Lower GI Bleed

T R WilsonDoncaster Royal Infirmary

Case 1

• 67 year old male• PMHx – AF, IHD on Warfarin, Atenolol, Statin• 24 hour history of fresh blood PR– 4 Episodes, No stool, No pain– BP 90/40, Pulse 60, Temp 35.5– After 1L crystaloid → BP up to 105/60– Hb 9.5 (was 13 2 weeks ago), INR 3.1

Aspects to consider in initial management

• Reversal of anticoagulation– Beriplex / Vit K

• Cross match– Keep Hb at around 10 and have 4 units is reserve– If > 6 units then consider FFP/platelets

• Tranexamic acid?• CT angiogram ?– >80% will settle with supportive care

• Once stable consider OGD

After admission

• In next 24 hours 4 further bleeds• BP drops intermittently to 95 systolic• After 4 units of blood Hb is still 9.0• Day 2: Bleeding less• Day 3: 2 further episodes bleeding → 2 units

RBC• CTA and angiogram negative• Where to go next??

Further management

• Patient remains stable but transfusion dependent

• Consider further investigations– OGD if not done– Consider preping and performing colonoscopy– CTA or angiogram asap if shock index <1• Leave in angiocatheter• Administration of tPA at time of angiogram

What next

• Patient continues to be transfusion dependent• OGD negative• 2 negative CTAs and an angiogram• Colonoscopy– Diverticulosis in left colon– Some fresh blood and clots predominantly in right colon

• Where next?– More investigations?– Surgery ?

Investigation vs Surgery

• Further investigations – Capsular endoscopy– Red cell scan– Repeat all previous investigations

• Surgical options– On table investigation

• Colonoscopy/enteroscopy• Irrigate bowel and soft clamps

– Segmental colectomy (left or right?)– Subtotal colectomy

Approach to massive lower GI Bleed

• If lower bleed in doubt consider OGD• If shock index < 1 then consider CT angiogram →

proceed to interventional radiology if required • If settles (80%) → Colonoscopy• If continues– Angiography → If source not identified (and patient remains

stable) →– Colonoscopy → If source not identified (and patient remains

stable) →– Radionucleotide scan

• If patient is unstable then surgery is necessary

Surgical approach to lower GI bleed• If source identified → Segmental resection

– Recurrent bleed 15%, Mortality <10%• If source cannot be identified

– Examine small and large bowel• Blood in upper SB suggests UGI bleed• Blood in lower SB may occur in right colonic bleed• Blood in right colon may come from left colonic bleed• Ensure there is no anorectal cause

– Consider on table lavage + colonoscopy +/- enteroscopy• Difficult and time consuming

– If in doubt → subtotal colectomy is safest option• Recurrent bleed low if rectal bleed excluded (risk small bowel source)• Mortality usually >10% (10-30%)

– Segmental colectomies carry• Risk of rebleeding 35-75%• Mortality 20-50%

Case 2

• 38 year old female – no PMHx• Intermittant PR bleeding for 3 days

– Up to 6 times a day – small volume– No pain– Not opening bowels

• O/E– looks well– Normal pulse and blood pressure– Normal abdominal and rectal examination

• Hb 9.7 (usually 11.5-12), WCC/CRP normal• Differential diagnosis and invesigation?

Investigations

• Rigid sigmoidoscopy - a bit of blood in lower rectum with contact bleeding

• Proctoscopy – partially prolapsing piles• Flexible sigmoidoscopy– Pools of liquid stool and blood– Proctosigmoiditis– Possible pseudomembranes

• Where next?

Further management

• Stool MC+S/c-diff• Biopsy of mucosa• Started PO metronidazole pending Ix

Case 3

• 69 year old lady• PMHx: MI/IHD, IBS/diverticulitis• 2/7 of low abdominal pain → 2 large episodes of

fresh Pr bleeding and some lose stool• o/e– Temp 38, Pulse 112 (sinus)– Markedly tender left side abdomen

• WCC 25, CRP 170, Hb 137• Differential diagnosis and investigation

• CT scan– 6.5 cm AAA– Marked diverticulosis – no inflammation– Thick walled colon on left side– No active bleeding

• Next management

• Suspected ischaemic colitis• Start antibiotics (Cef and Met)• Close observations• Consider– Stool MC+S– Flexible sigmoidoscopy (distribution / biopsy)

PR bleeding - classification

• 1. Massive PR bleeding– Diverticular – painless– Angiodysplasia – painless– Ischaemic colitis – pain

• 2. Bloody Diarrhoea– IBD: Crohns or UC– Infective– Ischaemic

• 3. Anal canal bleeding– Piles– Fissure– Protrusion

• 4. Higher bleeding (mixed with stool) – rarely seen

Management Massive Bleed

• Present as acutes• If pain and tenderness – consider CT ?

Ischaemia• Otherwise observation– Settles → OP colonoscopy– Unstable → CTA → Angio if bleeding point– Try and avoid surgery unless source of bleed

known

Management Colitis

• Acute / unwell– Stool cultures– Flexy sig and biopsy– Empirical antibiotics and steroids– DVT prophylaxis– Calcium

• Outpatient– Rigid sigmoidoscopy– Well → colonoscopy– Unwell – consider empirical steroids/ASA

Management – Anal canal bleeding

• Outpatients• Diagnosis depends on history and examination• All patients >30 should have a more proximal

lesion excluded– Full colonoscopy for all 2 week waits– ?Most cancers will be picked up incidentally