Lower GI bleeding.pdf

6 Lower GI bleeding ILOs At the end of this session, the student will be able to:  Define lower GIT bleeding and its incidence.  Enumerate different etiologies and presentation of LGIB.  Understand the different diagnostic tools to reach final diagnosis.  Outline the manag...

6 Lower GI bleeding ILOs At the end of this session, the student will be able to:  Define lower GIT bleeding and its incidence.  Enumerate different etiologies and presentation of LGIB.  Understand the different diagnostic tools to reach final diagnosis.  Outline the management plan for lower GIB.  Summarize Obscure gastrointestinal bleeding (OGIB) LOWER GASTROINTESTINAL BLEEDING It is bleeding below the ligament of Treitz. Normal fecal blood loss 1.2 ml/day. It is significant if the loss >10 ml/day. It might be presented as: Hematochezia ranges from bright red blood to old clots or Melena if the bleeding from proximal source with slow rate of bleeding. Incidence: It accounts for 22-30% of GIT bleeding. Lower tract bleeding is one-third as common as upper gastrointestinal hemorrhage and tends to have a more benign course.80% to 85% of lower GI bleeds originate distal to the ileocaecal valve, with only 0.7% to 9% originating from the small intestine. 80% resolve spontaneously and 25% will recur. The incidence rises steeply with increasing the age. It can be categorized into massive, moderate or occult bleeding. These patients usually present with brisk bleeding, melena, or bright red blood per rectum. Hematochezia associated with hemodynamic instability should lead to consideration of a brisk UGIB source, especially in at-risk patients such as those with a history of peptic ulcer disease or liver disease with portal hypertension and those using antiplatelet or anticoagulant medications. An elevated blood urea nitrogen to creatinine ratio (> 30) also suggests an UGIB source whereas red blood and clots are unlikely to be from an upper gastrointestinal source. Page 1 of 9 Types: we can classifiy the lower GI bleeding according to: Etiology. Site of bleeding Relation to the pain. A. According to the etiology: Congenital - Polyp’s / Meckel’s diverticulum /hereditary hemorrhagic telangiectasia. Inflammatory - Ulcerative colitis / Infective /Amoebic / Crohn’s disease. Neoplastic – Adenomas / Carcinomas / Polyps. Diverticulosis is the most common cause of lower GI bleeding. Vascular – Angiodysplasia / Ischaemic colitis / Vasculitis / Hamangioma. Clotting disorders - Haemophilia / Leukaemia / Warfarin therapy / DIC. Miscellaneous – Piles / Anal fissure / Injury to rectum. B. According to the presence of pain:  With pain: Fissure in Anus, Fistula in Anus. Ca. Anal Canal. Rup. perianal haematoma. Rup. AnoRectal abscess. Endometriosis. Injury.  Without pain: Blood Alone: Polyp, Villous Adenoma, Diverticular diseases Blood After Defecation: Hemorrhoids Page 2 of 9  Blood with mucus: Ulcerative colitis, Intussusception or Ischaemic Colitis. Blood Streaked on stool: Ca. Rectum. Clinical Findings: Symptoms and Signs: Painless large-volume bleeding usually suggests diverticular bleeding. Bloody diarrhea associated with cramping abdominal pain, urgency, or tenesmus is characteristic of inflammatory bowel disease, infectious colitis, or ischemic colitis. Brown stools mixed or streaked with blood predict a source in the rectosigmoid or anus. Large volumes of bright red blood suggest a colonic source. Maroon stools imply a lesion in the right colon or small intestine. Black stools (melena) predict a source proximal to the ligament of Treitz. Management of lower GIB: Patient evaluation should consider proper history taking, clinical examination especially the perianal area if hemorrhoids is suspected. Colonoscopy is the gold standard. CT angiography: Identifies bleeding rate of 0.5ml/mt as occurs in cases of Angiodysplasia / Tumors / Vasculitis – diagnosed. Radionuclear scanning – Identifies 0.1ml / mt Tc labelled sulphur colloid / tagged RBC scan. The patients presenting with lower GI bleeding are stratified as unstable or stable (unstable defined as a shock index >1. Shock index=heart rate/SBP Stable bleeds should then be categorized as major or minor, using a risk assessment tool such as the Oakland score. Table 1. Oakland score. is the first score that has been specifically designed for LGIB and externally validated. Page 3 of 9  The Oakland score has superior ability to identify patients who are at low risk of adverse outcomes. OS