Lower Git Bleeding

LOWER GIT BLEEDING
OTHIENO IVAN
othienoivan@gmail.com
Lower GIT Bleeding
Objectives:
 Define lower git bleeding
 pathophysiology
 Classical signs and symptoms of lower GITB
 Etiology of lower GITB
 Investigations
Classification
 Upper GI bleeding Vs Lower GI bleeding
 Acute Vs chronic bleeding
 Overt Vs Covert (occult)
Note:
Regardless of the classification the principles of initial management

of GIT bleeding are generally the same.
Definition
 Bleeding from anywhere below the suspensory muscle of
duodenum. (Small intestine ,large intestine, rectum, anus) and
presenting as either haematochezia (bright red blood, clots or
burgundy stools) or melena.
“The suspensory muscle of duodenum is a thin muscle

connecting the junction between the duodenum, jejunum, and
duodenojejunal flexure to connective tissue surrounding the
superior mesenteric artery and coeliac artery. It is also known as
the ligament of Treitz.”
Epidemiology
 It can range in severity from trivial to massive.
 LGIB accounts for approximately 20%- 30% 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.
 Increased in males and in older patients (mean age at presentation of 63 to 77
years).
 80-90% of cases will stop bleeding spontaneously.
 As many as 25% will re-bleed either during or after their
hospital admission.
 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, vascular anomalies or ischemic colitis.
Classical signs and symptoms
 Hematochezia 90% (most often painless). “Passage of frank
blood per rectum.”
 Anemia
 Occult blood in stool ( GUAIAC TEST usually positive).
 Melena 10% ( 90% in Upper GITB). “Passage of black tarry

stools per rectum.” (oxidation of haem)
 NGT Aspirate usually clear.

Etiology- lower GIT bleeding
 Bleeding can be from either
 Small bowel (small intestines)or Large bowel (colon).
 Etiological factors can be categorized into two i.e
 Benign causes and Malignant causes.

Colonic bleeding (large bowel).
Benign 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 ulcers are :

 Radiation.
 Sexual transmitted disease.

Hemorrhoids
 “Swollen and inflamed veins in the rectum and anus that cause discomfort and bleeding”
Fissure- in – ano
Rectal Ulcers
 “The rectum is a muscular tube that's connected to
the end of the colon. Solitary rectal ulcer syndrome
is a rare and poorly understood disorder that often
occurs in people with chronic constipation. Solitary
rectal ulcer syndrome can cause rectal bleeding and
straining during bowel movements.”
Diverticulitis
 Diverticular disease (diverticulitis)
 This is sac-like protrusions of the colonic mucosa, particularly at
locations where blood vessels(vasa recta) enter the colon.
 Contributes 20-60% of the cases of LGIB.
 In 75% of patients bleeding will stop spontaneously.
 Re-bleeding 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.
Diverticulitis
Angiodysplasia
 Angiodysplasia is a small vascular malformation of
the gut.
 Lesions are often multiple, and frequently involve

the cecum or ascending colon, although they can
occur at other places.
 Only about 15% of patients with vascular ectasia

(dilation) will develop gastrointestinal hemorrhage.
 The incidence in most recent studies is only 3%

compared to 15-27% previously as cause of LGIB.
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. Clinical presentation include: pain in the right iliac
fossa and left hypochondrium, vomiting and diarrhea, passing blood
in stool
 DDX: Carcinoma colon, ulcerative colitis, crohns disease,
tuberculosis
 RX: consertive mgt ie rest, iv fluids, antibiotics, analgesics
Other benign colonic etiologies
 Inflammatory bowel disease (IBD).
 Acute hemorrhage occurs 0.9-6%.
 Bleeding occurs 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.
OTHERS ARE: Infectious colitis or enteritis :Radiation colitis/proctitis,Trauma,

hematologic disorders and NSAIDs,Post polypectomy (occurs in 0.3% to 6.1% of
polypectomies).
Colonic etiologies cotn........
Malignant causes.
 (polyps, Carcinoma).
 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.

