Lower Gastro-

Intestinal Bleeding
 Division Of Upper And Lower Gastrointestinal Tract

Bleeding above DJ junction

Upper Gastrointestinal Bleeding
Ligament of Treitz
Bleeding below DJ junction
Lower Gastrointestinal Bleeding

Ligament of Treitz is used as

demarcation point
 TYPES OF BLEEDING

Occult Bleeding Moderate Bleeding Massive Bleeding

-Can affect any age -Can affect any age -Usually affects older
age group (>65)
- Present with - Present with
microcytic malaena or - Present with
hypochromic anemia hematochezia hematochezia/bright
due to occult blood red per rectum
loss -Hemodynamically
stable -Hemodynamically
-Hemodynamically unstable with signs of
stable hypovolemic shock
 Differential Diagnoses

Colon
Small Intestine -Diverticular
-Meckel Disease
Diverticulum -Angiodysplasia
-Intussusception -Tumour/Polyps
-Colitis
-IBD

Rectum Anus
-Tumour -Hemorrhoids
-Polyps -Anal fissure
-Proctitis -Anal fistula
-Rectal Ulcer -Perianal hematoma
-Rectal Prolapse
 History Taking
1. Demographic Data:-

Age - Children 3 months old to 5 y.o: Intussusception

- 15 35 y.o : Inflammatory Bowel Disease (IBD)
- Elderly : Diverticular diseases, neoplasm
2. Per Rectal Bleeding :-

Color of blood: Fresh blood (distal part of GIT) vs Malena (proximal

GIT)
Pain: Fissure, Rectal ulcer
Painless : Hemorrhoid, Malignancy, Diverticular disease
Amount: to assess the severity of bleeding - dribbling vs profuse
Relations to defecation
Blood alone Diverticular disease
Mix with stool Colon ca
After defecation Hemorrhoids
Mix blood with mucus Colitis
3. Other relevant history :-
History of trauma to the abdomen
Radiation
Drug history: especially anti-platelet or anti-coagulant
Smoking
Alcohol
Sexual abuse
Principal of Management

Priorities are:
1. Stabilize the patient
2. Identify source of bleeding
3. Definitive treatment of the cause
Initial assessment ABCDE

1. Resuscitation
- Supplemental O2
- 2 large bore branulas
- CBD
- Blood Ix
- Assess degree of shock
- Fluid resuscitation ( colloid/crystalloid/blood products )
- Correction of coagulopathy
2. Stop bleeding
3. Treat underlying cause
 Hemorrhoids
Enlarged and prolapsed anal cushions
Degeneration of supporting fibroelastic tissue and
smooth muscle
Enlargement & protrusion at 3, 7, 11 oclock position

Risk factor:
Constipation / Prolonged straining
Pregnancy
Portal hypertension
Anorectal varices
Clinical features:
Painless rectal bleeding (bright red, dripping/splashing
on pan/wiping/separated from the stool)
Aching/dragging discomfort on defecation
Pruritus (irritation of perianal skin if constant prolapse)

Examination:
Digital rectal examination: inspect for anal
tags/prolapsed/lumps/bleeding, ask patient to strain to
look for protruded mass, assess sphincter tone &
exclude other anal conditions
Proctoscopy: 1st and 2nd degree piles are rarely palpable
as they compress on pressure, hence diagnosed by
protoscopy.
Sigmoidoscopy: rule out other higher lesion in rectum
GRADE SYMPTOMS AND SIGNS MANAGEMENT
I Confined within anal canal, Dietary modifications
minimal bleeding but do Avoid constipation/straining
not prolapsed

II Prolapsed during Rubber band ligation

defecation;
reduced spontaneously

III Prolapsed with or without Surgical hemorrhoidectomy

straining, require manual Rubber band ligation
reduction
IV Irreducibly prolapsed Surgical hemorrhoidectomy
Conservative management
Encourage high fiber diet and adequate fluid intake
Dafflon regime: 1g TDS 4/7, then BD 3/7, then OD
1/52
Syrup lactulose/stool softener
Excision of thrombosed hemorrhoids
 Diverticular Disease
Diverticulae : Outpouchings of mucosa
through bowel wall

