Faculty of Medicine

University of Gezira
Surgical clarkship
Group Number 2

LOWER GIT BLEEDING

History

Examination

Diagnosis and reasoning

Chronic diarrhea is a relatively common complaint,
and may be due to a many causes.
However, the presence of blood and mucus in this
patient narrows the likely etiologies into a few key
groups : infectious diarrhea, inflammatory diarrhea
and antibiotic associated diarrhea.
Her history of recent travel to South Asia makes
infectious diarrhea a possibility -especially intestinal
tuberculosis and amoebiasis.

Inflammatory diarrhea secondary to inflammatory bowel

disease (IBD) is also compatible with her age and
presentation.
Antibiotic associated diarrhea (such as pseudomembranous
colitis) is unlikely given that antibiotics were commenced only
after she became symptomatic.
Her full blood count reveals normochromic normocytic
anemia and thrombocytosis - in this context, this is
suggestive of a chronic inflammatory process.
The negative tuberculin test argues against tuberculosis
(although it does not exclude it definitively).

The stool culture and microscopy provides several important clues.

The negative cultures and absence of ova and parasites argue against
bacterial infections and amoebiasis. However, the presence of fecal
leukocytes
confirms the presence of bowel inflammation -making inflammatory
diarrhea the most likely etiology.
Thus, a colonoscopy is probably the next best step in the diagnostic workup - and
in
this patient reveals proctosigmoiditis.
In addition, the biopsies obtained show that this is superficial inflammation,
with features suggestive of ulcerative colitis (UC).
Considering her clinical and biochemical parameters, this can be classified as a
moderate episode of UC.
UC primarily involving the left colon is best treated with a combination of a
mesalazine suppository and oral mesalazine. While Azathioprine is an option down
the line, it is not indicated immediately.

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Introduction
LGIB is defined as bleeding that is of recent duration, originates
beyond the ligament of Treitz, results in instability of vital signs,
and is associated with signs of anemia with or without need for
blood transfusion, is a frequent cause of hospital admission and
is a factor in hospital morbidity and mortality.
Its accounts for approximately 20-33% of episodes of
gastrointestinal (GI) hemorrhage, with an annual incidence of
about 20-27 cases per 100,000 population .
However, although LGIB is statistically less common than upper
GI bleeding (UGIB), it has been suggested that LGIB is
underreported because a higher percentage of affected patients
do not seek medical attention.[1]
LGIB encompasses a wide spectrum of symptoms, ranging from
trivial hematochezia to massive hemorrhage with shock.

LGIB is classified under 3 groups according to the amount of

bleeding, as shown in the image below. Massive hemorrhage is a
life-threatening condition and requires transfusion of at least 4
units (U) of blood.

Introduction
LGIB has a mortality rate ranging from about 10-20%, with
patients of advanced age (>60 y) and patients with comorbid
conditions (eg, multiorgan system disease, transfusion
requirements in excess of 5 U, need for operation, and recent
stress, such as surgery, trauma, and sepsis) at greatest risk.
LGIB is more likely in the elderly because of a higher incidence
of diverticulosis and vascular disease in these groups.
The incidence of LGIB is higher in men than in women.
Effective management with less invasive modalities has also
reduced healthcare costs and, more importantly, patient
morbidity and mortality.

Epidemiology

LGIB that requires hospitalization represents less than 1% of all

hospital admissions[2]
Annual incidence rate was 20.5 patients per 100,000 (24.2 in
males vs 17.2 in females).

Anatomy
The average length of the large intestine is 135-150 cm.
Ascending and descending segments of the colon are fixed to the
retroperitoneum.
However, the transverse and sigmoid colon are supported by a
mesentery in the abdomen.
A comprehensive understanding of small bowel and colonic vascular
anatomy is essential for any physician performing a primary lower GI
procedure for hemorrhage or other diseases.
.

The terminal ileum empties into the cecum through the ileocecal valve. The
cecum measures approximately 7.5 cm in diameter and 10 cm in length.
The appendix extends from the cecum and measures 8-10 cm in length. The
ascending colon is 15 cm long.
The posterior surface is fixed against the retroperitoneum along the white line
of Toldt.
The lateral and anterior surfaces are intraperitoneal.
The transverse colon is 45 cm in length.
It is fixed by the nephrocolic ligament at the hepatic flexure and by the
phrenocolic ligament at the splenic flexure.
It is completely invested in visceral peritoneum.
The colon has specific characteristics that distinguish it from other parts of the
gastrointestinal tract.
Omental appendices are bodies of fat enclosed by peritoneum.
Taeniae coli are 3 bands of longitudinal muscle; haustra form between the
bands.

