management of lower gastrointestinal bleeding- light bg

7/24/2019 Management of Lower Gastrointestinal Bleeding- Light BG

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Management of LowerGastrointestinal Bleeding

Dr. Wasf M Salaita

Colorectal Surgeon - KHMC


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EpidemiologyIs defned as bleeding distal to the ligament o !reit".

It can range in se#erity rom tri#ial to massi#e.

Se#ere $%I& 'as defned by one or more o the

ollo'ing clinical characteristic(!ransusion o greater than or e)ual to * units o blood.

Decrease o hematocrit by greater than or e)ual to*+,. In the frst * hours.

ecurrent rectal bleeding ater * h o stabilityassociated 'ith urther decrease in hematocrit ogreater than or e)ual to *+,/ more transusions/ and

readmission 'ithin one 'ee0 o discharge.


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$%I& accounts or appro1imately *+, o all ma2or%I bleeds.

More commonly bleeding is rom a colonic rather

than a small bo'el source.

3nnual incidence *4 cases per 4++/+++.

Increasing age is considered re)uently as a ris0actor or $%I& and the mean age greater than 5+.

6o statistical di7erence bet'een males andemales 'ith $%I&.

ace has not been noted to be a predisposingactor or $%I&.


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Etiology- lo'er %I

bleedingAnorectal causes(Include hemorrhoids-anal ssureand rectal ulcer.

&leeding rom hemorrhoids and fssure is uncommonly

associated 'ith hemodynamic instability or large #olume oblood loss.

While rectal ulcer can cause se#ere hemorrhage andhemodynamic instability


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Diverticular disease(Contributes *+-5+, o the cases o $%I&.

In =:, o patients bleeding 'ill stopspontaneously.

ebleeding rate ater frst episode *:, andincrease to :+, ater t'o episodes.

:, 'ill ha#e se#ere hemorrhage.

di#erticular bleeding is distributed e)uallybet'een the right and let sides o the colon.

>bser#ation alone is generally recommendedollo'ing the frst episode o di#erticularhemorrhage. Ho'e#er/ ollo'ing a secondepisode/ the ris0 o subse)uent episodesappears to appro1imate :+,/ and thus electi#eresection has been recommended.


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Angiodysplasia(!he incidence in most recent studies is only ?,

compared to 4:-*=, pre#iously as cause o$%I&

3re dilated/ tortuous #essels in the mucosa andsubmucosa.

!he pathophysiology unclear/ but is elt to bedue to intermittent obstruction o thesubmucosal #eins.

May be sporadic/ usually de#eloping in theelderly.

May be ound in association 'ith a number odisorders including renal ailure/ cirrhosis/ theCES! syndrome/ radiation in2ury/ #onWillebrand@s disease/ and aortic stenosis.


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May occur any'here in the %I tract/ but aremore commonly ound in the colonAmostcommon in the cecum and ascending colonB /ollo'ed by the small intestine and the stomach.

!hese lesions usually lead to occult blood loss/but can also cause o#ert %I bleeding.

sually apparent at endoscopy/ at 'hich timetherapy 'ith laser or thermal probes may beapplied.

&leeding that is reractory to endoscopic ormedical therapy is an indication or surgical

resection.


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olorectal neoplasm3lthough colorectal cancer is most commonly

associated 'ith occult blood loss rather thano#ert bleeding/ patients 'ith rectosigmoidlesions may present 'ith hematoche"ia.

C-cancers are source o $%I& in 9-4?, opatients.


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Ischemic colitis>ccurs in 9-48, o patients.

esults rom a sudden and oten temporaryreduction in mesenteric blood ;o'/ typicallycaused by hypoperusion/ #asospasm/ orocclusion.

!he usual areas a7ected are the 'atershed

areas o the colon( the splenic ;e1ure and therectosigmoid 2unction.


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!ther colonic etiologies"In#ammatory $owel disease"3cute hemorrhage occurs +.9-5, in CD and 4.-, in

C.&leeding occurred in both young and old patients and

not related to disease duration.Malignant lesion must be considered in patient 'ith

long standing history o I&D and $%I&.

Infectious colitis or enteritis(

%adiation colitis&proctitis.'rauma, hematologic disorders and

()AIDs.

*ost polypectomy +occurs in +.?, to 5.4,o polypectomies.

Bleeding from %-anastomosis +o.:-4.8,B.


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)mall $owel sources account for -/0 ofall cases of LGIB"3ngiodysplasiaismost common cause o

small bo'el hemorrhageA=+-8+,.

small bo'el di#erticula/Mec0el@s di#erticula/

neoplasia/ Crohn@s disease/

aorto-enteric fstulas.


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Clinical presentation$%I& has many presentations re;ecting the di#erse

pathology ound in the upper and lo'er %I!.

!he #ariety o presentations creates a diagnostic and

management )uandary.We can classiy the patients 'ith $%I& into three groups

depending on the #olume o hemorrhage(Minor and sel limited.

Ma2or and sel limited.

Ma2or and ongoing.

So the clinical presentation ranges rom maniestationso iron defciency anemia to maniestation ohemorrhagic shoc0.


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M363%EME6! >F $%I &$EEDI6%Initial assessment, resuscitation and triage(Intra#enous access 'ith at least t'o large-bore lines.

6asogastric tube placement (

pper %I bleeding sources are seen in 44, opatients 'ho present 'ith a $%I&.

!he 6% tube can be let and used or the bo'elpreparation i an urgent colonoscopy is needed.

Determination o hematocrit and coagulation studies/and type and cross or blood products.


