Management of Lower

Gastrointestinal Bleeding
Dr. Wasfi M Salaita
Colorectal Surgeon - KHMC

Epidemiology
Is defined as bleeding distal to the ligament of Treitz.

It can range in severity from trivial to massive.

Severe LGIB was defined by one or more of the
following clinical characteristic:
Transfusion of greater than or equal to 2 units of blood.
Decrease of hematocrit by greater than or equal to

20%. In the first 24 hours.

Recurrent rectal bleeding after 24 h of stability
associated with further decrease in hematocrit of
greater than or equal to 20%, more transfusions, and
readmission within one week of discharge.

LGIB accounts for approximately 20% of all major

GI bleeds.
More commonly bleeding is from a colonic rather
than a small bowel source.
Annual incidence 21 cases per 100,000.
Increasing age is considered frequently as a risk
factor for LGIB and the mean age greater than 60.
No statistical difference between males and
females with LGIB.
Race has not been noted to be a predisposing
factor for LGIB.

80-90% of cases will stop bleeding

spontaneously.
25% will re-bleed.
While most patients have a self-limited illness,
the reported mortality ranges from 2-4%.
Among all patients presenting with lower GI
bleeding, diverticular disease is the most
common cause, followed by,inflammatory
disease and anorectal disease.

Etiology- lower GI
bleeding
Anorectal causes :
Include hemorrhoids -anal fissure and rectal ulcer.
Bleeding from hemorrhoids and fissure is uncommonly
associated with hemodynamic instability or large volume of
blood loss.
While rectal ulcer can cause severe hemorrhage and
hemodynamic instability
Possible causes of rectal ulcer are :
Radiation.
Sexual transmitted disease.
NSAIDs.
Liver disease.
Trauma.

Diverticular disease:
Contributes 20-60% of the cases of LGIB.
In 75% of patients bleeding will stop
spontaneously.
Rebleeding rate after first episode 25% and
increase to 50% after two episodes.
5% will have severe hemorrhage.
diverticular bleeding is distributed equally
between the right and left sides of the colon.
Observation alone is generally recommended
following the first episode of diverticular
hemorrhage. However, following a second
episode, the risk of subsequent episodes
appears to approximate 50%, and thus elective
resection has been recommended.

Angiodysplasia:
The incidence in most recent studies is only 3%

compared to 15-27% previously as cause of

LGIB
Are dilated, tortuous vessels in the mucosa and
submucosa.
The pathophysiology unclear, but is felt to be
due to intermittent obstruction of the
submucosal veins.
May be sporadic, usually developing in the
elderly.
May be found in association with a number of
disorders including renal failure, cirrhosis, the
CREST syndrome, radiation injury, von
Willebrands disease, and aortic stenosis.

May occur anywhere in the GI tract, but are

more commonly found in the colon(most

common in the cecum and ascending colon) ,
followed by the small intestine and the stomach.
These lesions usually lead to occult blood loss,
but can also cause overt GI bleeding.
Usually apparent at endoscopy, at which time
therapy with laser or thermal probes may be
applied.
Bleeding that is refractory to endoscopic or
medical therapy is an indication for surgical
resection.

Colorectal neoplasm
Although colorectal cancer is most commonly
associated with occult blood loss rather than
overt bleeding, patients with rectosigmoid
lesions may present with hematochezia.
CR-cancers are source of LGIB in 9-13% of
patients.

Ischemic colitis
Occurs in 9-18% of patients.
Results from a sudden and often temporary
reduction in mesenteric blood flow, typically
caused by hypoperfusion, vasospasm, or
occlusion.
The usual areas affected are the watershed
areas of the colon: the splenic flexure and the
rectosigmoid junction.
Patients tend to be elderly, often with significant
atherosclerosis or cardiac disease.