All vascular structures and lymph nodes are located in the mesocolon.
It is easiest to visualize the colon mesentery as being no different
than small bowel mesentery.
Both mesenteries attach at a 90 angle and contain arterial, venous,
and lymphatic channels.
The right colon differs from small bowel only in that the bowel and its
mesentery are Saran wrapped to the retroperitoneum.
The reason this distinction is important is that, in order to resect this
bowel, the colon and its mesentery must first be mobilized from its
retroperitoneal attachments; only then can a segmental resection with
lymphadenectomy be performed.
The arterial supply branches from the SMA to the ileocolic, right colic,
and middle colic arteries. The SMA territory ends at the distal
transverse colon, where the inferior mesenteric artery takes over to
supply the left colon.

The most common pattern of arterial supply relevant to a right

hemicolectomy consists of 3 arterial branches (ileocolic artery, right
colic artery, and middle colic artery) arising from the SMA. The
ileocolic artery, the most constant tributary of the SMA, supplies the
terminal ileum, cecum, and appendix. The right colic artery supplies
the ascending colon and hepatic flexure of the transverse colon.
The middle colic artery is the most proximal branch of the SMA,
supplying the proximal and distal transverse colon via the right and
left branches.
The middle colic artery is completely absent in up to 25% of
individuals; it is replaced by a large right colic artery.
The arc of Riolan (meandering mesenteric artery) is a collateral
artery that directly connects the proximal SMA to the proximal IMA
and may serve as a vital conduit when arterial occlusion occurs

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Etiology

Comprehensive knowledge of the etiology of LGIB is essential

for patient management and, ultimately, for patient outcome.
The diagram below outlines the most common causes of LGIB,
including anatomic (eg, diverticular bleeding), vascular (eg,
angiodysplasia, ischemic colitis, radiation-induced colitis),
neoplasms, and inflammatory.

Etiology

The leading causes of significant LGIB are diverticulosis and

angiodysplasia.
Diverticulosis accounts for around 30-50% of the cases of
hemodynamically significant LGIB, whereas angiodysplasia
accounts for about 20-30% of cases.
Some experts believe that angiodysplasia is the most frequent
cause of LGIB in patients older than 65 years.
Hemorrhoids are the most common cause of LGIB in patients
younger than 50 years, but the bleeding is usually minor, and
they are rarely the cause of significant LGIB.
According to a review of 7 series of patients with LGIB, the most
common cause of LGIB was diverticulosis, accounting for
approximately 33% of cases, followed by cancer and polyps,
which accounted for about 19% of cases.[4]

Common Causes of Lower Gastrointestinal Bleeding in

Adults
Lower Gastrointestinal Bleeding in Adults

Percentage of Patients

Diverticular disease:
Diverticulosis/diverticulitis of small intestine
Diverticulosis/diverticulitis of colon

60%

Inflammatory bowel disease:

Crohn disease of small bowel, colon, or both
Ulcerative colitis
Noninfectious gastroenteritis and colitis

13%

Benign anorectal diseases:

Hemorrhoids
Anal fissure
Fistula-in-ano

11%

Neoplasia :
Malignant neoplasia of small intestine
Malignant neoplasia of colon, rectum, and anus

9%

Coagulopathy

4%

Arteriovenous malformations (AVMs)

3%

TOTAL

100%

Lower Gastrointestinal Bleeding in Children and Adolescents

1-Intussusception:
Polyps and polyposis syndromes Juvenile polyps and polyposis
Peutz-Jeghers syndrome
Familial adenomatous polyposis (FAP)
2-Inflammatory:
Crohn disease
Ulcerative colitis
Indeterminate colitis
3-Meckel diverticulum

Etiology according to the origin

Anorectal:
Bright red blood, on the surface of the stool and paper, after defecation.
Haemorrhoids.
Acute anal fissure.
Distal proctitis.
Rectal prolapse.
Rectosigmoid:
Darker red blood, with clots, in surface of stool and mixed.
Rectal tumours (benign or malignant).
Proctocolitis.
Diverticular disease.
Proximal colonic:
Dark red blood mixed into stool or altered blood.
Colonic tumours (benign or malignant).
Colitis.
Angiodysplasia.
NSAID-induced ulceration.

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Diverticulosis
Is a common acquired condition ; approximately 50% of adults
older than 60 years have radiologic evidence of this disease.
A diverticulum is a saclike protrusion of the colonic wall that
develops at a small point of weakness where the penetrating
vessel has perforated through the circular muscle fibers.
The vessel becomes draped over the dome of the diverticulum,
separated from the bowel lumen only by mucosa.
Subsequent chronic trauma to the vasa recta along the luminal
aspect, as well as contraction and relaxation of the surrounding
muscularis propria, leads to eccentric thinning of the media.
Ultimately, erosion of the vessel and bleeding can occur.
.

