2020 LGITB [Autosaved].pptx

APPROACH TO LOWER GI TRACT BLEEDING Dr. Naseer Al Maliki  Objectives: 1. Definition of Lower GI Hemorrhage. 2. Classification, and Differential Diagnosis: Be able to differentiate the clinical presentations of occult and acute anorectal, non-anorectal lower Gl trac...

APPROACH TO LOWER GI TRACT BLEEDING Dr. Naseer Al Maliki  Objectives: 1. Definition of Lower GI Hemorrhage. 2. Classification, and Differential Diagnosis: Be able to differentiate the clinical presentations of occult and acute anorectal, non-anorectal lower Gl tract, and upper Gl tract bleeding. 3. Learn a diagnostic and therapeutic approach to lower Gl tract bleeding. -Interventions and Treatments  Lower GI bleeding is defined as bleeding from a source distal to the Ligament of Treitz.  Classification According to the: 1. Severity of blood loss: Mild ,Moderate Massive 2. Site of blood loss: Peri-anal and above peri-anal source. 3. Character of blood loss. 4. Age group: Children ,young ,adult ,elderly According to the Severity of blood loss: 1. Mild(OCCULT) , 2. Moderate 3. Massive According to the Site of blood loss: Peri-anal above peri-anal source. Rectal, Colonic, Small bowel. According to the Character of blood loss: Diagnosis of conditions presenting with rectal bleeding but no pain: Blood mixed with stool  colon carcinoma Blood streak on stool rectal carcinoma, Blood after defecation hemorrhoids,(few drop) Blood and mucus colitis Blood alone diverticular disease Melena peptic ulcer According to the Age group: 1. Children ,and adolescent 2. young , 3. adult , 4. elderly  Clinical Approach Melena (tarry stool) indicates the degradation of hemoglobin by bacteria and forms after blood has remained in the Gl tract for >14 hours. Melena is usually associated with upper Gl tract or small bowel bleeding but can occur with bleeding from the ascending colon.  The passage of maroon-colored stools generally excludes a possible bleeding source in the rectum and anus. Bleeding from the rectum is usually characterized by: A. the passage of formed stools streaked with blood. B. or the passage of fresh blood at the end of a normal bowel movement.  HISTORY TAKING alter bowel habit 1. Normal bowel habit. 2. Intermittent bouts of constipation interrupted by diarrhea: Carcinoma or Diverticular disease. 3. Diarrhoea: Inflammatory bowel disease or rectal villous tumour. 4. Tenesmus: Irritable bowel syndrome or abnormal mass of rectum or anal canal -CA, -polyps, -thrombosed hemorrhoid.  ANAL PAIN: During pregnancy/childbirth: anal Fissure, hemorrhoids. Throbbing, severe pain occur during defecation: anal Fissure.  HISTORY TAKING PREVIOUS HISTORY Previous peri-anal disease. Inflammatory bowel disease. Peptic ulcer disease. Liver disease. Coagulopathy. FAMILY HISTORY History of malignancy. Familial Adenomatous Polyposis.FAP,HNPCC  DRUGS HISTORY: Laxative agent. Anti-parkinson agent. Anti-coagulant therapy: warfarin. NSAID’s-risk factor of PUD. SOCIAL HISTORY: Low fiber diet. Smoking.  PHYSICAL EXAMINATION: General examination: 1. Anaemia 2. Bruising/ Purpura 3. Cachexic 4. Dehydrated 5. Jaundice Abdomen: 6. Inspection - distension, scar, prominent vein. 7. Palpation - tenderness, mass/ organomegaly 8. Percussion - shifting dullness, fluid Rectal :  Perianal Skin Lesion  Masses  Melena Lymph node:  Supraclavicular LN  Cervical LN  Axillary LN  Inguinal LN CNS:  Confusion ( Shock, liver failure….)  Neurological Deficit  Lab Investigation Appropriate blood tests include : 1. CBC 2. Serum electrolytes 3. Blood urea nitrogen, S. creatinine 4. Blood grouping and cross matching 5. Coagulation profile including: - (aPTT) , - (PT), - platelet count, - bleeding time Fecal Occult Blood Testing(FOBT) Normally lose 0.5-1.5mL blood/day from GIT Three types of test 1. Guaiac-based test. 2. Immunochemical test. 3. Heme-porphyrin test.  Barium Enema: No role in diagnosis of active lower GIT bleeding If used will obscure any subsequent attempts to visualize by arteriography or colonoscopy Double contrast enema has 70% sensitivity in elective detection of non-bleeding colonic lesions  Rigid proctosigmoidoscopy: A simple bedside procedure in which a non- flexible endoscope is used to visualize the most distal 25-cm segment of the lower GI tract.  Colonoscopy Diagnostic and therapeutic capabilities Can be used even with ongoing massive bleeding Characteristic endoscopic findings of recent upper GIT bleeding are the same as for lower GIT bleeding: – Active bleeding - focal adherent clots – Non-bleeding visible vessels  Colonoscopy Timing ideally 6-24 hours post presentation – Patient must be in stable condition. – Allows bowel preparation. – This is the time when recurrent bleeding usually occurs Increased risk of bowel perforation: – So should not be attempted with Bleeding Diverticulum  Nuclear Scintigraphy plan surgery on results? Useful as a prelude to angiography to confirm active hemorrhage +/- localization Active Bleeding from Meckel’s diverticulum  Angiography – Femoral artery punctured – Positive test if extravasation of contrast into bowel lumen. Selective injection of vasopressin or gel-foam can be applied to treat active bleeding in patients who are not suitable surgical candidates. So is is Diagnostic and potentially therapeutic: – Adrenaline infusion – Embolization Sensitivity 40-86% 1. Scintigraphy:Radioactive test using Technetium-99m (99mTc)-Labelled red cells -diagnose ongoing bleeding at a rate as low as 0.1 mL/min 2. Mesenteric angiography: -Can detect bleeding at a rate of more than 0.5 mL/min.  CT Angiography: New and evolving technology Requires modern CT scanner Fast - < 15mins Non-invasive Identifies large and small bowel bleeding Sensitivity and specificity 72-80% Ix of choice in the future? CT Colonoscopy (Virtual colonoscopy): – May have a role in assessment of pts with +ve FOB Capsule Endoscopy (CE)  Obscure GIT bleeding ~5% of patients have bleeding which remains unlocalized despite extensive Ix. Investigative options: 1. Push enteroscopy / Sonde enteroscopy 2. Capsule enteroscopy 3. Small bowel follow-through 4. Meckel’s Scan 5. Diagnostic laparoscopy 6. Exploratory laparotomy +/- enteroscopy  Enteroscopy Requires special instruments – push Enteroscope 2.7m long thin scope – Sonde Enteroscope scope with balloon attached to peristalses through the bowel – Paediatric colonoscope use has been reported Permits inspection of Small Bowel: – to proximal jejunum with push enteroscopy – entire SB with Sonde scope ~25% diagnostic yield in reported series.  What are the three components of m anagement of lower gastrointestinal ( GI) bleeding (LGIB)?