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
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