Diverticula are most commonly located in the sigmoid and descending

colon, and diverticular bleeding originates from vasa rectae located in the
submucosa, which can rupture at the dome or the neck of the
diverticulum.[5]
Up to 20% of patients with diverticular disease experience bleeding, which
stops spontaneously in 80% of patients; however, in 5% of patients with
diverticular disease, the bleeding from diverticular disease can be
massive.
Although about 75% of the diverticula occur on the left side of the colon,
right-sided diverticula are responsible for approximately 50-90% of the
bleeding.[5]
This may be because false right-sided diverticula have wider necks and
domes, which expose the vasa recta to injury over a greater length.
The incidence of true right-sided diverticula is uncommon.
True right-sided diverticula are usually solitary and originate in the
anterior cecum adjacent to the ileocecal valve.
Usually true right-sided diverticula cause right-sided diverticulitis and are
misdiagnosed as appendicitis

Angiodysplasia

Colonic angiodysplasias are arteriovenous malformations

located in the cecum and ascending colon; these are acquired
lesions that affect elderly persons older than 60 years.
Most colonic angiodysplasias are degenerative lesions that arise
from chronic, intermittent, low-grade colonic contraction that
obstructs the mucosal venous drainage.
Over time, mucosal capillaries dilate, become incompetent, and
form an arteriovenous malformation.

Hemorrhoids
The term hemorrhoid is usually related to the symptoms caused by
hemorrhoids. Hemorrhoids are present in healthy individuals.
In fact, hemorrhoidal columns exist in utero. When these vascular
cushions produce symptoms, they are referred to as hemorrhoids.
Hemorrhoids generally cause symptoms when they become enlarged,
inflamed, thrombosed, or prolapsed.
Decreased venous return, Straining and constipation,
Pregnancy, Portal hypertension and anorectal varices are
important predisposing factors

Hemorrhoids
Internal:
cannot cause cutaneous pain, because they are above the dentate line and
are not innervated by cutaneous nerves.
However, they can bleed, prolapse, and, as a result of the deposition of an
irritant onto the sensitive perianal skin, cause perianal itching and irritation.
Internal hemorrhoids can produce perianal pain by prolapsing and causing
spasm of the sphincter complex around the hemorrhoids.
This spasm results in discomfort while the prolapsed hemorrhoids are
exposed.
This muscle discomfort is relieved with reduction.
Internal hemorrhoids can also cause acute pain when incarcerated and
strangulated.
Again, the pain is related to the sphincter complex spasm.
Strangulation with necrosis may cause more deep discomfort.
When these catastrophic events occur, the sphincter spasm often causes
concomitant external thrombosis.

Hemorrhoids
External :
External hemorrhoids cause symptoms in 2 ways.
First, acute thrombosis of the underlying external hemorrhoidal vein can occur.
Acute thrombosis is usually related to a specific event, such as physical exertion,
straining with constipation, a bout of diarrhea, or a change in diet. These are acute,
painful events.
Pain results from rapid distention of innervated skin by the clot and surrounding edema.
The pain lasts 7-14 days and resolves with resolution of the thrombosis.
With this resolution, the stretched anoderm persists as excess skin or skin tags.
External thromboses occasionally erode the overlying skin and cause bleeding.
Recurrence occurs approximately 40-50% of the time, at the same site (because the
underlying damaged vein remains there).
Simply removing the blood clot and leaving the weakened vein in place, rather than
excising the offending vein with the clot, will predispose the patient to recurrence.
External hemorrhoids can also cause hygiene difficulties, with the excess, redundant
skin left after an acute thrombosis (skin tags) being accountable for these problems.
External hemorrhoidal veins found under the perianal skin obviously cannot cause
hygiene problems; however, excess skin in the perianal area can mechanically interfere
with cleansing.

Hemorrhoids
External thrombosis causes acute cutaneous pain.
This constellation of symptoms is referred to as acute hemorrhoidal crisis
and usually requires emergent treatment.
Internal hemorrhoids most commonly cause painless bleeding with bowel
movements.
The covering epithelium is damaged by the hard bowel movement, and the
underlying veins bleed.
With spasm of the sphincter complex elevating pressure, the internal
hemorrhoidal veins can spurt.
Internal hemorrhoids can deposit mucus onto the perianal tissue with
prolapse.
This mucus with microscopic stool contents can cause a localized
dermatitis, which is called pruritus ani.
Generally, hemorrhoids are merely the vehicle by which the offending
elements reach the perianal tissue.
Hemorrhoids are not the primary offenders.

Colitis

Massive hemorrhage due to inflammatory bowel disease (IBD) is rare.

Ulcerative colitis causes bloody diarrhea in most cases. In up to 50%
of patients with ulcerative colitis, mild to moderate LGIB occurs, and
approximately 4% of patients with ulcerative colitis have massive
hemorrhage.
LGIB in patients with Crohn disease is not as common as in patients
with ulcerative colitis; 1-2% of patients with Crohn disease may
experience massive bleeding.
The frequency of bleeding in patients with Crohn disease is
significantly more common with colonic involvement than with small
bowel involvement alone.
The mucosal pattern of injury is similar to that found in patients with
infectious and ischemic colitis, with the mucosa appearing friable,
erythematous, edematous, and ulcerated.
In severe Crohn disease, the inflammatory process may extend into
the serosa, leading to colonic perforation.

