GIT Kurdistan Board GEH Journal club; Lower GIB ASGE Guidelines 2014.

2. Dealing with LGIB:Overview
LGIB
Algorhythm
Causes
Endoscopic
interventions
Recommend
ations

3. Lower GIB: Overview
F •Introduction
A •Aetiologies
S •Management algorythms
T •Endoscopic hemostasis

4. Introduction:
• LGIB is diagnosed in 20-30% of all patients presenting with
major GI bleeding.
• The annual incidence is 0.03%.
• increases * 200 from 2nd- 8th decades of life.
• The mean age at presentation is 63 - 77 years.
• A full-time gastroenterologist manages >10 cases/ year.
• Blood loss can be trivial or massive & life-threatening, but the
majority have self-limited& uncomplicated hospitalization.
• LGIB tend to present with a higher Hb &less likely to develop
hypotensive shock or require blood transfusions.
• Mortality is 2- 4%, usually from comorbidities& noscom infs.
• Reported decreased incidence of LGIB & lower age/gender-
adjusted fatality rate over the past decade.

5. Definitions:
• Before deep enteroscopy: Bleeding from a source distal to the
ligament of Treitz
• Now: bleeding from a source distal to ICV.
• Now small-bowel sources called midgut bleeding.
• Acute LGIB: of recent duration (<3 days) that may result in
hemodynamic instability, anemia&/or the need for blood
transfusion.
• Chronic LGIB: passage of blood per rectum over a period of
several days or longer& usually implies intermittent or slow
loss of blood& present with occult fecal blood, intermittent
melena or maroon stools, or scant amounts of bright red
blood per rectum.

7. Diverticular bleeding:
• Present in up to 30% >50 ys, to 60% >80 ys.
• Accounts for 20- 65% of acute LGIB episodes.
• Clinically significant bleeding occurs in 3-15% with colon diverticula,
usually as a result of trauma to the vasa recta at the neck or dome
of the diverticulum.
• NSAIDs increase the risk for diverticular bleeding.
• Hypertension&anticoagulation also may contribute to severe
bleeding.

8. Diverticular bleeding:
• The clinical presentation:
• Painless hematochezia, resolves spontaneously in 75-80% but recurs
in 25-40% within 4 years.
• Early rebleeding is uncommon after endoscopic treatment.
• Using epinephrine/or thermal coagulation early (<30 days)
rebleeding 0-38%.
• Using endoscopic clips: no early rebleed & late rebleeding in 18-
22%.
• Late rebleeding may occur from diverticula at a location different
from that of the index bleed.

9. Diverticular bleeding:
• The diagnosis is presumptive in most patients, based on the
presence of colon diverticula& the absence of another obvious
source.
• A definitive diagnosis is made in 22% who have active bleeding or
high-risk stigmata of a visible vessel or clot on colonoscopy.
• Diverticular bleeding is detected by colonoscopy more commonly in
the left side of the colon (50-60%)& by angiography more
commonly in the right side of the colon (50-90%).

10. Ischemic colitis:
• 1- 19% Of LGIB most commonly elderly results from a sudden, often
temporary, reduction in mesenteric blood flow secondary to
hypoperfusion, vasospasm, or occlusion of the mesenteric
vasculature.
• The typical locations affected by non-occlusive colon ischemia are
the “ watershed” areas of the colon: the splenic flexure&
rectosigmoid junction;sigmoid colon in 20.8%, descending colon to
sigmoid colon in 9.9%, transverse colon to sigmoid colon in 4.2%, &
pancolonic involvement in 7.3%.
• Patients often have underlying CVD &present with hypotension or
hypovolemia, which results in mesenteric hypoperfusion&
vasoconstriction&bleeding results from reperfusion injury after the
hypoperfusion has resolved.

11. Ischemic colitis:
• Mesenteric occlusion related to cardiac thromboembolism in 1/3
• Hypercoagulable states,vasculitis&medications are less common.
• The clinical presentation: sudden onset of cramping abdominal
pain, followed by hematochezia or bloody diarrhea within 24 hours.
• Typical endoscopic findings: submucosal hemorrhage& ulcerations
with segmental distribution with an abrupt transition between
abnormal& normal mucosa.
• The rectum usually is spared, because of its dual blood supply.
• A single linear ulcer along the longitudinal axis of the colon on the
antimesenteric border (“ single-strip” sign) also may occur.
• None of these endoscopic findings are pathognomonic of ischemic
colitis&infectious / inflammatory colitides should remain in the DD.

