Gastrointestinal Bleeding
Dr. Wasfi M Salaita
Colorectal Surgeon - KHMC
Epidemiology
Is defined as bleeding distal to the ligament of Treitz.
GI bleeds.
More commonly bleeding is from a colonic rather
than a small bowel source.
Annual incidence 21 cases per 100,000.
Increasing age is considered frequently as a risk
factor for LGIB and the mean age greater than 60.
No statistical difference between males and
females with LGIB.
Race has not been noted to be a predisposing
factor for LGIB.
spontaneously.
25% will re-bleed.
While most patients have a self-limited illness,
the reported mortality ranges from 2-4%.
Among all patients presenting with lower GI
bleeding, diverticular disease is the most
common cause, followed by,inflammatory
disease and anorectal disease.
Etiology- lower GI
bleeding
Anorectal causes :
Include hemorrhoids -anal fissure and rectal ulcer.
Bleeding from hemorrhoids and fissure is uncommonly
associated with hemodynamic instability or large volume of
blood loss.
While rectal ulcer can cause severe hemorrhage and
hemodynamic instability
Possible causes of rectal ulcer are :
Radiation.
Sexual transmitted disease.
NSAIDs.
Liver disease.
Trauma.
Diverticular disease:
Contributes 20-60% of the cases of LGIB.
In 75% of patients bleeding will stop
spontaneously.
Rebleeding rate after first episode 25% and
increase to 50% after two episodes.
5% will have severe hemorrhage.
diverticular bleeding is distributed equally
between the right and left sides of the colon.
Observation alone is generally recommended
following the first episode of diverticular
hemorrhage. However, following a second
episode, the risk of subsequent episodes
appears to approximate 50%, and thus elective
resection has been recommended.
Angiodysplasia:
The incidence in most recent studies is only 3%
Colorectal neoplasm
Although colorectal cancer is most commonly
associated with occult blood loss rather than
overt bleeding, patients with rectosigmoid
lesions may present with hematochezia.
CR-cancers are source of LGIB in 9-13% of
patients.
Ischemic colitis
Occurs in 9-18% of patients.
Results from a sudden and often temporary
reduction in mesenteric blood flow, typically
caused by hypoperfusion, vasospasm, or
occlusion.
The usual areas affected are the watershed
areas of the colon: the splenic flexure and the
rectosigmoid junction.
Patients tend to be elderly, often with significant
atherosclerosis or cardiac disease.
UC.
Bleeding occurred in both young and old patients and
not related to disease duration.
Malignant lesion must be considered in patient with
long standing history of IBD and LGIB.
Infectious
colitis or enteritis :
Radiation colitis/proctitis.
Trauma, hematologic disorders and
NSAIDs.
Post polypectomy (occurs in 0.3% to 6.1%
of polypectomies).
Bleeding from CR-anastomosis (o.5-1.8%).
Clinical presentation
LGIB has many presentations reflecting the diverse
Diagnosis:
History and physical:
Patients with suspected lower GI bleeding should also
be asked about:
hemorrhoids,
associated diarrhea,
change in bowel habits,
personal or family history of inflammatory bowel
disease,
A history of radiation therapy.
A family history of GI disorders, malignancy or
bleeding disorders should also be obtained.
Physical examination should include digital
examination and Anoscopy to rule out local causes in
anal canal and distal rectum.
Diagnostic
Colonoscopy:
Both diagnostic and therapeutic.
The likelihood of identifying the source of bleeding
Angiography:
Both diagnostic and therapeutic.
Sensitivity (40-86%) and specificity in 100%.
To be positive the bleeding rate must
to be performed:
Localize the site of bleeding by injection
detected.
It is positive in 16-91%.
Using a positive scintigraphy as a requirement for
angiography led to an increase in positive
angiogram from 22-53%.
of LGIB.
Blood flow can be detected at 0.3
ml/min.
Positive when vascular contrast material
is extravasated into the bowel lumen.
Advantages:
It
Surgery:
The majority of patients with LGIB will
Indications:
Hemodynamically unstable patient (who have
massive ongoing bleeding and unresponsive to
initial resuscitation).
Patients who have had the source of bleeding
localized but no therapeutic measures
performed or they failed.
Patients who required at least six units of
packed red cells within 24h.
GI bleeding.
Unexplained iron deficiency anemia.
Small bowel tumors.
Suspected crohn's disease.
Refractory malabsorption.
Contraindications:
Any
capsule endoscopy.
High suspicious of small bowel source.
Can
Thank you