2. Lower GIT Bleeding & Management

3. Lower GI bleed
  Lower GI Bleed
Lower gastrointestinal bleeding is defined as
abnormal hemorrhage into the lumen of the bowel
from a source distal to the ligament ofTreitz.
Originates in the portion of GIT further down the
digestive system –small intestine
--colon
--rectum
--anus

4.  more common in male > female.
This increase is largely attributable to the
various colonic disorders commonly associated
with aging (e.g., diverticulosis and
angiodysplasia).
In more than 95% of patients with lower GI bleeding,
the source of hemorrhage is the colon.

5. Categorization by pathology
and intensity
By intensity – occult where the amount of blood is
so small that it can only be detected by
laboratory testing .
 Acute mild
 Acute massive .
By pathology
Benign
 Inflammatry
 Neoplastic

6. History
 We should assess the chronicity of bleeding and
medication use .
 Particularly regarding anti coagulants such as
warfarin.
 low molecular weight heparin.
 inhibitors of platelet aggregation such as NSAID .
 clopidrogel this can associated with mesentric
ischemia
 Use of digitalis should be documented because this
can associated with mesenteric ischemia.

7. Causes of Lower Gastrointestinal
Bleeding:
Severe acute Moderate,chronic/subacute
Diverticular disease Anal disease(fissure,haemorrhoids)
angiodysplasia Inflammatory bowel disease
ischemia carcinoma
Meckel’s diverticulum Large polyps
angiodysplasia
Radiation enteritis
Solitary rectal ulcer

8. Other Causes of Severe
Hematochezia
1. Diverticulosis
2. Colon cancer or polyps
3. Colitis
4. Ischemic colitis
5. Inflammatory bowel disease (IBD)
6. Non-infectious colitis
7. Infectious colitis
8. Angioectasia
9. Postpolypectomy bleeding
10. Rectal ulcer
11. Hemorrhoids
12. Anorectal source (unspecified)
13. Radiation colitis
14. Rectal Dieulafoy’s lesions.
15. Rectal varices.

10. symptoms
 bloody bowel movements, or black, tarry stools.
Symptoms associated with blood loss can include :
 Fatigue
Weakness
 Shortness of breath
 Abdominal pain
 Pale appearance
 Bright red or maroon stool can be from either a lower GI
source or from brisk bleeding from an upper GI source.
 Long-termGI bleeding may go unnoticed or may cause
fatigue, anemia, black stools, or a positive test for
microscopic blood.

11. diagnosis
 Lower GI bleeding typically presents with
1.hematochezia(which can range from bright-
red blood to old clots.)
 2.melena (If the bleeding is slower or from a
more proximal source)
 Hemorrhage less severe
more intermittent,
commonly ceases spontaneously

12.  The diagnostic modalities for lower GI bleeding are not as
sensitive or specific in making an accurate diagnosis. .
 After resuscitation has been initiated, the first step in the
workup is to rule out anorectal bleeding is either by ;
 Anoscopy.
 Flexible sigmoidoscopy.
 nuclear scintigraphy.
 Angiography.
 CT and computed tomography colonography.
 Colonoscopy.
 Barium enema.
 MRI
 Intraoperative endoscope

13.  With significant bleeding, it is also important
to eliminate an upper GI source.
 An NG aspirate that contains bile and no
blood effectively rules out upper tract
bleeding in most patients.

16. colonoscopy
 Colonoscopy is most appropriate in the
setting of minimal to moderate bleeding;
major hemorrhage interferes significantly
with visualization, and the diagnostic yield
is low.
 in the unstable patient, sedation and
manipulation may be associated with
additional complications and can interfere
with resuscitation.

