Lower Gastrointestinal Bleed

PPt from the presentation at Kathmandu Model Hospital.

1. Lower GI Bleeding Dr. Kiran Pandey MS General Surgery Resident (NAMS) MS General Surgery Resident

2. Lower GI bleeding is define d as abnormal hemorrhage into the lumen of the bowel from a source distal to the ligament of Treitz

3. Epidemiology Overall mortality <5 %. [ Frequency and severity of UGIB >LGIB ] LGIB is more common in women > men. Incidence and prevalence related to specific etiologies More than 80% of lower GI bleeds will stop spontaneously, and overall mortality has been noted to be 2% to 4% .

4. Lower GI bleeds: 20% to 30% of all patients presenting with major GI bleeding.  The incidence is higher in older patients and multiple medications.  Approximately, 80% to 85% originate distal to the ileocaecal valve, with only 0.7% to 9% originating from the small intestine. The remaining cases usually begin in the upper GI tract. Present with brisk bleeding, melena , or bright red blood per rectum.

5. Categorizatio n base d o n severity Massive Moderate Mild

6. https://www.ncbi.nlm.nih.gov/books/n/statpearls/article-22103

7. Ris k factors Low fiber diet Obesity, Physical Inactivity Radiation NSAID or Aspirin usage Advancing age Co morbidities

8. Causes in adults Diverticulosis (30 - 50%) Angiodysplasia (20 - 30%) ( or AVM, or Vascular Ectasias) Neoplastic (10- 15%) Polyps Cancer

9. Causes in adults Inflammatory (15 - 20%) Radiation - Intestinal damage due to fibrosis and ischemia. IBD Ulcerative colitis Crohn’s Disease Infectious (E. Coli 0157:H7, C. Difficile , C. Jejuni ) Ischemic ( Hypoperfusion and Vasoconstriction) Hypotension, Heart Failure, Arrhythmia Vasculitis

10. Others (5 – 10%) Post-polypectomy bleeding Aortoenteric fistula Coagulation deficiency Hemorrhoids (< 50 y.o. most common) (5 – 10%) Unknown (10 – 15%) Causes in adults

11. Causes in children Anal Fissure Infectious Colitis IBD Crohn’s Disease Ulcerative Colitis Polyps Intussusception Meckel’s Diverticulum (embryonic diverticulum) Pseudomembransous Colitis

12. Histo r y chronicity of bleeding and medication use . anti coagulants such as warfarin. low molecular weight heparin. inhibitors of platelet aggregation such as NSAID clopidrogel this can associated with mesentric ischemia

13. History Use of digitalis can associated with mesenteric ischemia Comorbid medical conditions like cardiac conditions. Family history of colorectal cancer Coagulopathy

14. Sign s an d Symptoms Hematochezia (most often painless) Anemia Occult blood in stool Rarely melena (UGIB most common) Normal Bowel Sounds, Normal Renal Function (BUN/Cr) Nasogastric aspirate usually clear

15. M assive upper gastrointestinal bleed can present with hematochezia. An NG aspirate that contains bile and no blood effectively rules out upper tract bleeding in most patients . Majority of cases bleeding regresses spontaneosly

16. Outcome depends on risk stratification Predictors of poor outcome in lower GI bleed Hemodynamic instability Ongoing hematochezia Presence of comorbid illness

17. CONDITIONS WITH RECTAL BLEEDING BUT NO PAIN: Blood mixed with stool :colon carcinoma Blood streak on stool:rectal carcinoma Blood after defaecation : haemorrhoids Blood and mucus: colitis Blood alone diverticular disease Melaena:peptic ulcer

18. PAIN AND BLEEDING: Fissures PAIN, LUMP AND BLEEDING: Prolapsed haemorrhoids Carcinoma of the anal canal Prolapsed rectal polyp or carcinoma Prolapsed rectum

19. Manangeme n t Includes Identification of site of bleeding Stopping the bleeding and treating the cause Digital rectal examination should be done to exclude anorectal pathology as well as confirm the patient’s description of stool color.

