LOWER GASTROINTESTINAL BLEED - Surgery.pptx

Lower gastrointestinal bleeding - causes, classification and management

1. LOWER

2. GI BLEEDING Gastrointestinal bleeding (GIB) is a term that describes the loss of blood from along the alimentary canal. GIB is classified by its anatomic location relative to the ligament of Treitz. Upper GIB (UGIB) is defined as being proximal to the ligament of Treitz .

3. GI BLEEDING Upper intestinal hemorrhage is the most common presentation of GIB and is commonly from peptic ulcer disease (PUD) or oesophageal varices. Pancreatic, liver, and other biliary origins of blood loss also are encompassed by this term. Lower GIB (LGIB) accounts for 30% to 40% of all bleeds and is defined as distal to the ligament of Treitz. This most often originates from the colon from diverticular disease or angiodysplasias .
The term massive GIB refers to intestinal blood loss leading to hemodynamic instability or transfusion requirement, whereas occult GIB refers to anemia that persists or recurs after negative endoscopic evaluation and imaging workup.

4. GI BLEEDING

5. LOWER GI BLEEDING Bleeding from the GI tract distal to the ligament of Treitz, mainly from the small intestine, colon, rectum, or anus. Normal faecal blood loss is 1.2 ml/day . A loss more than 10 ml/day is significant. Incidence : Accounts for 30% to 40% of all GI bleeds.
More common in elderly patients and those with comorbidities. Severity : Can range from self-limiting to life-threatening hemorrhage requiring surgical intervention

6. ANATOMY – Lower GI Tract Small Intestine (Jejunum, Ileum)
Colon (Ascending, Transverse, Descending, Sigmoid)
Rectum & Anus Vascular Supply: •Superior Mesenteric Artery (SMA) → Supplies small intestine, ascending & transverse colon
•Inferior Mesenteric Artery (IMA) → Supplies descending colon, sigmoid, rectum
•Internal Iliac Artery branches → Supply the anorectal region

7. DIFFERENTIAL DIAGNOSES OF LOWER GI BLEEDING

8. CLASSIFICATION A.Based on etiology: 1 .Congenital : Polyp’s, Meckel’s diverticulum. 2. Inflammatory : Ulcerative colitis, infective, Crohn’s disease. 3 .Neoplastic : Adenomas, carcinomas, polyps. 4. Vascular : Angiodysplasia, mesenteric artery ischaemia, colitis. 5. Others : Piles, fissure-in-ano

9. CLASSIFICATION B. Based on site : 1 . Small bowel bleed : Polyps, Meckel’s diverticulum, mesenteric ischaemia, intussusception; small bowel tumor. 2.Large bowel bleed : Angiodysplasia, carcinoma, colitis, diverticulitis, carcinoma. 3 . Anorectal diseases : Piles, fissure-in-ano, carcinomas.

10. CLASSIFICATION C. Based on intensity : 1.Massive bleeding: Bleeding> 1.5l/day. Associated hemodynamic instability(HOTN, tachycardia). Need blood transfusion of greater than 2U. 2.Moderate bleeding: No significant hemodynamic instability. May require transfusion but usually responds to conservative management. 3.Occult bleeding: >10 ml/day but not revealed. No hemodynamic instability.

11. CAUSES Angiodysplasia . Diverticular disease (commonest cause in Western countries.) Tumours of colon or small bowel. Anorectal diseases(haemorrhoids, fissure-in-ano) Ulcerative colitis, Crohn’s disease . Colorectal polyps; rectal carcinomas. Intussusception. Tumours, either benign or malignant of colon or small bowel. Meckel’s diverticulum. Ischaemic colitis. Stercoral ulcer. Infectious colitis. Mesenteric artery occlusion.

12. CAUSES

13. Diverticula form at points of weakness in the bowel wall , where the vasa recta penetrate the circular muscle layer. As the dome of the diverticulum expands, the penetrating vessel is stretched and undergoes changes that can lead to vessel rupture and bleeding. DIVERTICULA

14. COLITIS Inflammation of the colon can result from multiple disease processes, including IBD, infectious colitis, radiation proctitis after treatment for pelvic malignancies, and ischemia.