17.  Although the blood is cathartic, gentle
preparation with polyethylene glycol, either
orally or through an NG tube, can improve
visualization.
 Findings may include an actively bleeding site,
clot adherent to a focus of mucosa or a
diverticular orifice, or blood localized to a
specific colonic segment, although this can be
misleading because of retrograde peristalsis in
the colon. Polyps, cancers, and inflammatory
causes can frequently be seen

18.  angiodysplasias are often very difficult to
visualize, particularly in the unstable patient
with mesenteric vascular constriction.
 Diverticula are identified in most patients,
whether they are the source of the
hemorrhage or not.
 Despite these limitations, recent studies
report that colonoscopy is successful in
identifying the bleeding source in up to 95% of
patients

19. Diverticulosis, Diverticulitis

20. Colonic Polyps,malignancy

21. Hemorrhoids

22. Radionuclide Scanning
 These are helpful in identifying the sites of
ongoing bleeding .
 The scan are more sensitive than
angiogram in detecting less rapid bleeding
rate .1-.5 ml / min .
 Radionuclide scanning with technetium-
99m (99mTc)-labeled RBCs is the most
sensitive .

23.  It have a advantage of repeating the scan up
to 24 hrs . After initial scan .
 This is particularly helpful in in those pt whose
have a slow bleeding in whom initial scan may
not demonstrate any source of bleeding .
 Initially, images are collected frequently and
then at 4 hour intervals for up to 24 hours.
 The tagged RBC scan can detect bleeding as
slow as 0.1 mL/min and is reported to be more
than 90% sensitive.

25.  Active bleeding from Ascending Colon

26.  Other diagnostics procedures
CT angiogram
 mesenteric angiography
-to identifying the vascular patterns of
angiodysplasia,
-localizing actively bleeding diverticula

27. Advantages and disadvantages of common diagnostic procedures used in the evaluation of lower
gastrointestinal bleeding
Procedure Advantages Disadvantages
Colonoscopy • Therapeutic possibilities • Bowel preparation required
• Diagnostic for all sources of
bleeding
• Can be difficult to orchestrate without on -
call endoscopy facilities or staff
• Needed to confirm diagnosis in
most patients regardless of initial
testing
• Invasive
• Efficient/cost -effective
Angiography • No bowel preparation needed • Requires active bleeding at the time of the
exam
• Therapeutic possibilities • Less sensitive to venous bleeding
• May be superior for patients with
severe bleeding
• Diagnosis must be confirmed with
endoscopy/surgery
• Serious complications are possible
Radionuclide
scintigraphy
• Noninvasive • Variable accuracy (false positives)
• Sensitive to low rates of bleeding • Not therapeutic
• No bowel preparation • May delay therapeutic intervention
• Easily repeated if bleeding recurs • Diagnosis must be confirmed with
endoscopy/surgery
Flexible
sigmoidoscopy
• Diagnostic and therapeutic • Visualizes only the left colon
• Minimal bowel preparation • Colonoscopy or other test usually
necessary to rule out right -sided lesions
• Easy to perform

28. Video Capsule Endoscopy
 Capsule endoscopy uses a small capsule with a
video camera that is swallowed and acquires
video images as it passes through the GI tract.
 This modality permits visualization of the
entire GI tract, but offers no interventional
capability.
 It is also very time consuming because
someone has to watch the video to identify
the bleeding source, and then a means to deal
with the pathology has to be developed.

30. Intraoperative Endoscopy
 Intraoperative enteroscopy is reserved for
patients who have transfusion-dependent
obscure-overt bleeding in whom an
exhaustive search has failed to identify a
bleeding source.
 This typically uses a pediatric colonoscope
introduced through the mouth or through
an enterotomy in the small bowel made by
the surgeon.

31. Causes and Management

32. 1- Diverticular Disease
the most common cause of significant lower GI bleeding.
common in Western countries with frequency of 50% in older
adults. By contrast, diverticula are found in fewer than 1% of
continental African and Asian populations.
 colonic diverticula are herniations of colonic mucosa and
submucosa through the muscular layers of the colon.
Bleeding generally occurs at the neck of the diverticulum .
believed to be secondary to bleeding from the vasa
recti(small arteries) as they penetrate through the submucosa.
Of those that bleed, more than 75% stop spontaneously,
although about 10% rebleed within 1 year and almost 50%
within 10 years

33. Diverticular hemorrhage should be classified carefully based on
findings at colonoscopy, angiography, anoscopy, terminal
ileum examination, push enteroscopy (when colonoscopy
reveals diverticulosis without stigmata and no other significant
lesions seen in colon and by anoscopy)
Management:
 blood transfusion of fewer than four units of packed RBCs.
 Endoscopic Hemostasis - colonoscopic hemostasis of
actively bleeding diverticula has been reported using MPEC
cauterization, epinephrine injection(a sclerotherapy needle can
be used to inject epinephrine diluted 1:20,000 in saline),
hemoclips, fibrin glue, or combinations of epinephrine and
MPEC or hemoclips.
 Electrocautery can also be used, and most recently,
endoscopic clips have been successfully applied to control the
hemorrhage.