12. Ischemic colitis:
• Angiography should be considered in severe ischemic colitis or
right-sided involvement, when there is suspicion for an underlying
thromboembolism or concomitant mesenteric ischemia involving
the small bowel.
• The majority improve with conservative management including:
• IV hydration.
• Correction of the underlying etiology.
• Involvement of the right side of the colon& total colon ischemia
(usually after a major abd surgery) may have unfavorable outcome
because of concomitant small-bowel ischemia or transmural
infarction & may require surgical management.

14. Angioectasias(angiodysplasias):
• The prevalence varies with clinical presentation (1-2% in
asymptomatic patients undergoing screening colonoscopy; 40- 50%
in those presenting with hematochezia).
• Account for 3-15% of patients with LGIB.
• The incidence increases with age& >2/3 of these lesions are seen in
> 70 years.
• Angioectasias are caused by degenerative changes& chronic
intermittent low-grade obstruction in the submucosal vessels.
• They are located predominantly in the cecum & the ascending
colon.
• Multiple angioectasias may be seen on colonoscopy appear as red,
flat lesions, 2 mm- several cms, with ectatic blood vessels radiating
from a central feeding vessel

15. Angioectasias(angiodysplasias):
• Risk factors include:
• Advanced age, comorbidities, the presence of multiple
angioectasias & the use of anticoagulants or antiplatelet agents.
• Patients can present with occult bleeding, melena, or painless
intermittent hematochezia.
• Colonoscopy has a sensitivity of 80% for detection of angioectasias.
• Narcotics for sedation may reduce mucosal blood flow and impair
the detection of these lesions at colonoscopy.
• Bleeding from angioectasias in AS( Heyde syndrome) explained that
severe AS may result in type 2 VWD, which precipitates bleeding in
patients with underlying angioectasias.
• There is a high rebleeding rate despite endoscopic treatment& defi
nitive management may involve AV replacement.

17. Hemorrhoids:
• Aplexus of dilated AV vessels that arise from the superior & inferior
hemorrhoidal veins,located in the submucosa of the distal rectum
classified as internal or external, based on their location relative to
the dentate line.
• Although may be present in up to 75% with LGIB, the majority are
considered incidental findings.
• Hemorrhoidal bleeding accounts for only 2- 10- 24- 64.4% of acute
LGIB or hematochezia.
• Patients typically present with painless, intermittent, scant
hematochezia characterized by bright red blood on the toilet paper,
coating the stool, or dripping into the toilet bowl.

19. CR neoplasias:
• Bowel habit changes&weight loss should raise suspicion for a
colorectal neoplasia&prompt colonoscopy in patients with LGIB.
• Accounts for up to 17% of GIB & presents more commonly with
occult bleeding.
• Acute LGIB associated with colorectal neoplasia usually results from
surface ulcerations of an advanced tumor.
• Patients with tumors in the right side of the colon are more likely to
present with occult blood loss &IDA whereas those with left-sided
tumors more commonly present with hematochezia.
• Endoscopic hemostasis is rarely required because bleeding is slow
in the majority.

20. Postpolypectomy bleeding:
• Account for 2- 8% of acute LGIB, 8.7/1000 procedures.

21. NSAID use :
• Associated with increased risk of LGIB, including DD.
• NSAID users had a significantly higher incidence of lower GI
adverse events, including bleeding
• The prevalence of NSAID use is up to 86% LGIB.
• Mechanisms not well understood: local mucosal trauma
&platelet inhibition in susceptible individuals & concomitant
use of warfarin&other antiplatelets.
• Use of NSAIDs is associated with exacerbations of IBD.
• NSAIDs can induce NSAID colopathy, which may be
misdiagnosed as IBD, characterized by colon ulcerations and
diaphragm-like strictures, predominantly located in the
terminal ileum& right side of the colon.
• NSAID colopathy may be associated with LGIB &perforation.

