Approach to lower gi bleeding(LGIB).pptx

approach to LGIB

1. SEMINAR PRESENTATION ON APPROACH TO LGIB Presenter: Omer M.(Intern) Moderators: Dr Solomon L.(General surgeon) Dr Moges (GSR4) 9/5/2024 LGIB By Omar * COLLEGE OF MEDICINE AND HEALTH SCIENCES SCHOOL OF MEDICINE DEPARTMENT OF SURGERY

2. Outline Objectives of the presentation Introduction Causes Clinical presentation Investigations Approach to patients 9/5/2024 LGIB By Omar 2

3. Objectives of the presentation At the end of the presentation, you will be able to: Know common causes of LGIB Detect various clinical presentation of patients with LGIB Approach to patients with LGIB 9/6/2024 LGIB By Omar 3

4. Case scenarios A 60 year old woman presents to ED complaining bright red blood with stool. She also complains left sided lower abdominal pain. Otherwise she has no other contributory history. What is the most likely diagnosis? A 30 year old man presents with perianal pain since yesterday morning. He describes excruciating pain and bleeding produced by defecation. What is the most likely diagnosis? How to approach the above patients? 9/5/2024 LGIB By Omar 4

5. Introduction LGIB refers to bleeding distal ligament of teirtz Majority of bleeding is from the colon(95 %) Much less common than UGIB Incidence increases with age Majority of cases are self limiting 9/5/2024 LGIB By Omar 5

6. 9/5/2024 LGIB By Omar 6

7. 9/6/2024 LGIB By Omar 7 Causes of LGIB

8. 9/5/2024 LGIB By Omar 8

9. Age specific causes 9/5/2024 LGIB By Omar 9 Children Young patients Old patients NEC Meckel’s diverticulum Inussusception Enterocolitis Anorectal disease IBD Dysentery Carcinoma Diverticular disease Angiodysplasia IBD

10. Diverticular disease Diverticula are outpouchings of- Mucosa and submucosa-False diverticula All layers-True diverticula Diverticulosis is simply the presence of diverticula 9/5/2024 LGIB By Omar 10

11. Diverticular disease… The most common cause of LGIB in westerns Sigmoid colon is the most common site Risk factors include: Age Dietary NSAIDs Smoking and alcohol 9/5/2024 LGIB By Omar 11

12. Diverticular disease… Pts will present with bright red bleeding per rectum. Usually associated with: LLQ pain Bowel habit changes 9/5/2024 LGIB By Omar 12

13. Neoplasia Colorectal polyps and carcinomas Sloughing of the lesion presents as LGIB In majority of cases bleeding is occult 9/5/2024 LGIB By Omar 13

14. Colorectal ca The most common malignancy of GI tract Risk factors include: Age Dietary Smoking and alcohol FAP and HNPCC IBD 9/5/2024 LGIB By Omar 14

15. Clinical features Nonspecific until the cancer is locally advanced Change in bowel habit and rectal bleeding Unexplained anaemia Abdominal pain, bloating other signs of obstruction Left sided tumours are more likely to cause obstruction 9/6/2024 LGIB By Omar 15

16. Anorectal disease Hemorrhoids, anal fissures, fistulas and anal ca Hemorrhoids are the most common of these entities Usually low volume bright red bleeding 9/5/2024 LGIB By Omar 16

17. Haemorrhoids They are cushions of submucosal tissue in the anal canal But the term haemorrhoid is restricted to their abnormality Risk factors include: Conditions that increase intraabdominal pressure Dietary factors Advanced age 9/5/2024 LGIB By Omar 17

18. Haemorrhoids… Internal haemorrhoids Proximal to dentate line More common Painless External haemorrhoids Distal to DL Painful 9/5/2024 LGIB By Omar 18

19. Classification of internal haemorrhoids 1 st degree Painless bleeding, no prolapse Dietary fibers , stool softners , sitz bath, 2 nd degree Prolapse during straining but reduces spontaneously The same as above 3 rd degree Prolapse requiring manual reduction Rubber band ligation, sclerotherapy, surgical hemorrhoidectomy 4 th degree Cannot be reduced Operative heorrhoidectomy 9/5/2024 LGIB By Omar 19