34. Hemostatic clip application in bleeding diverticulosis

35. If none of these maneuvers is successful or if
hemorrhage recurs—>
Angiography and surgery – angiography
embolization can be performed in selected cases of
diverticular bleeding, but with a risk of bowel
infarction, contrast reactions, and acute kidney
injury.
Surgical resection for diverticular bleeding is
rarely needed and is reserved for recurrent bleeding.
The decision to operate is best guided by
colonoscopic, angiographic, or nuclear medicine
studies.
Blind subtotal colectomy, often performed in the
past when a definite bleeding site could not be
identified, should be avoided as possible.

36. 2- Angiodysplasia/Vascular
Ectasias
 Hemorrhage secondary to angiodysplasia
accounts for up to 40% of lower GI bleeding.

Angiodysplasias of the intestine, also referred to
as arteriovenous malformations (AVMs), are
distinct from hemangiomas and true congenital
AVMs..
 They are thought to be acquired degenerative
lesions secondary to progressive dilation of
normal blood vessels within the submucosa of
the intestine.

37.  The hemorrhage tends to arise from the right
side of the colon,
-the most common location=cecum
- it can occur anywhere in the colorectum and
small bowel.
 Most patients present with
- chronic bleeding; in up to 15% of patients
-hemorrhage may be massive.
-Bleeding stops spontaneously in most cases

38.  diagnosed by = colonoscopy
=visceral angiography.
=laparotomy with on table
colonoscopy
treatment of choice : endoscopic thermal
ablation
If these measures fail or bleeding recurs and
the lesion has been localized, segmental
resection
most commonly right colectomy, is effective.

40. 3- Colorectal cancer
 Colorectal cancer
3rd commonest malignancy in UK
 M:F = 3:1 peak age 45-70yo
 Risk Factor’s:
 FH of Colorectal Ca, FAP, HNPCC,
 Prev Hx of Colon,Breast, Ovarian or Uterine Ca
 Prev Hx ofAdenomatous Polyps
 Chronic UC or Colonic Crohn’s disease
 Western diet, Obesity, Smoking
 Presentation depends on site:
 Left-sided:Altered bowel habit (constipation & diarrhoea), PR bleeding bright red coating
the stool,Tenesmus, Painful defecation? Small diameter of Left Colon Tendency towards
obstruction
 Right-sided: Present later. Weight loss, Right abdo pain/mass,Tendency to bleed, Blood
mixed in with stools, high incidence of IDA
 Emergency (40%): Obstruction, Perforation w/Peritonitis, Acute Haemorrhage

41.  Investigations:
 FBC  Microcytic hypochromic anaemia, LFTs  deranged with hepatic spread
 + Faecal occult blood
 Sigmoidoscopy/Colonoscopy + biopsy  Lesion (w/ 3-5% synchronous)
 Barium Enema may show ‘Apple core’ appearance
 CT/MRI for rectal cancers, local pelvic spread and metastasis
 Liver US  Hepatic Mets
 Raised Carcino-embryonic antigen (CEA) used for monitoring

42.  Treatment: Surgical Resection with curative intent
+/- Chemo
 Right Hemicolectomy  Caecal, Ascending,
Proximal Transverse Ca
 Left Hemicolectomy  Distal Transverse,
Descending
 Sigmoidectomy  Sigmoid Ca
 Anterior Resection  Low sigmoid/High Rectal Ca
 Abdominoperineal (A-P) Resection  Low Rectal
Tumours <8cm from Anal canal permanent
colostomy
 **Hartmann’s Carcinoma w/ Acute Obstruction
(excision, colostomy, rectal stump)
 Other options: Chemotherapy (5-FU) for Duke’s
B&C, RT, Palliation