Ischemic colitis is a disease of the elderly population and is

commonly observed after the sixth decade of life.
This condition is the most common form of ischemic injury to
the digestive system, frequently involves the watershed areas,
including the splenic flexure and the rectosigmoid junction.
Ischemia causes mucosal and partial-thickness colonic wall
sloughing, edema, and bleeding.
In most cases, the precipitating event cannot be identified.
However, although abdominal pain and bloody diarrhea are the
main clinical manifestations, ischemic colitis is not associated
with significant blood loss or hematochezia.
The pathophysiologic mechanism of infectious colitis may be
due to either colonic tissue invasion by bacteria, such as
Salmonella and Shigella, or toxin-mediated damage, as with
Escherichia coli 0157:H7.

Colon carcinoma

Colorectal adenocarcinoma is the third most common cancer .

Colorectal carcinoma causes occult bleeding as a result of
mucosal ulceration or erosion, but the incidence of massive
bleeding due to colorectal carcinoma varies from 5% to 20% in
different series.

Other diseases

Postpolypectomy hemorrhage is reported to occur in 0.1%-3% of

patients up to 1 month following colonoscopic polyp resection.
Various small intestinal conditions, such as, Peutz-Jeghers
syndrome, hemangiomas, and small intestinal
adenocarcinomas, may cause small intestinal bleeding, but
these hemorrhages are usually occult in nature.

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Symptoms

The clinical presentation of LGIB varies with the anatomical

source of the bleeding, as follows:
1- Maroon stools, with LGIB from the right side of the colon
2- Bright red blood per rectum with LGIB from the left side of the
colon.
3- Melena with cecal bleeding.
In practice, however, patients with upper GI bleeding and rightsided colonic bleeding may also present with bright red blood
per rectum if the bleeding is brisk and massive.
An older patient with diverticular bleeding or angiodysplasia
may present with painless bleeding and minimal symptoms.

Symptoms

Ischemic colitis, abdominal pain, and varying degrees of

bleeding are usually observed in patients with multiple
comorbidities such as congestive heart failure (CHF), atrial
fibrillation, or chronic renal failure (CRF).
LGIB can be mild and intermittent, as often is the case of
angiodysplasia and colon carcinoma, or moderate or severe, as
may be the situation in diverticula-related bleeding.
Colon carcinoma rarely causes significant LGIB.

Physical findings
Vital signs
Orthostatic hypotension implies at least a 15% loss of blood volume.
Abdominal examination
Evaluate for tenderness, masses, liver span, and splenomegaly.
Rectal examination
Key elements include inspection of the anus,palpation for masses,
characterization of the stool color.
The presentation of LGIB can also vary depending on the etiology.
# A young patient with infectious or noninfectious (idiopathic) colitis may
present with the following:
1- Fever.
2- Dehydration.
4- Abdominal cramps.
4- Hematochezia.
# LIF tenderness suggests diverticular inflammation with bleeding.

Physical findings
Massive lower GI bleeding usually occurs in patients aged 65 years and
older who have multiple medical problems, and produces the following
manifestations:
Systolic blood pressure of less than 90 mm Hg
Pale.
The passage bright red blood from the rectum

Lower Gastro
intes

tinal Bleedin
g

Workup

Approach Considerations

The 3 nonsurgical modalities used to diagnose lower

gastrointestinal bleeding (LGIB) are colonoscopy, radionuclide
scans, and angiography.
Apart from colonoscopy, endoscopic procedures, such as
esophagogastroduodenoscopy (EGD), wireless capsule endoscopy
(WCE), push enteroscopy, and double-balloon enteroscopy, are
used depending on the clinical circumstance. The sequence of
using various modalities depends on such factors as rate of
bleeding, hemodynamic status of the patient, and inability to
localize bleeding with the initial modality.
Patients who have experienced multiple episodes of LGIB without
a known source or diagnosis should undergo elective mesenteric
angiography, upper and lower endoscopy, Meckel scanning, upper
gastrointestinal (GI) series with small bowel, and enteroclysis.
Elective evaluation of the entire GI tract may identify uncommon
lesions and undiagnosed arteriovenous malformations (AVMs).

Routine Testing

Appropriate blood tests include a complete blood cell (CBC);

serum electrolytes levels and a coagulation profile, including
activated partial thromboplastin time (aPTT), prothrombin time
(PT), manual platelet count, and bleeding time.