22. Rectal ulcers :
• 8% of severe hematochezia&32% LGIB after ICU admissions for
other critical illnesses.
• Patients often have major medical comorbidities:
• ESRD on HD
• Respiratory failure requiring mechanical ventilation,
• Decompensated cirrhosis
• Malignancy.
• Endoscopic findings:clean-based ulcers (82%),adherent clots
(17%),nonbleeding visible vessels (33%),active bleeding (50%).
• Early rebleeding after endoscopic treatment is 44% -48%
&mortality rate of 33-48% in high-risk stigmata who have
multiple comorbidities.

23. Radiation proctopathy:
• LGIB occurs in 4-13% with rad colitis.
• This disorder is caused by radiation-induced endarteritis
obliterans, which results in neovascularization&
telangioectasias in the rectum.

24. IBD:
• Commonly present with LGIB.
• Acute LGIB requiring hospitalization is uncommon & reported
to account for only 1.2-6% of all admissions in patients with
Crohn’ s disease &0.1- 4.2% in patients with ulcerative colitis.
• Clinically significant bleeding in Crohn’ s disease is more
common in patients with colon involvement than in those
with isolated small-bowel disease.
• Bleeding resolves spontaneously in up to 50% of patients, but
there is a recurrence rate of up to 35%.
• Medical management with biologics can be effective in the
management.

25. HIV:
• LGIB occurs in 2.6% of patients with HIV, usually in the setting
of AIDS-related thrombocytopenia&associated with an
inpatient mortality rate of 28%.
• The most common etiologies of LGIB in these patients are
opportunistic infections, including cytomegalovirus, herpes
simplex virus, Kaposi’ s sarcoma& idiopathic proctocolitis.

26. U& SI source of LGIB :
• UGI source may be present in 11- 15% of patients with
suspected LGIB
• Small-bowel sources constitute 2-15% of cases.

27. Management: Resuscitation/ evaluation
• Initial assessment: whether or not an urgent intervention is
necessary.
• The majority, manifesting as occult fecal blood or scant
hematochezia, can be managed electively in OP.
• Patients presenting with acute LGIB with melena or
hematochezia usually require inpatient management, because
the majority are elderly with significant comorbidities.
• Should undergo stabilization&resuscitation with crystalloids or
blood products.
• Coagulation factors &platelets may be necessary in patients
who are on antithrombotics or with underlying bleeding
disorders.

28. Management: Resuscitation/ evaluation
• ICU admission:
• Clinical evidence of ongoing or severe bleeding.
• Transfusion > 2 units of packed RBCs
• Significant comorbidities.
• NGT lavage to exclude an upper GI bleeding source should be
considered in patients presenting with hematochezia &
hemodynamic instability.
• An actively bleeding upper GI source is unlikely if bile is seen
in NG Lavage, but it cannot be ruled out with clear aspirate.
• A targeted history: NSAID use, prior bleeding episodes, recent
polypectomy, radiation therapy for prostate or pelvic
malignancies, IBD, CRC risk.

29. Management: Resuscitation/ evaluation
• Risk stratification:
• High risk of severe bleeding 80%: > 3 the following RFs.
• Moderate risk (45%) with 1-3 RFs.
• Low risk No Rfs (< 10%):.
• HR 100/minute, systolic blood pressure % 115 mm Hg,
syncope, nontender abdominal exam, rectal bleeding during
the first 4 hours of evaluation, aspirin use, multiple comorbid
illnesses.

30. Management: Resuscitation/ evaluation
• Another model: independent predictors of severe LGIB.
• Initial hematocrit! 35%, presence of abnormal vital signs
(SBP<100 mm Hg or HR> 100/minute) 1 hour after initial
medical evaluation& gross blood on initial rectal exam. Kollef
et al100 developed and validated another
• BLEED model; Outcome prediction tool for UGIB&LGIB: predict
resource utilization& inpatient adverse events, including
mortality.
• Ongoing bleeding, low SBP, elevated PT, erratic mental status,
&unstable comorbid illness.

31. Occult GI bleeding
• Colonoscopy for evaluation of underlying CR neoplasia.
• CT colonography may be an alternative if high risk for
colonoscopy-related adverse events& for the detection of
proximal lesions in those who have had an incomplete
colonoscopy.
• An EGD should be considered if a bleeding source is not
identifi ed in the colon, especially in those patients with upper
GI symptoms, IDA, or NSAID use( overall yield 13- 41%, with
PUD &esophagitis)
• Small-bowel evaluation if fecal occult blood&persistent
anemia, after negative EGD &colonoscopy.