43. 4- Anorectal Disease
 The major causes of anorectal bleeding :
1.hemorrhoids,
2.anal fissures,
3. colorectal neoplasia.
 hemorrhoids: the most common
: only 5% to 10% bleeding.
Anorectal hemorrhage is not massive and
presents as bright-red blood per rectum

44. Hemorrhoidal bleeding Anal fissure
1. Bright red
2.Occur : during/after defecation
1.Bright red bleeding
2.occur: during defecation + anal pain
3.Diagnose by : protoscopy
4.colonoscopy/barium enema
-to exclude coexisting colorectal
cancer
3.May reqiure surgery
(due to forceful straining during passage
of hard stool may cause tears)
5. age:over 40 years 4.Medically ttt: stool bulking agents
: water intake
: stool softners
: topical nitroglycerin
ointment/ diltiazem

46. 5- Colitis
 Inflammation of the colon is caused by a multitude of disease
processes.
 inflammatory bowel disease (Crohn's disease, ulcerative colitis)
 Infectious colitis .
 Ischemic colitis ;
present as painless hematochezia (results from mucosal hypoxia and
is thought to be caused by hypoperfusion of the intramural vessels of
the intestinal wall) or painful hematochezia (caused by large vessel
occlusion and has worse outcomes) with mild left-sided abdominal
discomfort.
 Radiation proctitis after treatment for pelvic malignancies, and
ischemia.

47.  Ulcerative colitis
1. much more likely than Crohn's disease to
present with GI bleeding.
2. A mucosal disease
3.starts distally in the rectum
4. progresses proximally
5.occasionally involve the entire colon.
 Patients can present with up to 20 bloody
bowel movements per day.
 These episodes are accompanied by
abdominal cramping, tenesmus, and
occasionally abdominal pain

48.  Ulcerative colitis
6.The diagnosis -careful history
-flexible lower endoscope
with biopsy.
 7. Medical therapy: steroids,
:5-aminosalicylic acid
:(ASA) compounds,
:Immunomodulatory
agents,
:supportive care
 8.Surgical therapy -is rarely indicated
(unless the patient develops a toxic megacolon or
hemorrhage that is refractory to medical
management.)

49. 6- Mesenteric Ischemia
 Mesenteric ischemia can be secondary to either acute or
chronic arterial or venous insufficiency.
 Predisposing factors -preexisting cardiovascular disease
- recent abdominal vascular surgery
-hypercoagulable states,
- medications
(vasopressors and digoxin),
-vasculitis
 Patients present with abdominal pain and bloody
diarrhea.
 CT scanning often shows a thickened bowel wall.

50.  The diagnosis: flexible endoscopy
which reveals edema, hemorrhage, and a
demarcation between the normal and abnormal
mucosa.
 Treatment :focuses on supportive care
:bowel rest,
:intravenous antibiotics,
:cardiovascular support, and
: correction of the low-flow state.
 In 85% of cases, the ischemia is self-limited and
resolves without incident, although some
patients develop a colonic stricture.

51.  15% of cases
surgery is indicated
because of- progressive ischemia
-gangrene.
During the surgery -resection of the ischemic
intestine and
-creation of an end ostomy is
indicated.

52. 7- Meckel's diverticulum
 Bleeding of the diverticulum is most common
in young children, especially in males who are
less than 2 years of age
 Symptoms : bright red blood in stools
(hematochezia), weakness,
abdominal tenderness or pain, and
even anaemia in some cases

53.  Diagnosis :
- A technetium-99m (99mTc) pertechnetate scan,
also called Meckel scan investigation of choice in
children. Colonoscopy and screenings for bleeding
disorder. Angiography can assist in determining the
location and severity of bleeding
- Capsule endoscopy and double-balloon
enteroscopy(via an oral or rectal approach).
 Treatment:
Treatment is surgical, which is small bowel resection
(with bowel complication) and simple resection
(without complication).