15. COLITIS

16. ANGIODYSPLASIA Also known as: arteriovenous malformations , angiectasias , and vascular ectasia. Vascular abnormality of GIT characterised by dilated, thin walled blood vessels in mucosa and submucosa . Commonly occurs in the right colon (cecum and ascending colon) The presentation is similar to diverticular bleeding in that it is painless, usually self-limiting, and intermittent. Unlike diverticular bleeding, this tends to be venous bleeding . Associated with aging, chronic kidney disease, von Willebrand disease, and aortic stenosis ( Heyde syndrome ).

17. ANGIODYSPLASIA Also known as: arteriovenous malformations , angiectasias , and vascular ectasia.

18. PRESENTATIONS Symptoms: - Haematochezia : Bright red or maroon stools → suggests colonic source.
- Melena : Black tarry stools → suggests small bowel or right-sided colonic source.
- Abdominal pain : Present in IBD, ischemic colitis, or infectious colitis.
-Signs of hypovolemia : Dizziness, pallor, hypotension, tachycardia.
-Chronic blood loss occurs in piles, fissures, colitis. Presents with hypochromic, microcytic anaemia. -Tenesmus, subacute obstruction, loss of appetite, decreased weight, bloody diarrhoea is seen in carcinoma distal, large bowel.

19. Signs on Examination -Abdominal exam: Tenderness (IBD, ischemia), distension (obstruction), mass palpable in left or right iliac fossa or mass of intussusception
-Per-rectal examination: Hemorrhoids, masses, fissures, or blood in the rectum. Blood with mucus — colitis, carcinoma Fresh blood as splashes in the pan — piles Maroon coloured stool — Meckel's diverticulum Red currant jelly in stool — intussusception Bright red blood in stool — polyps PRESENTATIONS

20. MANAGEMENT INITIAL STABILIZATION (Resuscitation and supportive care) Rapid triage of hemorrhaging patients while localizing the areas of blood loss is essential for resuscitation and prompt intervention. 1 . The ABCDEs 2.IV Access and Monitoring Establish two large-bore IV lines(14- or 16- gauge) Consider central access for massive hemorrhage Urinary catheter placed to monitor resuscitation adequacy 3.Recognizing severe hemorrhage Hypotension(SBP<90 mmHg) suggests>30% blood loss. Tachypnea, tachycardia, hypotension, agitation, and mental status changes are all indicators of a severe degree of hemorrhage.

21. 4.Additional management priorities: Type and crossmatch,CBC, metabolic panel, coagulation profile, LFT. Serum lactate can be utilized as an endpoint of resuscitation when elevated. 5.Fluid Resuscitation and Transfusion Strategy: Massive transfusion protocol for severe hemorrhage Blood Transfusion: Hb <7 g/dL (stable) or <9 g/dL (unstable/cardiac disease). Monitor coagulation(PT, PTT, fibrinogen, platelets) Use of rapid infuser to prevent hypothermia. MANAGEMENT

22. DIAGNOSTIC APPROACH Step 1: Initial Clinical Assessment 1.1 History Age & Risk Factors : Elderly: Diverticulosis, ischemic colitis, angiodysplasia, colorectal cancer. Young Adults: IBD, haemorrhoids, infectious colitis. Nature of Bleeding : Bright red blood per rectum (haematochezia): Distal colonic or rectal source.
Maroon- coloured stools: Right colon or small bowel source.
Melena (black, tarry stools): Upper GI or proximal small bowel source.

23. Associated Symptoms: Abdominal pain: IBD, ischemic colitis, diverticulitis.
Diarrhea: Infectious colitis, IBD.
Tenesmus: Rectal malignancy, ulcerative colitis.
Weight loss, altered bowel habits: Suggests malignancy. Medication History : NSAIDs, aspirin: Risk of diverticular bleeding, peptic ulcer disease.
Anticoagulants (Warfarin, DOACs): Increased risk of severe bleeding. Past Medical History: History of radiation therapy: Radiation proctitis. Atherosclerosis, cardiovascular disease: Ischemic colitis.

24. DIAGNOSTIC APPROACH

25. 1.2 Physical Examination Vital Signs (Assess for Shock):Hypotension, tachycardia, pallor → suggests severe bleeding. Abdominal Examination :
-LLQ pain: Ischemic colitis.
-Tender, palpable mass: Malignancy.
-Absent bowel sounds, distension: Perforation, toxic mega-colon. Digital Rectal Exam (DRE): -Bright red blood: Haemorrhoids, anal fissures, proctitis.
-Mass: Rectal cancer.