20. Anal fissures Linear defects in the anorectum Located in the midline with posterior location Causes include: Trauma Infections like TB, syphilis, STI Patients will present with: Excruciating pain Bleeding per rectum during defecation Patients usually remember the time the fissure developed based on symptoms 9/6/2024 LGIB By Omar 21

21. Clinical presentation of LGIB Overt bleeding Patients with LGIB typically present h ematochezia Although it can be seen in case of massive UGIB Melena if the bleeding is slower or from proximal source Occult bleeding Patients present with anemia 9/5/2024 LGIB By Omar 22

22. Clinical presentation cont... Associated symptoms: Perianal pain, lump Abdominal pain Characteristics of blood with stool Bleeding tendency 9/5/2024 LGIB By Omar 23

23. 9/5/2024 LGIB By Omar 24 INVESTIGATIONS

24. Lab studies Blood tests CBC Co agulation profile Stool examination Ova/cysts worms FOBT OFT and serum electrolyte 9/5/2024 LGIB By Omar 25

25. Colonoscopy Investigation of choice in LGIB Both diagnostic and therapeutic Findings may include: Actively bleeding site, Blood localized to a specific colonic segment, Polyps, cancers and inflammatory cause 9/5/2024 LGIB By Omar 26

26. Radionuclide scanning Technetium labelled RBC scintigraphy Most sensitive but least accurate Detects very small amount of blood(0.05-0.1ml/min ) Only diagnostic value 9/5/2024 LGIB By Omar 27

27. A ngiography Can detect hemorrhage in the range of 0.5-1mL/min Can identify the vascular patterns of angiodysplasias Can localize actively bleeding diverticula Therapeutic-catheter directed vasopressin infusion 9/5/2024 LGIB By Omar 28

28. Other investigations Upper GI endoscopy Abdominal U/S Abdominal CT Biopsy 9/5/2024 LGIB By Omar 29

29. APPROACH TO PATIENTS 9/5/2024 LGIB By Omar 30

30. Approach to patients Quick assessment Stratify patients as stable and unstable Aggressive resuscitation Prompt consultation 9/5/2024 LGIB By Omar 31

31. 9/5/2024 LGIB By Omar 32

32. Management of LGIB Resuscitation and initial assessment Localization of the bleeding site Therapeutic intervention to stop the bleeding Cause specific treatment 9/5/2024 LGIB By Omar 33

33. Initial evaluation History of: Prior episodes Medication use Comorbidities Symptoms that suggest particular etiology 9/5/2024 LGIB By Omar 34

34. Initial evaluation… Physical examination Assessment of hemodynamic status Targeted physical exam Laboratory CBC OFT Coagulation profile Serum electrolyte 9/5/2024 LGIB By Omar 35

35. Initial management General supportive measures-ABC of life O2 administration IV access and appropriate fluid and blood resuscitation Management of coagulopathies 9/5/2024 LGIB By Omar 36

36. Localization of the bleeding Colonoscopy for stable patients Failure of colonoscopy to localize: T argeted RBC scan Angiography requires ongoing bleeding Small bowel endoscopy Capsule endoscopy 9/6/2024 LGIB By Omar 37

37. Localization of the bleeding… More than one potential source in 40% of cases It is critical to confirm the responsible lesion before aggressive therapy This approach occasionally requires a period of observation 9/6/2024 LGIB By Omar 38

38. Treatment of the bleeding site Embolization Endoscopic interventions Epinephrine injection Cauterizations Endoscopic clips Patients rarely need surgery 9/5/2024 LGIB By Omar 39

39. Indications for surgery 9/5/2024 LGIB By Omar 40

40. References Schwartz's principle of surgery 11 th edition Sabiston’s text book of surgery 19 th edition Maingot’s abdominal operations 13 th edition Uptodate 2024 9/5/2024 LGIB By Omar 41

41. 9/5/2024 LGIB By Omar 42