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3dmission to the hospital is re)uired or

most patients presenting 'ith $%Ibleeding:

1-!hose 'ho present 'ith ran0 hypotension or 'hoha#e e#idence or ongoing bleeding re)uire

monitoring in an intensi#e care unit and urgente#aluation

2-!hose 'ho present 'ith mild or no orthostasis/ ha#eno e#idence or continued bleeding/ but ha#e had a

signifcant drop in hematocrit are generally

hospitali"ed on a surgical ;oor.3-young patients 'ith sel-limited %I bleeding 'ho

present 'ithout orthostasis or hemodynamicinstability and 'ho ha#e no signifcant comorbid

conditions may be managed as outpatients.


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Diagnosis(

1istory and physical(


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olonoscopy"&oth diagnostic and therapeutic.

!he li0elihood o identiying the source o bleeding

'ith colonoscopy ranges rom :-9:,.!he timing o colonoscopy is debatable.

rgent colonoscopy is perormed 'ithin * hoursAater bo'el preparation and patient

hemodynamically stableB.Endoscopic inter#entions 'ere perormed in 4+-4:,

o patients 'ho under'ent an urgent colonoscopy.

>#erall complication rate o colonoscopy in $%I& is4.?,.

I the source o bleeding identiy and not treatedendoscopically/ the area should be mar0ed by Aclip ortattooB .i patient rebleed again and re)uire surgery.


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Angiography"&oth diagnostic and therapeutic.

Sensiti#ity A+-85,B and specifcity in 4++,.

'o $e positive the $leeding rate mustoccur at 3./ ml&min or faster.

)uccess rate from 43-530.

%e$leeding rate 3-0 and signicantischemia of less than 60.

)uper selective em$oli7ation is thepreferred treatment for positiveangiograms +em$oli7ation occurs at thelevel of vasa recta or marginal artery.


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Materials used for emoli7ation include"Microcoils.*ermanent materials.

Multiple si7es.8asily visi$le during #uoroscopy.

*olyvinyl alcohol particles.*ermanent.

*oorly visuali7ed.Gelfoam.(ot permanent agent with vessel recanuli7ation

in days to wee9s and it is not routinely used.


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If superselective em$oli7ation is una$leto $e performed"Locali7e the site of $leeding $y in:ection

methylene $lue into artery providing atemporary mar9er for the surgeon.

Intra-arterial vasopressin infusion.

Infusion rate of vasopressin 3.;


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)uperselective em$oli7ation for sources otherthan diverticuli has higher failure rates.

Indications"

*atients with ma:or, ongoing hemorrhage.*atients who re$leed.

*atients who have negative upper and lowerendoscopy with continued evidence of $leeding.


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%adionuclide scintigrahy"+ radioactive la$eling ofred $lood cellIn comparison to colonoscopy and angiography"

It does not have any therapeutic capa$ilities. It is not invasive.Does not re@uire a $owel preparation. It does not re@uire specialist to perform.

Bleeding rate as low as 3.> ml&min can $e

detected.It is positive in >4-5>0.


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'he role of %adionuclide scintigrahy in themanagement of LGIB poorly denedIf scan is negative, re$leeding rates are not

negligi$le +reach up to ;/0.olonoscopy performed after a negative scan

found potential $leeding etiologies in?50 of

patients.More important than the recurrent $leeding is

the ina$ility of scintigraphy to ade@uatelylocali7e the source of $leeding so surgicalresection $ased on radionuclide scintigraphy is

not recommended.

!ne advantage of scan is that re$leedingwithin ;=h can $e restudied promptly without

second la$eling procedure.


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Multidetector %ow omputed tomography"

Increase role in the diagnostic wor9upof LGIB.

Blood #ow can $e detected at 3.ml&min.

*ositive when vascular contrast materialis e2travasated into the $owel lumen.

Advantages"It is easy to perform and readily availa$le in

emergency rooms with '-scanners.Accurate locali7ation of $leeding site which

allows for directed angiogram and lesscontrast use

Identication of other pathologies.


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)urgery"

'he ma:ority of patients with LGIB willstop spontaneously and never re@uiresurgery

appro2imately >3-;/0 of patients will

re@uire operative intervention Indications"1emodynamically unsta$le patient +who have

massive ongoing $leeding and unresponsive toinitial resuscitation.

*atients who have had the source of $leedinglocali7ed $ut no therapeutic measuresperformed or they failed.

*atients who re@uired at least si2 units of

pac9ed red cells within ;=h.


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'he aim of the preoperative diagnostic wor9up is to locali7e the source of $leeding.If a colonic source is locali7ed then segmental

rather than su$total colectomy can $eperformed.

Mortality rates associated with segmental andsu$total colectomy for lower GI $leeding are=->=0 and 3-=30, respectively.

'he need for emergent surgery withoutlocali7ed source of $leeding is uncommonoccurring in =.?0 of patients with LGIB.


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>bscure %astrointestinal &leedingDened as recurrent acute or chronic GI

$leeding for which no source has $eenfound despite evaluation with 8GD and

colonoscopy with or without routinesmall $owel follow-through.

It accounts >.>5-50 of LGIB.

'he most fre@uent causes are ")mall $owel tumors.

Angiodysplasia.


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'he diagnosis needs more procedures thanpatients with upper GI and colonic $leeding

include"apsule endoscopy. Indications"!$scure GI $leeding.


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Dou$le $alloon enteroscopy.Indications"*ositive capsule endoscopy.1igh suspicious of small $owel source.

an $e performed oral or rectal.'he diagnostic yield is /?0.


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!han0 you

management of lower gastrointestinal bleeding- light bg

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