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LOWER GI BLEEDING

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Arkaprovo Roy
Arkaprovo Roy

Lower gastrointestinal tract bleeding can be caused by various conditions affecting the colon and small intestine. The most common cause is diverticular disease, followed by hemorrhoids. Bleeding may present as hematochezia, melena, or occult bleeding resulting in anemia. Colonoscopy is the primary diagnostic tool for evaluating the source and managing bleeding, while other modalities like capsule endoscopy and angiography can also be used. Treatment depends on the underlying cause and may involve endoscopic therapies, medications, or surgery.

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Lower Gastrointestinal tract Bleeding SIDDHARTHABHATTACHARJEE 22.02.2017 MALDA MEDICAL COLLEGE
• Introduction • Lower gastrointestinal tract bleeding is defined by any bleeding in the GI tract distal to ligament of Treitz. • Majority of the LGI Bleeding is self limiting. • Only 10-20% patients presents with massive lower GI bleeding • In 90% of the cases colon is the source of bleeding. • Incidence increases with age, as the causes are age related • Most common cause of significant LGI bleeding is Diverticular diaease. • Most common cause of LGI bleeding in India is Hemorrhoids(rarely massive bleeding).
Causes of LGI bleeding Colonic bleeding(95%) Small intestinal bleeding(5%) • Diverticular disease • Angiodysplasia • Anorectal disease (hemorrhoid , anal fissure, fistula in ano, solitary rectal ulcer etc) • Crohn’s disease and infectious disease • Neoplasia( polyp,ulcerated lesions) • Neoplasia( polyp,ulcerated lesions) • Inflammatory bowel diseass • Infectious collitis • Radiation • Angiodysplasia • Meckel’s diverticulum • Radiation collitis/ proctitis • Aortoenteric fistula • Other • Mesenteric Ischemia
Presentation of LGI bleeding • Haematochezia- It is defined as passage of fresh blood through the anus , usually in or with the stool. • Melena- It is production of dark sticky feces containing partly digested blood as a result of internal bleeding or swallowing of blood. • Occult LGI Bleeding- Presents as severe anemia
Diagnostic modalities for LGI Bleeding 1. Colonoscopy- Full length colonoscopy is the most important investigation. It helps in visualising from rectum to last 10-15cm of terminal illeum.
Colonoscopy • Therapeutic uses are 1. Electro-cauterization of bleeding points 2. Polypectomy • Diagnostic uses are 1. Imaging 2. Biopsy of the lesion
Ulcerative colitis CA colon with bleeding Crohn's disease Diverticulosis
Radionucleotide scanning (Technecium-99m labelledRBC scintigraphy) • A sample of patient's blood is taken and then the RBC of the sample is labelled with Tc-99m. • Next the sample of blood is injected into the patient and serial scintigraphy scan are taken in fixed intervals. • It only has diagnostic purpose. But the advantage is that it can detect very small amount of bleeding(0.05-0.1 ml/min) Increasing amount of bleeding at the descending colon
Mesenteric Angiography • In this procedure bleeding rate of 0.5-1ml/ min can be detected. • Selective angiography is done by catheterising the arterieas selectively under fluoroscopic guidance. • Therapeutic implication is done by embolisation of the culprit vessel
Capsule Endoscopy • Non invassive procedure • Done in stable patients • Duration is 8h/50000 images • Only diagnostic value • The imaging cannot be controlled from outside, thus pathological site may be missed
Capsule Endoscopy
Double Balloon Endoscopy
Approach to a patient with LGI Bleeding
DIVERTICULARDISEASEOF LGITRACT • Most common cause of significant LGI bleeding. • Incidence increases with aging • Prevalent in western countries and developing countries where the dietary fibers in the food is less in amount. • Less dietary fiber causes increased duration of transit followed by increased amount of intraluminal pressure. • Caused by mucosal outpouching at the site of entrance of vessel i.e Appendices epiploica of the colon. • Present on the anti mesenteric border of LGI tract • Bleeding occurs in 3-15% of patient with diverticulosis • More than 75% of bleeding stops spontaneously with 10% rebleeds in 1year and 50% in 10 years.
