Lower Gastrointestinal Bleeding (LGIB)

Background
Lower gastrointestinal (GI) hemorrhage is defined as
bleeding from the bowel distal to the ligament of
Treitz

During recent years, colonoscopy has emerged as

the procedure of choice, but angiography still
remains the best option in a patient in unstable
condition
 Lower Gastrointestinal Bleeding (LGIB)

Background
In cases in which colonoscopy is unsuccessful:
scanning during episodes of bleeding and
arteriography
are considered to be next imaging tests to
determine the cause of the bleeding

Arteriography also provides therapeutic options

 Lower Gastrointestinal Bleeding (LGIB)
Pathophysiology
The causes of acute lower GI bleeding include:
Diverticulosis

Angiodysplasia

Colon cancer

Colitis including:
infectious
ischemic or
radiation-induced forms
 Lower Gastrointestinal Bleeding (LGIB)
Pathophysiology
The causes of acute lower GI bleeding include:

Inflammatory bowel disease (IBD)

Polyps

Meckel diverticulum and

aortoenteric fistula
 Lower Gastrointestinal Bleeding (LGIB)

Pathophysiology
Hemorrhoids are probably the most common
cause of lower GI bleeding, but:
* they usually do not pose difficulties in the
diagnosis and
* they rarely cause massive bleeding
 Lower Gastrointestinal Bleeding (LGIB)

Pathophysiology
Similarly, anorectal fissures can bleed, but again,
these are easily diagnosed on the basis of the:
* history and
* clinical findings
 Lower Gastrointestinal Bleeding (LGIB)
Pathophysiology
Lower GI bleeding appears as the passage of bright
red blood per rectum

In about 10-15% of cases, the cause may be

proximal to the ligament of Treitz

In these cases, nasogastric tube placement is

frequently needed to confirm that the upper GI tract is
the source of the bleeding
 Lower Gastrointestinal Bleeding (LGIB)

Pathophysiology
The most common cause of lower GI bleeding
involves the ► colonic diverticula

Diverticulosis has been implicated as the source of

bleeding in as many as 60% of cases of lower GI
bleeding
 Lower Gastrointestinal Bleeding (LGIB)

Pathophysiology
The diverticula are more prevalent in the left or sigmoid colon,
but positive arteriographic findings for bleeding localizes the
bleeding to the right colon in 60% of cases

Angiodysplasia has an incidence of 1-2%

Pathophysiology
Other causes of lower GI bleeding include:
neoplasia, such as a:
polyp or
carcinoma
Significant bleeding can also occur in about 2-4% of
cases

Inflammatory bowel disease and other types of

colitis account for as many as 30% of cases of
acute lower intestinal bleeding
 Lower Gastrointestinal Bleeding (LGIB)
Pathophysiology
Less frequent causes of acute colorectal
bleeding include:
solitary rectal ulcer

portal colopathy

Dieulafoy lesions of the colon

endometriosis and

colonic varices
 Lower Gastrointestinal Bleeding (LGIB)
Pathophysiology
An association with various systemic diseases
has been described; these diseases include:

Aortic stenosis
von Willebrand disease
Chronic obstructive pulmonary disease (COPD)
Cirrhosis
Chronic renal disease and
Collagen vascular disease
 Common Causes of Lower GI Hemorrhage in
Children and Adolescents:
In Adults:
Diverticular Diseases (60%)
Diverticulosis/diverticulitis of small intestine
Diverticulosis/diverticulitis of colon

IBD: 13%
*Crohn disease of small bowel, colon, or both
*Ulcerative colitis
*Noninfectious gastroenteritis and
*Colitis
 Common Causes of Lower GI Hemorrhage in
Children and Adolescents:
In Adults:
Benign anorectal diseases (11%)
Hemorrhoids
Anal fissure
Fistula-in-ano
Neoplasia (9%)
Malignant neoplasia of small intestine
Malignant neoplasia of colon, rectum, and anus
Coagulopathy (4%)
Arteriovenous malformations (AVM) (3%)
 Common Causes of Lower GI
Hemorrhage in Children and Adolescents:
In Children and Adolescents:
Intussusception
Polyps and polyposis syndromes
Juvenile polyps and polyposis
Familial adenomatous polyposis (FAP)
IBD
Crohn disease
Ulcerative colitis
Indeterminate colitis
Meckel diverticulum
 Lower Gastrointestinal Bleeding (LGIB)

Pathophysiology
Lower GI bleeding is classified under 3 groups
according to the amount of bleeding:
1) Massive bleeding
2) Moderate Bleeding
3) Occult Bleeding
 Lower Gastrointestinal Bleeding (LGIB)
Pathophysiology
Patients with massive hemorrhage present with a
systolic blood pressure of less than 90 mm Hg and a
hemoglobin level of 6 g/dL or less

