colonoscopy - Highly accurate, diagnostic yield 53 % 90 %. - Safe (compared to arteriography) - Procedure of choice, except if ongoing bleeding, or fail lo localize source - If no colonic source, ileum should be intubated & if ve do upper endoscopy

Diagnostic testing
Radio-labeled Red Blood Cell Scanning

(Technetium-99m) Highly sensitive 80% - 98% Accuracy rate 93% Bleeding rate 0.1 0.4 ml/min Tc-labeled sulfur colloid Considerable disagreement in literature concerning specificity in identifying the anatomic site of bleeding No therapeutic intervention cababilities Used in patients with none-life threatening lower GIT bleeding as guide to mesenteric angiography

Diagnostic testing
Angiography (Selective Mesenteric Angiography)
Less sensitive, bleeding rate at least 1.0 1.5 ml/min Invasive +ve if contrast extravasation into lumen of bowel Once bleeding vessel has been identified angiographically, area must be marked with methylene blue Diagnostic yield 27% - 67% Complication rate 2% - 4% (allergy, renal failure, bleeding and / or embolism) Therapeutic options (vassopressin, embolization) Compared to colonoscopy, lower diagnostic yield and higher complication rate

Diagnostic testing
Provocative Angiography for Continued Obscure Bleeding Short acting anticoagulant agents (Unfractionated heparin, vasodilators, thrombolysis or combinations thereof) Promising, however, Little published on this technique

Therapeutic Intervention
Majority of cases of lower GIT bleeding stop spontaneously

Endoscopic therapy
Thermal contact probe LASER photocoagulation Electrocauterization Injection of vasoconstrictors Application of metallic clip Injection of sclerotherapy

Therapeutic Intervention
Angiographic therapy
(1) Intra-arterial injection of vasopressin Cause arteriolar vasoconstriction & bowel wall contraction Infusion rate 0.2 U/min can be increased to 0.4 U/min Repeat angiography within 20 30 min, if under control infusion for 6 to 12 hr, if continues to be under control, give for another 6 to 12 hr @ 50% rate

Therapeutic Intervention
Side effects - myocardial ischemia - peripheral ischemia - hypertension - dysrhythmias - mesentric thrombosis - intestinal infarction - death

Therapeutic Intervention
Success rate 60 to 100 % Incidence of major complications 10% to 20 % Re-bleeding rate up to 50%

Therapeutic Intervention
(2)Transcatheter Embolization Embolizing agent (gelatin sponge, microcoil, polyvinyl alcohol particles, or a balloon) Success rate 90% to 100% Very low re-bleeding rate Reasonable complication rates Intestinal infarction

Therapeutic Intervention
Surgical Therapy No absolute criteria - Patient requiring > 4 units of blood in 24 hr to remain hemodynamically stable - Bleeding has not stopped after 72 hr - Re-bleeding within one week of initial episode

Therapeutic Intervention
If hemodynamic status permits, surgery only after localization Segmental resection (re-bleeding 0 to 14%, mortality 0 to 13%) Bind segmental colectomy (re-bleeding up to 75% & mortality up to 50%) If hemodynamic compromise and ongoing hemorrhage make it necessary to perform surgery, effort should be made intra-operatively to localize source of bleeding (colonoscopy, enteroscopy If bleeding site still cant be localized, colectomy is the procedure of choice (mortality 5 to 33%)

Etiology of Lower GIT Bleeding

(1)Diverticular Disease Prevalence in western societies 37 45% 17% of pts with diverticulosis experience bleeding (minor to life threatening) 80 85 % stop spontaneously 2nd episode 25% Semi-selective surgical therapy offered after 2nd episode as > 50% will have 3rd episode

Etiology of Lower GIT Bleeding

(2) Colitis
o Infectious Colitis (Salmonella typhi, E. Coli, Clost. Difficile) rare o Radiation Colitis 1 5 % of lower GIT bleeding o IBD (10% OF UC present with bleeding , bloody diarrhea) o Idiopathic Ulcers

(3) Neoplasia
o 7 33% of lower GIT bleeding o Adenomatous polyp accounts for 5 11% of lower GIT bleeding o Post polypectomy bleeding (immediate or delayed) 0.2 6% of cases of polypectomy

Etiology of Lower GIT Bleeding

(4) Coagulopathy
o Iatrogenic (Heparin or Warfarin) or Hematologic (thrombocytopenia) o ? Cause spontaneous hemorrhage or predispose to bleeding from existing leasion
o Always need to thoroughly investigate for a leasion

(5)Benign Anorectal Disease

o Up to 11% of lower GIT bleeding o Always need to more proxima

Etiology of Lower GIT Bleeding

(6)Colonic Arteriovenous Malformation
o (Vascular ectasia, angiomas, and angiodysplasi) o AVM are ectatic leasions seen in mucosa and submucosa of GI tract, they are degenerative lesions occur more frequently with advancing age o In autopsy series, reported incidence 1 2% o 2 to 30% in patients older than 50 years o The prevalence is 0.8% in healthy assymptomatic adults o AVMs most common in cecum o Have been associated with may systemic diseases Atherosclerotic cardiovascular disease Aortic stenosis Von Wellbrand disease COPD Cirrhosis of liver (No definitive causal relationship)

Etiology of Lower GIT Bleeding

(6)Colonic Arteriovenous Malformation
o Dx at time of colonoscopy or angiography o Angiography shows ectatic slow emptying veins, vascular tufts or early filling veins o Colonoscopy, angiodysplasias appear as red flat lesions 2 20 mm in diameter some times accompanied by feeding vessel o Typically bleeding is slow and intermittent, they account for only 2% of cases of acute bleeding o Bleeding stops spontaneously in 85% of cases, but recurs in 25 to 85% of cases, that is why definitive surgical or endoscopic treatment should be rendered once lesion has been identified

Etiology of Lower GIT Bleeding

(7)Colonic Ischemia
o 3 9% of cases of lower GIT bleeding

(8)Small Intestine source

o Up to 9% of cases o 70 80% of cases are attributable to AVMs o Less common cause jujenoileal divericule, Meckles diverticulum, neoplasia, regional enteritis, aortoenteric fistula o Difficult to localize

(9)NSAID