32. Melena:
• EGD is the initial test in the evaluation of melena
• Melena also may result from slow bleeding emanating from
the colon or small-bowel.
• Colonoscopy should, be pursued after negative EGD.
• Persistent melena after negative results with bidirectional
endoscopy warrant small-bowel endoscopy.

33. Intermitent scant hematochesia:
• Is the most common pattern of LGIB.
• Usually is caused by an anorectal or distal colon source
• A digital rectal exam&flexible sigmoidoscopy ( yield of 9-58%),
with or without anoscopy, may be sufficient for the evaluation
of healthy patients aged< 40 years.
• A colonoscopy should be pursued in the absence of a defi
nitive source of bleeding on flexible sigmoidoscopy, patients
aged> 50 years, IDA, CRC risk, or alarm symptoms of weight
loss or bowel habit changes.

34. Severe hematochesia:
• An emergent EGD is the test of choice for patients presenting
with severe hematochezia & hemodynamic instability,
followed by a colonoscopy after if the later is normal.
• In hemodynamically stable patients with severe
hematochezia, colonoscopy should be performed first,
followed by an EGD, if the colonoscopy is negative.
• The main advantage of colonoscopy lies in the ability to
perform a therapeutic intervention in conjunction with
diagnosis of the underlying lesion.
• The diagnostic yield of colonoscopy is 45-100% in LGIB &
significantly higher than radiologic evaluation with RBC scan &
angiography.

35. Severe hematochesia:
• Urgent colonoscopy should be performed within 8-24 hours of
admission.
• Early colonoscopy increases its diagnostic yield &likelihood of
a therapeutic intervention.
• Endoscopic therapy is performed in 10-40%, with immediate
hemostasis achieved in 50-100%.
• Earlier colonoscopy is associated with higher higher successful
hemostasis,reduced duration of hospitalization&cost of care
but no improvement rebleeding or surgery.

36. Severe hematochesia:
• Colon preparation is important to improve visualization,
increase the diagnostic yield&reduce the risk of perforation.
• Polyethylene glycol– based solutions can be administered
orally (or via NGT in patients at increased risk of aspiration or
who are unable to complete oral consumption) at 1 L/30-45
minutes until the effluent is free of fecal material.
• Colonoscopy is performed within 1- 2 hours of preparation.
• The reaccumulation of blood in the colon after preparation
may be helpful in localizing the bleeding source.
• Endoscopic hemostatic interventions include epinephrine
solution injection, thermal contact coagulation, argon plasma
coagulation, hemostatic clips&band ligation.

37. Endoscopic hemostasis : Bleeding DD
• Thermal contact modalities:heater probe&bipolar coagulation
alone or in combination with epinephrine injection.
• Epinephrine solution in a dilution of 1:10,000 or 1:20,000 is
injected in aliquots of 1 mL-2 mL at the site of active bleeding
or around a non-bleeding visible vessel.
• An adherent clot, may be guillotined by using a polypectomy
snare.
• The visible vessel can be treated effectively by using a heater
probe (10 J-15 J) or bipolar coagulation (10 W-16 W) with 2 to
3– second pulse&application of mild contact pressure.
• Perforation reported with contact thermal coag in thin-walled
right side colon in up to 2.5%, so higher settings or repeated
applications avoided to prevent transmural injury.

38. Endoscopic hemostasis: Bleeding DD
• Endoscopic clips is an alternative to thermal coagulation&has
the advantage of quick&easy application.
• Clips can be deployed over a bleeding vessel at the neck of the
diverticulum or to oppose the walls& close the diverticular
orifice, thereby tamponading a vessel within the dome.
• The use of an endocap has been described to evert the
diverticulum and facilitate clipping of bleeding vessels within
the dome of a diverticulum.
• There are no reports of early rebleeding after endoscopic
treatment with clips.

39. Endoscopic hemostasis : Bleeding DD
• Endoscopic band ligation described in some small series ,but
limited by inadequate suction of diverticula with small orifi
ces or large domes&high early rebleeding.
• A tattoo should be placed adjacent to the bleeding
diverticulum, if identified at colonoscopy, for future identifi
cation in recurrent bleeding &necessity for repeat endoscopic
or surgical intervention.
• Placement of an endoscopic clip also may be useful to allow
localization of the bleeding source at angiography.