Colonoscopy

In most patients with LGIB, colonoscopy is the initial diagnostic

method of choice. Colonoscopy is successfully used to identify
the origin of severe LGIB in approximately 74-82% of patients. [6
In addition to its diagnostic utility, colonoscopy offers the
opportunity for therapeutic intervention in the treatment of
vascular ectasias, diverticular bleeding, neoplastic lesions, and
ulcerative processes.
Rapid colonic lavage (orally or by nasogastric [NG] tube) clears
the intraluminal blood, clot, and stool, providing an adequate
environment for visualization of the lower GI mucosa and lesions.
Urgent colonoscopy tends to result in improved patient
outcomes. In patients who are hemodynamically stable with
moderate to severe bleeding, diagnostic urgent colonoscopy is
the test of choice, because of its higher diagnostic yield and
lower complication rate as compared with angiography. [7,8}

Actively bleeding lesions can be treated with colonoscopic thermoregulation,

epinephrine injection, photocoagulation, clip application, and a combination of
these various methods.[9]
Incidentally discovered lesions should be left alone
Candidate screening criteria
Candidates for urgent colonoscopy should be properly screened and include
patients who are hemodynamically stable with no ongoing brisk bleeding,
because the diagnostic yield is lowered in such patient populations.
Thus, the best candidates for urgent colonoscopic evaluation are patients who
are bleeding slowly or who have already stopped bleeding.
The bowel should be well prepared, with a rapid oral purge (or via NG tube in
selected patients), because performing an urgent colonoscopy on an unprepared
bowel is difficult and frequently unsuccessful.
Alternatively, emergent/immediate unprepared hydroflush colonoscopy can be
performed in a patient in the intensive care unit with ongoing active severe LGIB.
[10]

The bowel preparation does not reactivate or increase the rate of bleeding.
In cases of suspected perforation or obstruction, plain abdominal radiography
should be performed before colonoscopy to rule out these complications.

Advantages and disadvantages of colonoscopy

The advantages of colonoscopy include the following:
(1)A bleeding lesion is localized in about 50-70% of patients.
(2) Definitive treatment, such as thermoregulation, epinephrine injection
therapy, clip application, or laser photocoagulation, is possible during the
procedure.
(3) Massively bleeding lesions that have stopped hemorrhaging are identified
more often with colonoscopy than with angiography.
The disadvantages of colonoscopy include the following:
(2)Urgent or emergent colonoscopy must be performed by skilled endoscopists.
(2) Urgent colonoscopy requires a bowel preparation that can cause a 4- to 6hour delay.
(3) Emergent unprepared hydroflush colonoscopy requires several 1 L of tap
water enemas and a 1-hour delay.
(4) A perforation during the examination is possible, particularly in a patient
who is ill.
(5) Colonoscopy carries the risks of sedation for patients who are acutely
bleeding.
(6) Technical problems can make diagnosis and treatment more difficult.

Radionuclide Scanning/Nuclear Scintigraphy

The role of radionuclide scanning, or nuclear scintigraphic imaging, in

the diagnosis and treatment of patients who present with LGIB remains
controversial.
Radionuclide scans include the technetium-99 ( 99 Tc) sulfur colloid scan
and the99m Tc pertechnetatelabeled autologous red blood cell scan
(TRBC scan), as well as indium-111 ( 111 In)labeled RBC scintigraphy.
Nuclear scintigraphy is a sensitive diagnostic tool (86%) and can
detect hemorrhage at rates as low as 0.1 mL/min (0.1-0.5 mL/min), as
opposed to angiography, which detects bleeding at rates of 1-1.5
mL/min.
This technique is reportedly 10 times more sensitive than mesenteric
angiography in detecting ongoing bleeding, but it suffers from a low
specificity (50%) compared with endoscopy or angiography due to its
limited resolution; this has led many investigators to recommend that
scintigraphic imaging be used primarily as a screening examination to
select patients for mesenteric angiography

Angiography
Angiography is performed when active bleeding that precludes
colonoscopy occurs and after colonoscopy has failed to identify
a bleeding site.
Selective mesenteric angiography can detect bleeding at a rate
of more than 0.5 mL/min.
In a patient with active GI bleeding, the radiologist first
cannulates the superior mesenteric artery, because most of the
hemodynamically significant bleeding originates in the right
colon. The extravasation of contrast material indicates a
positive study finding.
If the findings from the study are negative, the inferior
mesenteric artery is cannulated, followed by the celiac artery.

Diverticula, angiodysplasia, and intestinal varices can be

visualized by angiography.
The characteristic angiographic findings of colonic
angiodysplasias are clusters of small arteries, accumulation of
contrast media in vascular tufts, early opacification, and
persistent opacification due to the late emptying of the draining
veins.
Once the bleeding point is identified, angiography offers
potential treatment options, such as selective vasopressin drip
and embolization.