These patients are usually:

aged 65 years and older
have multiple medical problems, and
are at risk of death from:
acute hemorrhage or
its complications
 Lower Gastrointestinal Bleeding (LGIB)

Pathophysiology
Therefore, the overall mortality rate for massive lower GI
hemorrhage ranges from 0-21%

Occult bleeding manifests as:

microcytic hypochromic anemia and
intermittent guaiac reaction
Pathophysiology
Definition of massive lower GI bleeding:
Passage of a large volume of red or maroon blood
through the rectum

Hemodynamic instability and shock

Initial decrease in hematocrit (HCT) level of 6 g/dL or less

Transfusion of at least 2 units of packed RBCs

bleeding that continues for 3 days

significant rebleeding in 1 week

Frequency
The incidence of lower GI bleeding is essentially
unknown

Although lower GI bleeding is common, most patients do

not require hospital admission
Clinical Presentation
Massive lower GI bleeding is a life-threatening
condition

Although massive lower GI bleeding manifests as

maroon stools or bright red blood from the rectum,
patients with massive upper GI bleeding may also
present with similar findings
Clinical Presentation
Regardless of the level of the bleeding, one of the
most important elements of the management of
patients with:
massive upper or
lower GI bleeding
is the initial resuscitation

These patients should receive 2 large-bore

intravenous catheters and isotonic crystalloid
infusions
Clinical Presentation

Meanwhile, rapid assessment of vital signs, including:

heart rate

systolic blood pressure

pulse pressure and

urine output
► should be performed
Clinical Presentation
Orthostatic hypotension (i.e. a blood pressure fall of
>10 mm Hg) is usually ► indicative of blood loss of
more than 1000 mL
Clinical Presentation
History
Document prior episodes of GI bleeding as well as:
significant medical history and
prior medications
including:
peptic ulcer disease, liver disease, cirrhosis,
coagulopathy, IBDs

And use of:

NSAIDs and/or
Warfarin
Clinical Presentation
History
Symptoms are also important in identifying the
source of bleeding

The symptoms of young patients with:

abdominal pain
rectal bleeding
diarrhea and
mucous discharge
► may be associated with IBD
History
symptoms of elderly patients with:
abdominal pain
rectal bleeding and
diarrhea
►can be associated with ischemic colitis
History
symptoms of elderly patients with:

stools streaked with blood

perianal pain and

blood drops on the toilet paper or in the toilet bowl

► may be associated with perianal pathology, such as:

anal fissure or
hemorrhoidal bleeding
Physical Examination
► The physical examination must include careful
inspection and examination of the:
oropharynx
nasopharynx
abdomen
perineum and
anal canal
Physical Examination
Nasogastric aspirates usually correlate well with
upper gastric hemorrhage proximal to the Treitz
ligamentum

Therefore, insert a nasogastric tube to confirm the

presence or absence of blood in the stomach
Physical Examination
If necessary, perform gastric lavage with warm
isotonic fluids to obtain bilious discharge from the
nasogastric tube to exclude any upper GI bleeding
beyond the pylorus
Physical Examination
Remember
Nasogastric tube aspirates can provide false-negative results in approximately
50% of cases

If the aspirate contains ► no bile or

if the ► bleeding is intermittent ▼

These patients eventually need esophagogastroduodenoscopy (EGD) to obtain

a more specific evaluation of the upper GI tract
Physical Examination
►Place a Foley catheter to monitor urine output

Careful digital rectal examination

Anoscopy and

Rigid proctosigmoidoscopy;

► should exclude an anorectal source of bleeding

• IIlustration: Anoscope and Foley Catheter
Workup
Lab Studies
Appropriate blood tests include:
CBC
serum electrolytes (sequential multiple analysis 7 [SMA7])

and coagulation profile, including:

aPTT
PT
Workup
Imaging Studies
►The sensitivity of the 99mTc-labeled RBC scintigraphy is reportedly
20-95%

► The value of mesenteric emergency angiography in the:

* diagnosis and
* management of lower GI bleeding
has been well established
Workup
Imaging Studies

► Helical CT scan of the:

abdomen and
pelvis
can also be used when routine workup fails to determine the
cause of active GI bleeding
Workup
Imaging Studies
Other Tests
Double-contrast barium enema examinations can
be justified only for elective evaluation of
unexplained lower GI bleeding
Diagnostic Procedures

Colonoscopy has an important role in the diagnosis

and treatment of lower GI bleeding

Rapid colonic lavage with GoLYTELY clears the

intraluminal
blood
clot and
stool
►providing an adequate environment for visualization
of the lower GI mucosa and lesions
TREATMENT
Medical therapy
1. Vasocontrictive agents
such as vasopressin (Pitressin), can be used
2. Superselective embolization
3. Endoscopic coagulation

Surgical Therapy
THANKS