Other colonic etiologies:

Inflammatory bowel disease:
Acute

hemorrhage occurs 0.9-6% in CD and 1.4-4% in

UC.
Bleeding occurred in both young and old patients and
not related to disease duration.
Malignant lesion must be considered in patient with
long standing history of IBD and LGIB.
Infectious

colitis or enteritis :
Radiation colitis/proctitis.
Trauma, hematologic disorders and
NSAIDs.
Post polypectomy (occurs in 0.3% to 6.1%
of polypectomies).
Bleeding from CR-anastomosis (o.5-1.8%).

Small bowel sources account for 3-5% of

all cases of LGIB:

Angiodysplasia

is most common cause of

small bowel hemorrhage (70-80%).
small bowel diverticula,
Meckels diverticula,
neoplasia,
Crohns disease,
aorto-enteric fistulas.

Clinical presentation
LGIB has many presentations reflecting the diverse

pathology found in the upper and lower GIT.

The variety of presentations creates a diagnostic and
management quandary.
We can classify the patients with LGIB into three groups
depending on the volume of hemorrhage:
Minor and self limited.
Major and self limited.
Major and ongoing.

So the clinical presentation ranges from manifestations

of iron deficiency anemia to manifestation of

hemorrhagic shock.

MANAGEMENT OF LGI BLEEDING

Initial assessment, resuscitation and triage:
Intravenous access with at least two large-bore lines.
Nasogastric tube placement :
Upper GI bleeding sources are seen in 11% of
patients who present with a LGIB.
The NG tube can be left and used for the bowel
preparation if an urgent colonoscopy is needed.
Determination of hematocrit and coagulation studies,
and type and cross for blood products.
Patients with altered mental status should undergo
endotracheal intubation for airway protection.
The patient should be stabilized before proceeding to
investigation.

Admission to the hospital is required for

most patients presenting with LGI
:bleeding
Those who present with frank hypotension or who-1
have evidence for ongoing bleeding require
monitoring in an intensive care unit and urgent
evaluation
Those who present with mild or no orthostasis, have -2
no evidence for continued bleeding, but have had a
significant drop in hematocrit are generally
. hospitalized on a surgical floor
young patients with self-limited GI bleeding who -3
present without orthostasis or hemodynamic
instability and who have no significant comorbid
.conditions may be managed as outpatients

Diagnosis:
History and physical:
Patients with suspected lower GI bleeding should also
be asked about:
hemorrhoids,
associated diarrhea,
change in bowel habits,
personal or family history of inflammatory bowel
disease,
A history of radiation therapy.
A family history of GI disorders, malignancy or
bleeding disorders should also be obtained.
Physical examination should include digital
examination and Anoscopy to rule out local causes in
anal canal and distal rectum.

Diagnostic

studies: depend on condition of

Colonoscopy:
Both diagnostic and therapeutic.
The likelihood of identifying the source of bleeding

with colonoscopy ranges from 45-95%.

The timing of colonoscopy is debatable.
Urgent colonoscopy is performed within 24 hours
(after bowel preparation and patient
hemodynamically stable).
Endoscopic interventions were performed in 10-15%
of patients who underwent an urgent colonoscopy.
Overall complication rate of colonoscopy in LGIB is
1.3%.
If the source of bleeding identify and not treated
endoscopically, the area should be marked by (clip or
tattoo) .if patient rebleed again and require surgery.

Angiography:
Both diagnostic and therapeutic.
Sensitivity (40-86%) and specificity in 100%.
To be positive the bleeding rate must

occur at 0.5 ml/min or faster.

Success rate from 60-90%.
Rebleeding rate 0-33% and significant
ischemia of less than 7%.
Super selective embolization is the
preferred treatment for positive
angiograms (embolization occurs at the
level of vasa recta or marginal artery).

Materials used for emolization include:

Microcoils.
Permanent materials.
Multiple sizes.
Easily visible during fluoroscopy.
Polyvinyl alcohol particles.
Permanent.
Poorly visualized.
Gelfoam.
Not permanent agent with vessel recanulization
in days to weeks and it is not routinely used.