Diverticulardiseaseof LGItract • Diverticullitis is the infected diverticula due to impaction of fecal material at neck of diverticula which complicates into perforation/intraperitonial abcess/peritonitis/LGI bleeding/ fistula. • Best method of diagnosis-Full length colonoscopy • Indication of surgery in Diverticullitis are 1. No improvement in medical therap 2. Atleast 2 documented attacks of diverticullitis 3. Complicated diverticullitis 4. Recurrent or persistent hemorrhage.
Diverticulardiseaseof LGItract • Therapeutic use of colonoscopy is done to controll bleeding by 1. Epinephrine injection 2. Electrocautery 3. Endoscopic clips. • If hemorrhage recurs then colonic resection is indicated.
Anorectal diseases Hemorrhoid:- • These are cushions of submucosal tissue containing venules, arterioles, smooth muscle fiber & elastic connective tissues • 3 anal cushions are found in 3,7&11 o'clock position in anal canal. • Caused by increased intra abdominal pressure i.e. 1. Obesity 2. Constipation 3. Pregnancy
Anorectal diseases • Internal hemorrhoid- located proximal to dentate line • Usually painless, thus banding, ligation can be done. • External hemorrhoid- located distal to dentate line • These are painful, usually self limited. • Classification of internal hemorrhoids and treatment 1st degree Painless bleeding, no prolapse Medical therapy by dietary fibre, stool softeners,sitz bath, Operative by rubber band ligation,infrared photocoagulation,sclerotherapy 2nd degree Prolapse through anus during straining but reduces spontaneously Same as above 3rd degree Prolapse through anus, requires manual reduction Rubber band ligation,sclerotherapy,operative hemorrhoidectomy 4th degree Cannot be reduced, thrombosed Operative hemorrhoidectomy
Anorectal diseases • Sclerotherapy is done by5% phenol in almond or arachis oil • Operative hemorrhoidectomy are done by Milligan-Morgan's open hemorrhoidectomy, Ferguson closed hemorrhoidectomy, Whitefield submucosal hemorrhoidectomy, Longo's stapler method.
Anorectal diseases • Anal fissure- It is a cause of painful bleeding per anus • Fissure is usually presenting with associated infection • Conservative management done by antibiotics, analgesics, stool softener, anal sphincter relaxant, local dry dressing.
Anorectal diseases • Fistula in ano- Mainly it is a chronic inflammation progressing into formation of anal fistula, which are almost always associated with infection may present as hematochezia • Management is usually surgical according type and site of fistula
Neoplasia of LGI tract including anal canal • Neoplastic growth are a significant cause of LGI bleeding • It may present as polyp, sessile polyp, ulcer or mass. • Sloughing off of the lesion may present as lower gi bleeding • Proper evaluation, investigation, biopsy, staging of the neoplasia is to be done for either/or chemotherapy, radiotherapy and/or oncosurgery
COLITIS • Both infective/inflammatory colitis present as LGI bleeding, mostly hematochezia, pus may also be present. • The diagnosis of Ulcerative colitis and Crohn's disease is usually confirmed by biopsies on colonoscopy. • Although colonoscopy and sigmoidoscopy are still employed, now stool testing for the presence of C. difficile toxins is frequently the first-line diagnostic approach with history of prior antibiotic use or hospitalization.
Angiodysplasia • Angiodysplasia is a small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. • Cases present with black, tarry stool (melena), the blood loss can be subtle, with the anaemia symptoms predominating • Diagnosis of angiodysplasia is often accomplished with endoscopy, either colonoscopy or esophagogastroduodenoscopy (EGD). • Treatment may be with colonoscopic interventions, angiography and embolization, medication, or occasionally surgery.
THANK YOU FOR YOUR PATIENCE☺