Occur between taenia coli where vessels

penetrate the bowel wall

Most common site : sigmoid colon ( high

intraluminal pressure )
 Asymptomatic ( diverticulosis )

Complications :
1. Diverticulitis - LIF pain
2. Intestinal obstruction
3. Massive bleeding
4. Perforation peritonitis
5. Fistula formation ( vesicocolic )
Investigations :
FBC haemoglobin, leucocytosis
Colonoscopy exclude Ca
Barium enema saw tooth appearance
( not in diverticulitis cause perforation )
Treatment :
Diverticulosis : High fibre diet, bed rest, anti-
spasmotic
Diverticulitis : bed rest, IV antibiotics
Abscess : surgical resection with abscess
drainage
Perforation : IV antibiotics, resuscitation due to
septic shock, surgical resection and peritoneal
lavage
Fistula : surgical resection and repair of bladder
Haemorrhage : embolize with gel foam
 Anal Fissure
Painful linear track/crack at the distal anal canal
-Short term ( involved only epithelium)
-Long term ( involved full thickness of anal
mucosa)
Cause by trauma to the inner lining of anus
- hard,dry,frequent bowel movement
- tight bowel sphincters
Symptoms : bright red blood on stool or toilet paper,
sharp pain when passing stools
 Features of chronic anal fissure:
Sentinel skin tag
Hypertrophied anal papilla

Management :
a) Non-surgical treatment
High fiber diet, stool softener, medications (diltiazem,
nitroglycerine, botulinum toxoid injection- relax
sphincter muscle)
b) Surgical management
Internal anal sphincterotomy
 Anal fistula
Abnormal communication connecting the
primary opening inside anal canal to a
secondary opening in the perineal skin.
Symptoms: ( anorectal pain, perianal cellulitis,
swelling, fever)- abscess, drainage, irritation at
perianal skin, rectal bleeding
Conditions associated with multiple anal
fistulas : Crohns disease, Tuberculosis
 Goodsalls law ( transverse line passing through
ischial spine, external openings of fistula tract within
3cm of anal verge)

-Anterior : straight tract

-Posterior : Curvilinear
Internal opening in posterior
midline ( level of dentate line )
- Tracts closer to anal verge : simpler, shorter
- Tracts further away : transphincteric, long, high
tracts
Goodsalls law
 Parks Classification
Type
1) Intersphincteric
- common ( 70%)
- internal sphincter>
intersphincteric space
>perineum
- high blind tract, high tract to
lower rectum or pelvis
2) Transphincteric
- internal,external
sphincter>ischiorectal
fossa>perineum ( low tract )
- high blind tract, high tract with
perineal opening
Type
3) Suprasphincteric
- intersphincteric
space>puborectalis
muscle>ischiorectal
fossa>perineum

4) Extrasphincteric
- perianal skin through levator ani
muscle to rectal wall ( completely
outside sphincter mechanism)
 Investigations :
a) Endoanal ultrasound-course of fistula
b) MRI visualise entire pelvis
c) CT/fistulography- complex fistula
 Management :

a) Simple fistula ( ASCRS )

- single, non-recurrent, crosses<30% of external
sphincter, not anterior fistula in women, absence of
history ( impaired continence, Crohns disease, pelvic
irradiation)
- Fistulotomy

b) Complex fistula
- Seton placement, Fibrin glue, endoanal or
endorectal advancement flaps.
INFLAMMATORY BOWEL DISEASE
Epidemiology
Affects young, 2nd & 3rd decades
Equal gender predominance
Genetic association

History

Crohns ds Ulcerative colitis

Patients often thin and may be
malnourished due to intestinal
malabsorption of nutrients
Diarrhea- only sometimes with
blood
Abdominal mass common
Remission achieved with
enteral feed followed by
exclusion diet
Weight loss usually related to
the severity of active disease
Often presented with bloody
diarrhea
Mass rarely present
Unaffected by diet