Emergency angiography

Emergency angiography as an initial study is indicated in a

highly selected group of patients with massive ongoing LGIB.
Two criteria are used to triage patients for emergency
angiography[11] : at least 4 units of blood transfusion in the first 2
hours following hospital admission and systolic blood pressure
of less than 100 mm Hg with aggressive resuscitation.
bleeding can be localized in 72% of patients.
Vasopressin infusion was successful in 91%; however, 50%
experienced bleeding following cessation of the vasopressin
infusion.[11]

Advantages and disadvantages of angiography

The advantages of angiography include:

(1)This modality provides accurate localization of the bleeding.
(2) It has a therapeutic utility that includes the use of
vasopressin infusion or embolization.
(3) It does not require preparation of the bowel.
The disadvantages of angiography include.
(2)It has a sensitivity of approximately 30-47%.
(2) It can only be performed during active bleeding.
(3) It has a complication rate of about 9%.
Such complications include thrombosis, embolization, and renal
failure.[26]

Barium Enema

Double-contrast barium enema examinations can be justified

only for elective evaluation of previous unexplained LGIB.
Do not use barium enema examination in the acute hemorrhage
phase, because it makes subsequent diagnostic evaluations,
including angiography and colonoscopy, impossible

Esophagogastroduodenoscopy

An esophagogastroduodenoscopy (EGD) is performed if a

nasogastric (NG) tube aspirate is positive for blood, because
about 10% of patients presenting with LGIB have bleeding
originating from the upper GI tract.
Small bowel endoscopic procedures are usually performed after
EGD, colonoscopy, radionuclide scans, and angiography have
been used and the bleeding site not localized.
If the nasogastric tube (NG) tube aspirate reveals bile, Upper GI
bleeding is practically excluded.
There may be a role for EGD in a small group of patients who
has both hemoglobin- and bile-negative NG tube aspirates.

Conclusion

MAN
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MEN
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Approach Considerations

The management of LGIB has 3 components, as follows:

1-Resuscitation and initial assessment.
2-Localization of the bleeding site.
3-Therapeutic intervention to stop bleeding at the site.
With advances in diagnostic and therapeutic endoscopy and
angiography, the ability to localize and subsequently treat lower
gastrointestinal bleeding (LGIB) has resulted in improved patient
outcomes and reduced healthcare costs.
The need for surgery also has been significantly reduced.

Initial resuscitation
Regardless of the level of the bleeding, one of the most important elements
of the management of patients with massive UGIB or LGIB is the.
These patients should receive:
Two large-bore intravenous (IV) catheters.
Isotonic crystalloid infusions.
Meanwhile, rapid assessment of vital signs, including heart rate, systolic
blood pressure, pulse pressure, and urine output, should be performed.
Orthostatic hypotension (ie, a blood pressure fall of >10 mm Hg) is usually
indicative of blood loss of more than 1000 mL.
A hematocrit level of less than 18% or a decrease of about 6% is indicative
of significant blood loss that requires blood transfusions; the goal is to
achieve a target hematocrit level of approximately 20-25% in young
patients and a target hematocrit level of around 30% in high-risk, older
patients.
A coagulopathy, such as an international normalized ratio (INR) of greater
than 1.5, may require correction with fresh frozen plasma;
thrombocytopenia can be corrected with platelet transfusions.

Transfer to ICU

Patients who require admission to the intensive care unit and

early involvement of both a gastroenterologist and a surgeon
include the following:
Patients in shock.
Patients with continuous active bleeding.
Patients at high risk, such as patients with serious
comorbidities, those needing multiple blood transfusions, or
those with an acute abdomen .

Localization of the Bleeding Site

In about 10% of patients presenting with LGIB, the source of

bleeding is from the upper gastrointestinal (GI) tract.
Some patients with LGIB should have a nasogastric (NG) tube
placed, and if the aspirate or lavage does not show any blood or
coffee groundappearing material but dose show bile, bleeding
originating from the upper GI tract is unlikely.
In case of high suspicion, obtain an
esophagogastroduodenoscopy (EGD) evaluation (see
Esophagogastroduodenoscopy).

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Vasoconstrictive Therapy

In patients in whom the bleeding site cannot be determined

based on colonoscopy and in patients with active, brisk LGIB.
Initially, vasoconstrictive agents, such as vasopressin (Pitressin),
can be used.
Although epinephrine and propranolol drastically reduced
mesenteric blood flow, they also caused a rebound increase in
blood flow and recurrent bleeding.
Vasopressin is a pituitary hormone that causes severe
vasoconstriction in the splanchnic bed.
Vasoconstriction reduces the blood flow and facilitates
hemostatic plug formation in the bleeding vessel.
Vasopressin infusions are more effective in diverticular bleeding,
which is arterial, as opposed to angiodysplastic bleeding, which
is of the venocapillary type.

The results are less than satisfactory in patients with severe

atherosclerosis and coagulopathy.
Intra-arterial vasopressin infusions begin at a rate of 0.2 U/min,
with repeat angiography performed after 20 minutes.
The bleeding stops in about 91% of patients receiving intraarterial vasopressin but recurs in up to 50% of patients when
the infusion is stopped.[38]
If bleeding persists, the rate of the infusion is increased to 0.40.6 U/min. Once the bleeding is controlled, the infusion is
continued in an intensive care setting for 12-48 hours and then
tapered over the next 24 hours.
In patients with rebleeding, surgery should be considered

Complications

During vasopressin infusion, monitor patients for recurrent

hemorrhage, myocardial ischemia, arrhythmias, hypertension,
and volume overload with hyponatremia.
Nitroglycerine paste or drip can be used to overcome cardiac
complications.
Selective mesenteric infusion induces bowel wall contraction
and spasms, which should not be confused with bowel wall
ischemia. Do not administer vasopressin into systemic
circulation intravenously, because this causes coronary
vasoconstriction, diminished cardiac output, and tachyphylaxis.
Vasopressin infusions are contraindicated in patients with
severe coronary artery disease and peripheral artery disease.