26. Step 2: Laboratory Investigations • CBC: -Anemia (Hb <7 g/dL → transfusion needed).
-Leukocytosis (infection, IBD, ischemia). • Coagulation Profile: INR, PT, APTT (for anticoagulant-induced bleeding). • Electrolytes & Renal Function: Hypovolemia-induced acute kidney injury. • Liver Function Tests: Rule out coagulopathy due to liver disease.
• Stool Studies: Occult blood test, fecal calprotectin (IBD), C. Difficile toxin assay. • Type & Crossmatch: Prepare for transfusion in case of significant bleeding.

27. Step 3: Imaging & Endoscopy 3.1 Colonoscopy (Gold Standard) Best for stable patients after initial resuscitation.
Can diagnose and treat diverticular disease, angiodysplasia, IBD, colorectal cancer. Findings : Diverticulosis: Outpouchings, active bleeding site. IBD: Mucosal inflammation, ulcerations. 3.2 CT Angiography (CTA) : When endoscopy is unable to localize a LGIB, angiography is an important diagnostic as well as therapeutic tool. Preferred in active bleeding (>0.3–0.5 mL/min). Findings : Contrast extravasation = active bleeding site. Vascular malformations (angiodysplasia).

28. Step 3: Imaging & Endoscopy 3.3 Radionuclide Scintigraphy (Tagged RBC Scan) Detects slower, intermittent bleeding (>0.1 mL/min).Useful when colonoscopy is non-diagnostic. 3.4 Capsule Endoscopy For obscure GI bleeding (if upper & lower endoscopy are normal).
Detects small bowel lesions (angiodysplasia, Crohn’s disease).

29. Step 4. Definitive Management 4.1: Endoscopic Therapy (First-line for Most Cases) Hemostatic Clipping: Preferred for diverticular bleeding, angiodysplasia. Thermal Coagulation: Used for bleeding ulcers, angiodysplasia.
Epinephrine Injection: Provides temporary vasoconstriction Band Ligation: For bleeding internal hemorrhoids. 4.2: Angiographic Embolization Indications: Persistent bleeding despite endoscopy. Patients unfit for surgery.
Procedure:
Super-selective embolization of bleeding artery (SMA, IMA branches).
Agents: Gelatin sponge, coils, or polyvinyl alcohol (PVA) particles.

30. Step 4. Definitive Management 4.1: Endoscopic Therapy (First-line for Most Cases) Hemostatic Clipping: Preferred for diverticular bleeding, angiodysplasia. Thermal Coagulation: Used for bleeding ulcers, angiodysplasia.
Epinephrine Injection: Provides temporary vasoconstriction Band Ligation: For bleeding internal hemorrhoids.

31. Step 4. Definitive Management 4.3: Medical Therapy •Proton Pump Inhibitors (PPIs): Used in peptic ulcer disease, gastric protection.
• Octreotide : Used in variceal bleeding (portal hypertension).
•Antibiotics: Metronidazole + Ciprofloxacin for infectious colitis. Vancomycin PO for C. Difficile colitis.

32. Step 4. Definitive Management 4.4: Surgical Intervention (Last Resort) Indications : Persistent hemodynamic instability despite resuscitation attempts or administering more than 4 units of blood in 24 hours or more than10 units of blood during the hospital stay are considered indications for surgery Surgical Options : Segmental Colectomy: If the source is localized (e.g., single diverticulum). Subtotal Colectomy: If diffuse bleeding or unable to identify the source.
Proctocolectomy: For severe ulcerative colitis. Note: Preoperative identification of the culprit lesion is particularly important in LGIB because, without localization, the empiric surgery for unlocalized LGIB is a total abdominal colectomy and end ileostomy.

33. Step 4. Definitive Management 4.4: Surgical Intervention (Last Resort) Surgical Options :

34. Recurrence Risk: Higher in diverticular disease, angiodysplasia. Mortality: Higher in elderly & those with comorbidities. Prevention Strategies: Colonoscopic surveillance for CRC & polyps.
Dietary modifications (high-fiber diet).
Avoid NSAIDs, aspirin in high-risk patients. PROGNOSIS & FOLLOW-UP

35. THANK YOU! REFERENCES: SABISTON TEXTBOOK OF SURGERY – 21 ST EDITION BAILEY & LOVE SHORT PRACTICE OF SURGERY – 28 TH EDITION SRB’S MANUAL OF SURGERY – 5 TH EDITION