Lower Gastrointestinal Bleeding (lgib)

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

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