Types of Colitis and Hemorrhages

Causes of Hemorrhagic Digestive Illness (HDI)

• Ischemic colitis: abdominal pain and bloody diarrhea, but most often blood loss is not significant
• Infectious colitis: manifested by bloody diarrhea
• Colon cancer: most often causes intermittent, occult bleeding due to ulcerations or mucosal erosions
• Hemorrhoidic hemorrhage: painless, manifested by the emission of red blood, over the stools or at the end of defecation, not mixed with the stools
• Hemorrhage from anal fissures: similar to hemorrhoids, but accompanied by ano-rectal pain

Paraclinical Examinations

• Laboratory tests:
  • Include hemogram, serum electrolytes, coagulation tests (aPTT, TP, INR), serum platelets, bleeding time - coagulation time
• Colonoscopy:
  • Gold-standard method of diagnosing HDI
  • Allows for biopsy samples and differential diagnosis of BII, colon cancer, histological type of polyp, etc.
  • Requires prior preparation with a 4-liter polyethylene glycol (Fortrans) substance
• Flexible sigmoidoscopy:
  • Evaluates the rectum and the left side of the colon without standard training
  • Inadequate for the evaluation of the anal canal

Other Conditions Responsible for HDI

• Anal fissures
• Ano-rectal fistulas
• Coagulopathies of any kind
• Vascular disorders (Enteral infarction)
• Accidental, iatrogenic trauma
• Bacterial infectious colitis (Campylobacter jejuni, Salmonella, Shigella, enterohemorrhagic E coli, Clostridium difficile)
• Viral infectious colitis (Cytomegalovirus)

Clinical Picture

• HDI can manifest in two ways:
  • When the source of the bleeding is located on the right colon: melena or haematochesia
  • When the source is located on the left colon or rectum: rectoragy
• Associated symptoms and signs range from mild, asymptomatic forms to signs of hemodynamic shock
• Clinical manifestations of shock include:
  • Hypotension
  • Tachycardia
  • Cold extremities
  • Intense sweating
  • Obnubility
• Indirect manifestations of HDI include:
  • Tegumental pallor
  • Fatigue
  • Dizziness
  • Lipotemia
  • Collapse

Specific Clinical Aspects

• Diverticular haemorrhage:
  • Sudden onset by recoragy with fresh, red blood
  • Pain-free
  • In most patients, the bleeding stops spontaneously
• Inflammatory bowel disease:
  • Ulcerative colitis causes bloody diarrhea in most patients
  • HDI in Chron's Disease is rare

Etiology

• The most common causes of HDI are:
  • Diverticulosis
  • Hemorrhoids
  • Ischemic lesions
  • Inflammatory bowel disease
  • Polypectomys
  • Colon cancer / Colon polyps
  • Rectal ulcer
  • Angiodisplasias
  • Colitis / irradiation processes

Diverticulosis

• Hernias of the mucosa and submucosa through the muscular layers of the colon
• Formed when the tissue is pushed due to the increased intraluminal pressure at the entry points of the small arteries (rectal vein) into the muscular layer of the colonic wall
• Weaknesses where the mucosa and submucosa herniate when the intraluminal pressure is increased

Ischemic Colitis

• Disorder most commonly seen after age 60
• Risk factors:
  • Old-age
  • Shock
  • Cardio-vascular or abdominal surgery
  • Heart failure
  • Colon cancer
  • Chronic constipation
  • Long-term use of laxatives
• Ischemia causes decreased colonic wall resistance, edemas and bleedings

Angiodysplasias

• Arteriovenous malformations commonly located in the cecum or ascending colon
• Usually occur after the age of 60 years
• Occur due to chronic, intermittent, low-intensity colonic contractions that obstruct the venous drainage of the colonic mucosa
• Dilation of the capillaries in the colonic mucosa with time, leading to the occurrence of arteriovenous malformations