Superselective Embolization

Embolization with agents such as gelatin sponge, polyvinyl

alcohol, and oxidized cellulose.
Embolization involves superselective catheterization of the
bleeding vessel to minimize necrosis, the most feared
complication of ischemic colitis.
This therapeutic modality is useful in patients in whom
vasopressin is unsuccessful or contraindicated.
COMPLICATIONS
Intestinal ischemia and infarction have also been reported.
To prevent this complication, perform embolization as close as
possible to the bleeding point in the terminal mural arteries.

Endoscopic Therapies

Endoscopic control of bleeding can be achieved using thermal

modalities or sclerosing agents.
Absolute alcohol, morrhuate sodium, and sodium tetradecyl
sulfate can be used for sclerotherapy of upper and lower GI
lesions.
Endoscopic epinephrine injection is used commonly because of its
low cost, easy accessibility, and low risk of complications
Endoscopic thermal modalities (eg, laser photocoagulation,
electrocoagulation, heater probe) can also be used to arrest
hemorrhage.
Endoscopic control of hemorrhage is suitable for GI polyps and
cancers, arteriovenous malformations, mucosal lesions,
postpolypectomy hemorrhage, and colonic and rectal varices.
Postpolypectomy hemorrhage can be managed by
electrocoagulation of the polypectomy site bleeding with either
snare or hot biopsy forceps or by epinephrine injection.

Emergent Surgery

Emergency surgery is required in about 10-25% of patients with

lower gastrointestinal bleeding (LGIB) in whom nonoperative
management is unsuccessful or unavailable.[13]
Surgical indications
The indications for surgery include the following[14, 6] :
1- Persistent hemodynamic instability with active bleeding.
2- Persistent, recurrent bleeding.
3- Transfusion of more than 4 units packed red bloods cells in a
24-hour period, with active or recurrent bleeding.
No contraindications exist with regard to surgery in
hemodynamically unstable patients with active bleeding.
In fact, if the patient is hemodynamically unstable because of
ongoing hemorrhage, perform an emergency operation before
any diagnostic study.

Segmental bowel resection and subtotal colectomy

Segmental bowel resection following precise localization of the bleeding

point is a well-accepted surgical practice in hemodynamically stable
patients.
Subtotal colectomy which is resection of part of the colon or a resection of
all of the colon without complete resection of the rectum is the procedure
of choice in patients who are actively bleeding from an unknown source.
According to the 2008 SIGN guideline, subtotal colectomy is
recommended for the management of colonic hemorrhage that is
uncontrolled by other procedures.[15]
In patients undergoing emergency laparotomy, every attempt should be
made to localize the bleeding intraoperatively, because a segmental
colectomy bleeder is preferred.
Right hemicolectomy and left hemicolectomy refer to the resection of
the ascending colon (right) and the descending colon (left), respectively.
When part of the transverse colon is also resected, it may be referred to
as an extended hemicolectomy.

Definitive management for specific conditions

Anorectal causes:
Most can be controlled by local measures, such as injection, coagulation, or packing.
Acute colitis:
IV or PO metronidazole if thought to be infective until organism identified.
IV hydrocortisone 100mg qds if thought to be ulcerative or Crohns
colitis.
Surgery may be necessary whatever the aetiology if bleeding persists
(subtotal colectomy and ileostomy formation).
Diverticular disease:
IV antibiotics (cefuroxime 750mg tds + metronidazole 500mg tds).
Angiographic embolization if bleeding fails to stop and patient not critically unstable
for time in radiology.
Surgery is high risk, but may be unavoidable. If the location is known, a directed
hemicolectomy may be performed (on-table colonoscopy
may be used). If not, a subtotal colectomy is safest.
Angiodysplasia:
Colonoscopic therapy (injection, heater probe, APC) is ideal.
Angiographic embolization may be possible.
Right hemicolectomy is occasionally unavoidable.

Comp
licatio
ns Of
LGIT
B

Complications Of Blood Transfusion

Complications of blood transfusions can be summarized as :
1-Acute Hemolytic reactions.
2-Delayed inreavascular hemolytic reactions.
3-Nonhemolytic febrile reactions.
4-Infectious diseases transmission.
5- TRALI.
5-Complications related to massive blood transfusions are
hypothermia, hypocalcemia, hyperkalemia, dilutional
thrombocytopenia, and coagulation factor deficiencies.

