lowergi-bleed-dr-151103081848-lva1-app6892.pptx

causes of lower GI bleed. Discussed in a systematic way.

management is also outlined

1. Lower GI Bleed Dr Vijay K umar ; Associate Prof.

2. Definition Lower GI - bleeding is defined as abnormal hemorrhage into the lumen of the bowel from a source distal to the ligament of Treitz. Normal faecal blood loss – 1.2 ml / day Significant - > 10 ml / day

3. Presentation Lower GI bleeding typically presents with Hematochezia (which can range from bright-red blood to old clots) Melena (If the bleeding is slower or from a more proximal source)

4. Massive Bleeding Presents as a large volume of bright red blood PR Bleeding > 1.5 l / day Hemodynamic instability & shock ↓ in hematocrit level of 6 g / dL Common causes – D / A Transfusion of at least 2 units of packed red blood cells Bleeding that continues for 3 days Moderate Bleeding Presents as haematochezia or malena Hemodynamically stable Causes – Ano-rectal / Cong./ Infla.& Neoplastic diseases Initial ↓ in hematocrit level of 8 g / dL or less

5. Occult Blood Detected by routine chemical tests of the stool, with or without systemic evidence of chronic blood loss. 10 ml. of blood loss / day is necessary to have stool occult blood positive.

6. T y pes Aetiology Site of Bleeding Pain + / - Classification

7. Aetiology – General causes Congenital - Polyp’s / Meckel’s diverticulum Infammatory - Ulcerative colitis / Infective /Amoebic / Crohn’s disease Neoplastic – Adenomas / Carcinomas / Polyps Vascular – Angiodysplasia / Ischaemic colitis / Vasculitis / Hamangioma Clotting disorders - Haemophilia / Leukaemia / Warfarin therapy / DIC Miscellaneous – Piles / Anal fissure / Injury to rectum

8. Site – Local causes Small Intestine - Polyp’s / Meckel’s diverticulum / Ulcers / Tumours / Intussusception Large intestine - Angiodysplasia / Carcinomas / Colitis / Diverticulitis Perianal – Injury / Rupture(Haematoma /Anorectal abscess) / Carcinoma / Condyloma Anal - Piles / Anal fissure / Carcinoma / Fistula-in-ano

9. With Pain Fissure in Ano Fistula in Ano Ca. Anal Canal Rup. perianal haematoma Rup. Ano Rectal abscess Endometriosis Injury

10. Without Pain Blood Alone Polyp Villous Adenoma Diverticular diseases Blood After Defecation Hemorrhoids Blood with mucus Ulcerative colitis Intussusception Ischaemic Colon Blood Streaked on stool Ca. Rectum

11. Common Causes Acute Sub-acute / Chronic Diverticular disease Anal disease Mesenteric ischaemia Inflammatory bowel disease Angiodysplasia Large polyps Ischaemic colitis Carcinoma Meckel’s diverticulum Solitary rectal ulcer Intussusception Radiation enteritis

12. Differential Diagnosis

13. Clinical Presentations Bleeding Per rectum – - - - - - - - Bright red blood Altered blood Maroon colour Streaks of blood Splash in pan Red currant jelly Blood with mucus Piles / Polyps / Fissure Ca / Ulcer / IBD / Dysentery Meckel’s diverticulum Anal fissure Piles Intussusception Colitis / Ca / Dysentery Note : Ask & Look for bleeding tendency

14. Relation to Defecation Streak of fresh blood – FIA At the time of passing stool – Bright red & Splashes over the pan - Piles Other than during defecation - Polyps / PP / RP / Ca / UC Bleeding per anum in child – Polyp

15. OTHERS Pain Altered bowel habits Anaemia / Malnutrition / LOW / LOA Mass palpable PA – Rt /Lt / MOI Per-rectal exam – Very important

16. Investigations 1. Blood Tests – Hb% / PCV / LFT Coag. Profile / RFT 2. Stool examination - Ova / cyst / worms Occult blood – FOBT

17. Investigations - Contd Small Bowel Enema Barium Enema

18. Investigations - Contd Proctoscopy Sigmoidoscopy

19. Investigations - Contd Colonoscopy – Gold Standard

20. Investigations - Contd Colonoscopy – Gold Standard

21. Investigations - Contd Colonoscopy – Gold Standard

22. Investigations - Contd Colonoscopy – Gold Standard

23. Investigations - Contd U/S abdomen – Angiography – Identifies bleeding rate of 0.5ml/mt All 3 vessels – are used Angiodysplasia / Tumours / Vasculitis – diagnosed Radionuclear scanning – Identifies 0.1ml / mt Tc labelled sulphur colloid / tagged RBC scan

24. Investigations - Contd Capsule Endoscopy CT / MRI - Angiography

25. T reatme n t Cause is treated Proper exploration – lengthy midline incision – essential Endoscopic polypectomy for polyps Massive resection – small bowel – mesenteric ischemia Surgical resection – colonic carcinoma Sigmoid colectomy – sigmoid diverticula Endoscopic fulguration / therapeutic embolization / Rt.hemicolectomy for angiodysplasia Drugs / Mesacol enema / Total proctocolectomy i IA anastomosis for ulcerative colitis Excision & ligation – piles

26. References