20. Investigations CBC - Anemia, Infection, Thrombocytopenia, Protein Levels, Iron, Crossmatch Coagulation Hemoccult and Stool cultures ECG

21. Endoscopic investigations Proctoscopy Sigmoidoscopy Colonoscopy Video Capsule Endoscopy Double balloon endoscopy Intraoperative Endoscopy

22. Radiological investigations Abdominal X rays Angiography Radionuclide scintigraphy Technetium Sulfur Colloid 99mTc pertechnate-labeled RBC Multidetector row CT (MDCT ) Barium studies have no role in lower GI bleeding

23. Colonoscopy Usually done after stabilizing the patient Provide both diagnosis and hemostasis Better than Sigmoidoscopy The diagnostic yield of urgent colonoscopy in between 75-97% , depending on the definition of the bleeding source, patient selection criteria, and timing of colonoscopy

24. Bowel preparation Recent studies have suggested that performi a ng colonoscopy shortly after presentation is advantageous

25. Criteria for identifying site of bleeding on colonoscopy Active colonic bleeding Adherent clot Fresh blood localized to a colonic segment Ulceration of diverticulum with fresh blood in adjoining area Absence of fresh bleed in terminal ileum with fresh blood in the colon

26. Screening of colorectal cancer and adenomatous polyps is Asymptomatic men and women ≥ 50 years of age Screening for colorectal cancer

27. Low-risk individuals : Complete colonoscopy (gold standard) : Repeat every 10 years if no polyps or Carcinoma  Annual  fecal occult blood test (  FOBT): Sigmoidoscopy  every 5 years  and FOBT every 3 y Annual fecal immunochemical testing (FIT) CT  colonography every 5 years

28. Histology of removed polyp Recommended interval until next control colonoscopy Hyperplastic Polyp < 10 mm in size in the  rectum or sigmoid 10 years Low risk  ademoma :  1–2 tubular polyps < 10 mm in size and without intraepithelial  Neoplasia  (IEN) 5–10 years High risk adenoma 3–10 tubular polyps 1 polyp ≥ 10 mm 1 villous or tubulovillous polyp 1 tubular polyp with high-grade  dysplasia 3 years More than  10 adenoma < 3 years; depends on the case (i.e., family history) Surveillance following Polypectomy

29. High-risk individuals   Complete colonoscopy 10 years earlier than the index patient's age at diagnosis or no later than 40 years of age

30. Lynch syndrome and FAP syndrome Colonoscopy: every 1–2 years, starting at 20–25 years of age, or 2–5 years before the earliest recorded case in family whichever comes first  Annual upper endoscopy with biopsy of the gastric antrum  starting at 30–35 years of age Annual physical exam and  urinylasis

31. Video Capsule Endoscopy Capsule endoscopy uses a small capsule with a video camera that is swallowed and acquires video images as it passes through the GI tract. This modality permits visualization of the entire GI tract, but offers no interventional capability. It is also very time consuming

32. Visualizes entire gastrointestinal tract in real time The two balloons inflate and deflate intermittently creating a peristaltic movement so that the scope can move forward Double balloon endoscopy

33. Intraoperative Endoscopy Intraoperative enteroscopy is reserved for patients who have transfusion-dependent obscure-overt bleeding in whom an exhaustive search has failed to identify a bleeding source. This typically uses a pediatric colonoscope introduced through an enterotomy in the small bowel made by the surgeon.