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LOWER GI BLEEDING

  • 2. • Introduction • Lower gastrointestinal tract bleeding is defined by any bleeding in the GI tract distal to ligament of Treitz. • Majority of the LGI Bleeding is self limiting. • Only 10-20% patients presents with massive lower GI bleeding • In 90% of the cases colon is the source of bleeding. • Incidence increases with age, as the causes are age related • Most common cause of significant LGI bleeding is Diverticular diaease. • Most common cause of LGI bleeding in India is Hemorrhoids(rarely massive bleeding).
  • 3. Causes of LGI bleeding Colonic bleeding(95%) Small intestinal bleeding(5%) • Diverticular disease • Angiodysplasia • Anorectal disease (hemorrhoid , anal fissure, fistula in ano, solitary rectal ulcer etc) • Crohn’s disease and infectious disease • Neoplasia( polyp,ulcerated lesions) • Neoplasia( polyp,ulcerated lesions) • Inflammatory bowel diseass • Infectious collitis • Radiation • Angiodysplasia • Meckel’s diverticulum • Radiation collitis/ proctitis • Aortoenteric fistula • Other • Mesenteric Ischemia
  • 4. Presentation of LGI bleeding • Haematochezia- It is defined as passage of fresh blood through the anus , usually in or with the stool. • Melena- It is production of dark sticky feces containing partly digested blood as a result of internal bleeding or swallowing of blood. • Occult LGI Bleeding- Presents as severe anemia
  • 5. Diagnostic modalities for LGI Bleeding 1. Colonoscopy- Full length colonoscopy is the most important investigation. It helps in visualising from rectum to last 10-15cm of terminal illeum.
  • 6. Colonoscopy • Therapeutic uses are 1. Electro-cauterization of bleeding points 2. Polypectomy • Diagnostic uses are 1. Imaging 2. Biopsy of the lesion
  • 7. Ulcerative colitis CA colon with bleeding Crohn's disease Diverticulosis
  • 8. Radionucleotide scanning (Technecium-99m labelledRBC scintigraphy) • A sample of patient's blood is taken and then the RBC of the sample is labelled with Tc-99m. • Next the sample of blood is injected into the patient and serial scintigraphy scan are taken in fixed intervals. • It only has diagnostic purpose. But the advantage is that it can detect very small amount of bleeding(0.05-0.1 ml/min) Increasing amount of bleeding at the descending colon
  • 9. Mesenteric Angiography • In this procedure bleeding rate of 0.5-1ml/ min can be detected. • Selective angiography is done by catheterising the arterieas selectively under fluoroscopic guidance. • Therapeutic implication is done by embolisation of the culprit vessel
  • 10. Capsule Endoscopy • Non invassive procedure • Done in stable patients • Duration is 8h/50000 images • Only diagnostic value • The imaging cannot be controlled from outside, thus pathological site may be missed
  • 13. Approach to a patient with LGI Bleeding
  • 14. DIVERTICULARDISEASEOF LGITRACT • Most common cause of significant LGI bleeding. • Incidence increases with aging • Prevalent in western countries and developing countries where the dietary fibers in the food is less in amount. • Less dietary fiber causes increased duration of transit followed by increased amount of intraluminal pressure. • Caused by mucosal outpouching at the site of entrance of vessel i.e Appendices epiploica of the colon. • Present on the anti mesenteric border of LGI tract • Bleeding occurs in 3-15% of patient with diverticulosis • More than 75% of bleeding stops spontaneously with 10% rebleeds in 1year and 50% in 10 years.
  • 15. Diverticulardiseaseof LGItract • Diverticullitis is the infected diverticula due to impaction of fecal material at neck of diverticula which complicates into perforation/intraperitonial abcess/peritonitis/LGI bleeding/ fistula. • Best method of diagnosis-Full length colonoscopy • Indication of surgery in Diverticullitis are 1. No improvement in medical therap 2. Atleast 2 documented attacks of diverticullitis 3. Complicated diverticullitis 4. Recurrent or persistent hemorrhage.
  • 16. Diverticulardiseaseof LGItract • Therapeutic use of colonoscopy is done to controll bleeding by 1. Epinephrine injection 2. Electrocautery 3. Endoscopic clips. • If hemorrhage recurs then colonic resection is indicated.
  • 17. Anorectal diseases Hemorrhoid:- • These are cushions of submucosal tissue containing venules, arterioles, smooth muscle fiber & elastic connective tissues • 3 anal cushions are found in 3,7&11 o'clock position in anal canal. • Caused by increased intra abdominal pressure i.e. 1. Obesity 2. Constipation 3. Pregnancy
  • 18. Anorectal diseases • Internal hemorrhoid- located proximal to dentate line • Usually painless, thus banding, ligation can be done. • External hemorrhoid- located distal to dentate line • These are painful, usually self limited. • Classification of internal hemorrhoids and treatment 1st degree Painless bleeding, no prolapse Medical therapy by dietary fibre, stool softeners,sitz bath, Operative by rubber band ligation,infrared photocoagulation,sclerotherapy 2nd degree Prolapse through anus during straining but reduces spontaneously Same as above 3rd degree Prolapse through anus, requires manual reduction Rubber band ligation,sclerotherapy,operative hemorrhoidectomy 4th degree Cannot be reduced, thrombosed Operative hemorrhoidectomy
  • 19. Anorectal diseases • Sclerotherapy is done by5% phenol in almond or arachis oil • Operative hemorrhoidectomy are done by Milligan-Morgan's open hemorrhoidectomy, Ferguson closed hemorrhoidectomy, Whitefield submucosal hemorrhoidectomy, Longo's stapler method.
  • 20. Anorectal diseases • Anal fissure- It is a cause of painful bleeding per anus • Fissure is usually presenting with associated infection • Conservative management done by antibiotics, analgesics, stool softener, anal sphincter relaxant, local dry dressing.
  • 21. Anorectal diseases • Fistula in ano- Mainly it is a chronic inflammation progressing into formation of anal fistula, which are almost always associated with infection may present as hematochezia • Management is usually surgical according type and site of fistula
  • 22. Neoplasia of LGI tract including anal canal • Neoplastic growth are a significant cause of LGI bleeding • It may present as polyp, sessile polyp, ulcer or mass. • Sloughing off of the lesion may present as lower gi bleeding • Proper evaluation, investigation, biopsy, staging of the neoplasia is to be done for either/or chemotherapy, radiotherapy and/or oncosurgery
  • 23. COLITIS • Both infective/inflammatory colitis present as LGI bleeding, mostly hematochezia, pus may also be present. • The diagnosis of Ulcerative colitis and Crohn's disease is usually confirmed by biopsies on colonoscopy. • Although colonoscopy and sigmoidoscopy are still employed, now stool testing for the presence of C. difficile toxins is frequently the first-line diagnostic approach with history of prior antibiotic use or hospitalization.
  • 24. Angiodysplasia • Angiodysplasia is a small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. • Cases present with black, tarry stool (melena), the blood loss can be subtle, with the anaemia symptoms predominating • Diagnosis of angiodysplasia is often accomplished with endoscopy, either colonoscopy or esophagogastroduodenoscopy (EGD). • Treatment may be with colonoscopic interventions, angiography and embolization, medication, or occasionally surgery.
  • 25. THANK YOU FOR YOUR PATIENCE☺