Early postoperative
complications
The most common are:
1-Intra-abdominal or anastomotic bleeding.
2-Ileus, mechanical small bowel obstruction (SBO).
3-Intra-abdominal sepsis.
4-localized or generalized peritonitis, wound infection and/or
dehiscence, Clostridium difficile colitis.
5-Pneumonia.
6-Urinary retention.
7-Urinary tract infection (UTI).
8-Deep venous thrombosis (DVT), and pulmonary embolus (PE).

Complications
Intra-abdominal sepsis following colorectal surgery is a lifethreatening complication and requires aggressive resuscitation.
Systemic conditions (eg, severe blood loss and shock, poor
bowel preparation, irradiation, diabetes, malnutrition,
hypoalbuminemia) may adversely affect anastomotic healing.
Changes in anatomy and physiology of the large bowel, high
bacterial content, improper operative technique, tension, and
ischemia can cause anastomotic leak associated with abscess
and intra-abdominal sepsis.
This condition requires either laparotomy (if the sepsis is
generalized) or percutaneous drainage (if the sepsis is
localized).

Delayed complications
Usually occur more than 1 week after surgery, the most common of
which are:
Anastomotic stricture.
Incisional hernia.
Incontinence.

Prognosis
LGIB ranges from trivial hematochezia to massive hemorrhage with
shock and accounts for up to 24% of all cases of GI bleeding.
This condition is associated with significant morbidity and mortality
(10-20%).
Patients of advanced age and patients with comorbid conditions are
at greatest risk.
Identification of the bleeding point is the most important initial step
in treatment; once the bleeding point is localized, the treatment
options are straightforward and curative.

BLEEDING
HISTORY
18 month old boy presents soon after passing a large amount of dark
blood per rectum.
During the preceding two days, he had passed dark red, jelly stool
several times.
No other symptoms were present apart from the fact that he had
been lethargic for the past 24 hrs.
His birth, family and medical histories are unremarcable.
EXAMINATION
Pale, wt, height, HC at 50th percentile, pulse is 140bpm, BP is 90/50
mmHg, CRT: 3 sec.
ABDOMEN:
Not distended, no tenderness, no palpable masses or inguinal hernias
Small amount of red blood present in the diaper
Heart ; no murmurs ..
Lung: clear

WHAT DO YOU WANT

TO DO..?

1- FBC:
WBC: 7.000/mm3
Hb is low 9,6 g/dl
HCT: 31%
Plt : 320,000/mm3
2- Clotting profile:
NORMAL
3- colonoscopy xxxxxxxx large amount of blood is present which
prevent visualization of the walls.
4- Tc 99m pertechnate scan:
An area of focal uptake is seen in he right lower quadrant of the
abdomen, it appear as the same time as gastric activity

Management
IV fluids .
Prophylactic antibiotics
Urgent surgery

Diagnosis and reasoning

This child has presented with acute rectal bleeding.
Examination reveals tachycardia and a delayed capillary refill time,
but a normal blood pressure.
These findings are suggestive of grade II hypovolemic shock.
Thus, the first priority is resuscitation and stabilization (similar to any
other emergency presentation).
Once he is hemodynamically stable, the next step is to determine the
cause of bleeding.
The history yields several important clues in this regard - the first of
which is the appearance of the blood.
Upper gastrointestinal (GI) bleeding (i.e. duodenum and above)
typically gives rise to malena, due to digestion of the blood in the
small intestine.

Bleeding from the terminal GI tract (i.e. from the sigmoid colon
onwards) typically results in passage of bright red blood.
Bleeding in-between these extremes (i.e. in the small bowel and
proximal colon) typically results in passage of altered blood - which is
dark red in color (as in this patient).
In a child of 18 months, the small bowel and colonic pathologies
which may potentially give rise to bleeding are Meckel's diverticulum,
vascular malformations, colonic polyps and intussusception.

In addition, bleeding disorders (such as acquired thrombocytopenias)

may also result in bleeding
into any part of the bowel.
The second clue in the history is the nature of the stools.
Dark red, jelly like stools are characteristically associated with
intussusception, but may also occur in Meckel's diverticulum.
Note that intussusception is very unlikely to cause this degree of
bleeding, and there are no clinical findings suggestive of intestinal
obstruction.
While his full blood count shows a reduction in the hemoglobin level,
this should not be used to guide management. as it does not reflect
the severity of acute bleeding.

In addition, his clotting profile and platelet counts are normal, virtually ruling
out a bleeding disorder.
As Meckel's diverticulum is the probable diagnosis, a Technetium 99m
pertechnate scan (Meckel's scan) is probably the next best step - and in this
patient demonstrates the presence of ectopic gastric tissue, clinching the
diagnosis.
Note that colonoscopy is of little diagnostic value during acute bleeding.
Severe bleeding is an indication for surgery in these patients.
After adqeuate resuscitation, he should be taken to the operating theatre
for a Meckel diverticulectomy.
As this is a clean-contaminated surgery, prophylactic antibiotics should be
administered peri-operatively.
An air enema would be indicated if he was diagnosed with intussusception.

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