34. Abdomina l X rays Perforation Obstruction “Thumb-printing” = Ischemic/Infectious Colitis Megacolon

35. Angiograph Both diagnostic and therapeutic Requires a bleeding rate of at least 0.5 to 1.0 ml/min Done in hemodynamically unstable patients Reserved for massive bleeding

36. Vasopressin was the first therapeutic modality Major complications occurred in 10% to 20% of patients and included arrhythmias, pulmonary edema, hypertension and ischemia Re bleeding occurred in up to 50% of patients Earlier embolization was associated with infraction Technologic advances in coaxial microcatheters and embolic materials have enabled the embolization of specific distal arterial branches with increased success and fewer complications

37. Radionuclide scintigraphy Non-invasive Done as screening before angiography More sensitive Detects bleeding as low as 0.1 ml/min Major disadvantage false localisation Two methods are used Technetium Sulfur Colloid 99mTc pertechnate-labeled RBC

38. Tc-99m Red Blood Cells Tc-99m RBCs remain in the vascular compartment In vitro or modified in vivo labeling of RBC is done Allows continuous monitoring of the whole gastrointestinal tract for a long period False-positive readings due to misinterpretation of intravascular activity and the possibility of free pertechnetate accumulation sensitivity and specificity of this method are very high

39. Tc-99m sulfur colloid Rapid blood clearance of this tracer from circulation allows for increased detection at very low bleeding rates (0.05 to 0.1 ml/min) Detects bleeding only up to 15 minutes after intravenous injection

40. Multidetector Row CT (MDCT) Show contrast extravasation into any portion of the gastrointestinal tract Detects bleeding rates as low as 0.3 to 0.5 ml per minute The average yield of MDCT for lower GI bleed Is 60%, with yields ranging from 25% to 95%. Lack of therapeutic capability is a major limitation Useful in guiding further:angioembolisation

41. Advantages and disadvantages of common diagnostic procedures used in the evaluation of lower gastrointestinal bleeding Procedure Advantages Disadvantages Colonoscopy - Bowel preparation required Can be difficult to orchestrate without on call endoscopy facilities or staff Invasive Angiograp h y Therapeutic possibilities Diagnostic for all sources of bleeding Needed to confirm diagnosis in most patients regardless of initial testing Efficient/cost - effective No bowel preparation needed Therapeutic possibilities May be superior for patients with severe bleeding Radionuc l ide scintigraphy Noninvasive Requires active bleeding at the time of the exam Less sensitive to venous bleeding Diagnosis must be confirmed with endoscopy/surgery Serious complications are possible Variable accuracy (false positives) Sensitive to low rates of bleeding No bowel preparation Easily repeated if bleeding recurs Flexible sig m oidoscopy Diagnostic and therapeutic Not therapeutic May delay therapeutic intervention Diagnosis must be confirmed with endoscopy/surgery Visualizes only the left colon Minimal bowel preparation Colonoscopy or other test usually necessary to rule out right- sided lesions Easy to perform

42. Conclusions: Post-interventional LGIB was effectively addressed by LE. For other causes of LGIB, CTA was efficient, and more available than colonoscopy. Treatment was conservative for most patients. In case of active bleeding, CTA could localize the bleeding source and predict the need for surgery.

43. References Bailey’s and Love Short Practice of Surgery, 26 th Edition Hammilton Bailey’s Demonstration of physical sign in clinical Surgery 19 th Edition Clerc et al. World Journal of Emergency Surgery (2017) 12:1 DOI 10.1186/s13017-016-0112-3 Edelman, D.A., Sugawa , C. Lower gastrointestinal bleeding: a review.  Surg Endosc   21,  514–520 (2007). https://doi.org/10.1007/s00464-006-9191-7 https://www.ncbi.nlm.nih.gov/books/n/statpearls/article-22103 Lower Gastrointestinal Bleeding, Don C. Rockey DOI:  https://doi.org/10.1053/j.gastro.2005.11.042 https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/screening-tests- https://www.amboss.com/us/knowledge/Colorectal_cancerused.html https://www.amboss.com/us/knowledge/Lynch_syndrome#xid=fS0k_2&anker=Z223291f8ddc1791ddb38550c25b8a05c