54. 8- Postpolypectomy bleeding
 Bleeding recurs after approximately 1% of colonoscopic
polypectomies.The bleeding occurs most commonly five to
seven days after polypectomy but can occur from 1 to 14
days after procedure;
 it generally self-limited and mild to moderate, with 50% to
75% of patients requiring blood transfusions.
 Endoscopic management techniques:
- for delayed postpolypectomy ulcer bleeding on the stigma
are found and similar to those used for peptic ulcer
hemorrhage,
- including : epinephrine injection, thermal coagulation,
hemoclip placement, and combination therapy.

55. Postpolypectomy bleeding

56. 9- Dieulafoy’s lesion of the
small intestine and rectum
 Uncommon causes of major gastrointestinal lesion
 It consists of a large caliber artery that protrudes through a
mucosal defect in the stomach causing significant and often
recurrent hemorrhaging from a pinpoint non-ulcerated arterial
lesion.
 Rectal Dieulafoy’s lesions are large submucosal arteries with
overlying mucosal ulceration that cause massive bleeding. And
it can be treated by endoscopic hemostasis.
 history of NSAID intake, peptic ulcer symptoms, or alcohol
abuse is usually absent, the condition is difficult to recognize.
 Dieulafoy lesion should be considered when evaluating any
acute and recurrent major gastrointestinal bleeding.
 If unrecognized, it may cause a life-threatening hemorrhage.
Usually, the mean hemoglobin level on admission has been
reported to be between 8.4-9.2 g/dL in various studies.

57. Diagnosis:
Awareness of the condition is a key to accurate diagnosis.
It can be easily overlooked at endoscopy as concomitant lesions
such as ulcers or varices may wrongly be considered responsible
for the bleeding episode.
Treatment:
-by endoscopic modalities like electrocoagulation and successfully
achieves permanent hemostasis in 85% of cases.
This case illustrates a rare and inherently difficult lesion to
recognize, because it presents with very low hemoglobin, which
is usually uncommon in Dieulafoy lesion, and did not have any
risk factor for gastrointestinal bleeding.
In practice, we have to consider unusual causes of common diseases
to decrease their mortality and morbidity.
-argon plasma coagulation.
-Bipolar coagulation.
-hemoclip placement.
-proton pump inhibitor therapy.

58. Actively bleeding jejunal Dieulafoy lesion
found during double-balloon enteroscopy.
Red blood pooled within a short segment of
jejunum (A).The area after water lavage,
revealing a focal area of active bleeding and a
very small protruding vascular structure (the
Dieulafoy vessel) (B). Another example of
focal active bleeding from a Dieulafoy lesion,
seen near the bottom of the endoscopic
image (C).
Non-steroidal anti-inflammatory drug-
induced jejunal ulcer (A) with a small
visible vessel (on left side of ulcer, at
approximately 8 o'clock position).The
visible vessel began bleeding
spontaneously during double-balloon
enteroscopy (B). Hemostasis was
achieved with epinephrine injection and
hemoclips placement (C).

59. 10- Blue Rubber Bleb Nevus
Syndrome
 It is a rare syndrome characterized by venous
malformations in the skin, soft tissue, and GI tract.
 Bleeding usually occurs in childhood and continues
into adulthood and results in chronic iron deficiency
requiring iron replacement and transfusions.
 Diagnosis: On endoscopy , lesions appear as large
protuberant polypoid venous bleb; they can occur
anywhere in the GIT, but especially in the small
bowel and colon,
 Treatment: Endoscopic band ligation or surgical
resection.

60. Blue Rubber Bleb Nevus
Syndrome
Intra-operative enteroscopy. Blue
rubber bleb nevus of the distal jejunum
Vascular malformation
typically seen in blue
rubber bleb nevus
syndrome.
Characteristi
c endoscopic
appearances
of small
intestinal
venous
malformatio
n in a patient
with blue
rubber bleb
nevus
syndrome
(A, B).

61. Thank You
 1.Amer Ridzuan bin Katiman(25)
2.Afiqah binti Muhamed Faizal(26)
3.Ainatul Mardhiah binti Che Wan
Ahmad (27)