If superselective embolization is unable

to be performed:
Localize the site of bleeding by injection

methylene blue into artery providing a

temporary marker for the surgeon.
Intra-arterial vasopressin infusion.
Infusion rate of vasopressin 0.2 U/min
may progress to 0.4 U/min.
Controls bleeding in as many as 91%.
Bleeding may recur in as many as 50%.

Superselective embolization for sources other

than diverticuli has higher failure rates.

Indications:
Patients with major, ongoing hemorrhage.
Patients who rebleed.
Patients who have negative upper and lower

endoscopy with continued evidence of bleeding.

Using Provocative angiography which uses
anticoagulant-vasodilators or fibrinolytics to
induce bleeding. (streptokinase- urokinase)
positivity in single study about 20-80%.

Radionuclide scintigrahy:( radioactive labeling of

red blood cell)

In comparison to colonoscopy and angiography:
It does not have any therapeutic capabilities.
It is not invasive.
Does not require a bowel preparation.
It does not require specialist to perform.
Bleeding rate as low as 0.1 ml/min can be

detected.
It is positive in 16-91%.
Using a positive scintigraphy as a requirement for
angiography led to an increase in positive
angiogram from 22-53%.

The role of Radionuclide scintigrahy in the

management of LGIB poorly defined

If scan is negative, rebleeding rates are not

negligible (reach up to 25%).

Colonoscopy performed after a negative scan
found potential bleeding etiologies in89% of
patients.
More important than the recurrent bleeding is
the inability of scintigraphy to adequately
localize the source of bleeding so surgical
resection based on radionuclide scintigraphy is
not recommended.

One advantage of scan is that rebleeding

within 24h can be restudied promptly without

second labeling procedure.

Multidetector Row Computed tomography:

Increase role in the diagnostic workup

of LGIB.
Blood flow can be detected at 0.3
ml/min.
Positive when vascular contrast material
is extravasated into the bowel lumen.
Advantages:
It

is easy to perform and readily available in

emergency rooms with CT-scanners.
Accurate localization of bleeding site which
allows for directed angiogram and less
contrast use
Identification of other pathologies.

Surgery:
The majority of patients with LGIB will

stop spontaneously and never require

surgery
approximately 10-25% of patients will
require operative intervention

Indications:
Hemodynamically unstable patient (who have
massive ongoing bleeding and unresponsive to
initial resuscitation).
Patients who have had the source of bleeding
localized but no therapeutic measures
performed or they failed.
Patients who required at least six units of
packed red cells within 24h.

The aim of the preoperative diagnostic work

up is to localize the source of bleeding.

If a colonic source is localized then segmental

rather than subtotal colectomy can be

performed.
Mortality rates associated with segmental and
subtotal colectomy for lower GI bleeding are
4-14% and 0-40%, respectively.

The need for emergent surgery without

localized source of bleeding is uncommon

occurring in 4.8% of patients with LGIB.

Obscure Gastrointestinal Bleeding

Defined as recurrent acute or chronic GI

bleeding for which no source has been

found despite evaluation with EGD and
colonoscopy with or without routine
small bowel follow-through.
It accounts 1.19-9% of LGIB.
The most frequent causes are :
Small bowel tumors.
Angiodysplasia.
Ulcer\erosion.

The diagnosis needs more procedures than

patients with upper GI and colonic bleeding

include:
Capsule endoscopy.
Indications:
Obscure

GI bleeding.
Unexplained iron deficiency anemia.
Small bowel tumors.
Suspected crohn's disease.
Refractory malabsorption.
Contraindications:
Any

condition interferes with transmission signals

e.g. pacemaker.
Any condition interferes with normal peristalsis.
Swallowing disorders.
Obstruction.
Stricture.
The

diagnostic yield of capsule is 38-83%.

Double balloon enteroscopy.

Indications:
Positive

capsule endoscopy.
High suspicious of small bowel source.
Can

be performed oral or rectal.

The diagnostic yield is 58%.

Thank you