Strongly associated with Associated with non-smokers

smoking or ex-smokers
Physical examination:
Usually normal +/- extra-intestinal manifestation.
Extraintestinal : clubbing, oral ulcer, erythema nodosum,
pyoderma gangrenosum, conjunctivitis/episcleritis/iritis,
arthritis/sacroilitis/AS, fatty liver
 Crohns disease Ulcerative colitis
Bowel Chronic relapsing Diffuse inflammatory d/o of
involvement inflammatory d/o of any part submucosa and mucosa of
of GIT (lips to anal) large bowel (mostly involve
rectum)
Types: -Colitis -Abscess
-Ileitis -Stricture/
-Fistula stenosis

Continuity Not continuous, with skip Longitudinal mucosal

lesion continuity

Histopathology Macroscopic : bowel is Macroscopic : granular

thick-walled & nodular
(cobblestone appearance)
with creeping fat,
mesenteric thickening &
deep linear ulcers.
appearance of mucosa, loss of
vascular markings,
pseudopolyps interspersed
with area of shallow
ulceration.
 Crohns disease
Microscopic : transmural
involvement, non-caseating
granulomas
(pathognomonic, but only
present in 2/3)
Complications Stricture, fistulae, sinuses,
malnutrition (SB
involvement), SB
obstruction, toxic dilatation,
CRC
Risk of Slight risk of CRC, risk
carcinoma of small bowel lymphoma
Associated Ab ASCA : anti-saccharomyces
Ulcerative colitis
Microscopic : only mucosal
& submucosal involvement,
ulcers, crypt abscesses
-muscularis propria & serosa
may be affected in fulminat
disease.
These complications absent.
Massive PR bleed, toxic
megacolon, venous
thrombosis, CRC++
Substantially higher risk of
CRC
Much higher risk with
concomitant PSC
p-ANCA : perinuclear
antineutrophil cystoplastic
Ab
Investigation
Supportive: -blood tests (FBC,RP,LFT,CRP,ESR, autoantibody assay)
-radiological (AXR & CXR)
Diagnostic : CD
-contrast radiographic studies (barium, CT scan)
-endoscopy (colonoscopy, OGD, endoanal u/s (EUS))
:UC
-endoscopy (flexible sigmoidoscopy with biopsy
Management
Medical
Biologics
Corticosteroid
Surgical
Preserve fx gut length to avoid short bowel syndrome (CD)
Pan-proctocolectomy (UC)
 Colon cancer
The most common GI malignancy and 2nd commonest
cause of cancer-related death in developed countries.

Risk factors:
- polyps
- personal/family history of cancer
- inflammatory bowel disease
- male gender, increasing age
- westernized diet (low fibre, high fat)
- obesity, smoking, alcohol
 Clinical Features of Colon cancer
Presentation depends on site
Left sided: more common, altered bowel habit,
hematochezia/melena, abdominal pain, tenesmus
Right sided: present later, weakness, anemia
symptoms, palpable mass, altered bowel
habit/obstruction is LATE symptom

Emergency: intestinal obstruction, perforation with

peritonitis
Macroscopic types of carcinoma of the colon
Annular - Ulcer
Tubular - Cauliflower
 Mode of spread
Direct spread
Lymphatic
Haematogenous
Transcoelemic
 Investigations
FBC: microcytic hypochromic anemia
AXR
Colonoscopy/sigmoidoscopy
Barium enema: apple core appearance short
stenosis with sharp shoulders at each end
LFT/CXR/Liver ultrasound to exclude metastases
CT of chest and abdomen for staging and
metastasis
 Management
SURGERY: elective resection with curative intent
- comprises en bloc resection of the primary tumour
and loco-regional nodes
Types of surgical resections
Right Hemicolectomy
Extended Right Hemicolectomy
Left Hemicolectomy

Adjuvant therapy: Radiotherapy, chemotherapy

Palliative therapy: for patients with local disease
relapse, hepatic or other distant metastases