40. Endoscopic hemostasis : Bleeding AD
• Both contact& noncontact thermal coagulation
• APC is useful in the endoscopic treatment of angioectasias.
• APC is the preferred technique because of its ease use, ability
to treat large surface areas& predictable depth of penetration.
• Lower APC power settings of 30- 45 W & 1 L/minute, 1-3 mm
away from the mucosal surface &at 1- 2– second pulses used
to decrease the risk for perforation in the thin-walled right
side of the colon.
• APC showed a significant improvement in Hb& reduction in
transfusion requirements with no adverse events.
• The use of endoscopic clips with APC reported.

41. Non- endoscopic treatments:
• Mesenteric angiography with or without a preceding RBC scan
is reserved for patients with:
• Severe bleeding who cannot be stabilized or prepped for a
colonoscopy
• Failed endoscopic management.
• The multidetector row CT scan may be superior to the nuclear
RBC scan for evaluation of LGIB& replaced RBC scan at several
centers.
• It decreases scan time, allows accurate acquisition of arterial
images&demonstrates contrast material extravasation into
any portion of the GI tract.
• A mesenteric angiogram can detect bleeding at 0.5 mL/min.

42. Non - endoscopic treatments:
• Superselective embolization with microcoils, polyvinyl alcohol
particles, or water-insoluble gelatin (gel foam) improved the
success rate of this technique&decreased the occurrence of
the adverse event of bowel infarction.
• Angiography & embolization as first-line therapy for LGIB
found embolization to be an effective treatment for
diverticular bleeding, with successful hemostasis in 85%
compared with 50% of those with bleeding from other sources
at 30-day follow-up with early re-bleeding after embolization
in 22%.
• The technique is less successful in angiodysplasia & with more
re-bleeding 40%.
• Major adverse events, including bowel infarction,
nephrotoxicity,hematomas.

43. Non endoscopic treatments: Surgery
• Surgery is rarely required &reserved for minority of patients
who have persistent or refractory diverticular bleeding.
• Indications for surgery:
• Hypotension&shock despite resuscitation.
• Persistent bleeding with transfusion of >units of Packed RBCs.
• Lack of a diagnosis despite a pan-intestinal evaluation for
persistent bleeding in a surgical candidate.
• It is important to attempt localization of the bleeding site for a
segmental colectomy opposed to a subtotal colectomy with
significantly higher mortality rate.
• Surgery should be performed elective, because there is a high
mortality with emergent one.

44. Recommendations:
• 1. We recommend colonoscopy in patients with occult GIB.
• 2. We recommend EGD in patients with occult GIB if a bleeding
source is not identified in the colon, especially in those
patients with UGI symptoms, IDA or NSAIDs use.
• 3. We suggest small-bowel evaluation after negative EGD&
colonoscopy results in patients with occult GIB who have
persistent anemia.
• 4. We recommend colonoscopy for the evaluation of chronic
intermittent scant hematochezia in patients > 50 years& for
patients who have IDA, risk factors for CR neoplasia, or the
alarm symptoms of weight loss or bowel habit changes.
• 5. We suggest that in younger patients presenting with chronic
intermittent scant hematochezia without alarm symptoms, a
DRE &flexible sigmoidoscopy may be sufficient evaluation.

45. Recommendations:
• 6. We recommend EGD in the initial evaluation of patients
with melena followed by colonoscopy if the EGD is negative.
• 7. We recommend an initial EGD in patients with severe
hematochezia&hemodynamic instability to evaluate for a
high-risk UGI lesion, followed by colonoscopy if EGD is –VE.
• 8. We suggest colonoscopy within 24 hours of admission after
a rapid bowel preparation in the evaluation of patients with
severe hematochezia.
• 9. We recommend endoscopic treatment with epinephrine
solution injection combined with thermal coagulation or
endoscopic clip placement as the preferred management in
patients presenting with diverticular bleeding.

46. Recommendations:
• 10. We recommend endoscopic clip or tattoo placement
adjacent to a bleeding diverticulum if identifi ed at
colonoscopy for future localization in the event of recurrent
bleeding.
• 11. We recommend endoscopic treatment with APC as the
preferred management in patients with bleeding
angioectasias.
• 12. We recommend surgical &radiologic consultation in
patients presenting with severe hematochezia who cannot be
stabilized for endoscopy or in whom endoscopic evaluation
has failed to reveal a bleeding source.