Polyps
Colon Cancer
Small Bowel Etiologies
 The small bowel (or small intestine) is the longest portion of
the gastrointestinal (GI) tract.
 Small bowel sources account for 3-5% of all cases of LGIB:
 Benign causes
 Angiodysplasia is most common cause of small bowel
hemorrhage (70-80%).
 AVMs become more common as people age and are
associated with other medical problems, such as chronic
kidney disease and valvular heart disease.
Small Bowel Etiologies
Contn.......
 small bowel diverticula (diverticulitis)
 Meckel’s diverticula
 Crohn’s disease
 Vascular-enteric fistulas e.g Aorto-enteric fistula
 Intestinal ulcers (NSAIDS)

Meckel's diverticulum
 A Meckel's diverticulum, a true congenital diverticulum, is a
slight bulge in the small intestine present at birth .
Crohn’s disease
 “Crohn’s disease is a chronic inflammatory bowel disease (IBD) characterized by
inflammation of the digestive, or gastrointestinal (GI) tract.”
Small bowel etiologies cotn..
Malignant causes
 Intestinal tumors
EG……………….,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
 polyps
Investigations
Blood
 CBC (leukocytosis with a left shift –neutrophilia).
 Platelets (Thrombocytosis-Secondary thrombocythemia)
 Red blood cells (hematocrit count reduced and a reduction in Hb)
 H.Pylori (Negative)
Investgn.....
Stool Analysis
 Gross. (Red color-LGITB, Black-UGITB)
 Microscopic. (ova and cysts, live parasites-infestation, RBCs-

occult bleeding, Leukocytes))
 Chemical. (pH low –acidic)
Gastric lavage
 NG tube aspirate- Negative

Investgn.....
Endoscopy
 Colonoscopy (indicate presence of abnormal growths on the
lining of the colon which may be cancerous or non cancerous).
 69-90% accuracy rate. It can also be therapeutic
 Proctoscopy
 Sigmoidoscopy ( rigid, flexible fibre optic).
NOTE
 Poor visibility with heavy bleeding
Investgn.....
Selective mesenteric angiography
 bleeding rate of 0.5 mL/min is necessary in order for angiography to
be positive
 helpful in the patient with massive GI bleeding from either an upper
or lower source
 reveals a bleeding site in up to 75% of patients with massive upper
GI bleeding
 success rate in LGIB 60-90% re-bleeding rate 0-33% and significant
ischemia 7%
Investgn.....
Imaging studies
 Abdominal Ultra Sound Scan
 Barium enema X-ray
 Abdominal CT scan (reveal presence of pseudoaneurysm which has the
presence of a double density that overlaps the origin of the arteries).
 Magnetic Resonance Imaging (reveal vascular abnormalities-aneurysms
and pseudoaneurysm, abnormal masses)
management
 Taking of adequate history is essential in management for example use of NSAIDS,
anticoagulants like warfarin which precipitates bleeding.
 The management depend on the cause of bleeding.
 It involves both supportive and definitive management.
 Supportive management include, oxygen administration, fluid resuscitation,

administration of antibiotics and gastric irrigation for example prior to endoscopy and
laparoscopy
 Definitive management involves surgery(open or laparoscopy) more so when it comes

to lower GI bleeding e.g. segmental resection of affected colon, subtotal colectomy,
diverting stoma, hemorrhoidectomy, local excision of the bleeding lesion
Complications of lower GIT bleeding
 Anemia
 Gangrenous bowel
 Toxic mega colon in transverse colon
 Perforation
 Fistula in and
 Carcinoma
DXX
 Inflammatory bowel disease
 Colorectal cancer
 Diverticulosis
 Hemorrhoids
 Angiodysplasia
 Meckel's diverticulitis
 anal fissure
 Rectal ulcer
Case presentation
 A 70 year old male presents to the emergence department with bright red blood per
rectum, mild abdominal pain, nausea with past medical HX of hypertension,
hyperlipidemia and diverticulitis( 5 yrs ago) on examination BP-100/60mmHg,pulse
120bp,temp- 37c
 Abdominal examination-tender in lower quadrants
 Rectal exam-bright red blood
 Lab-HB-10g/dl,hematocrit-30%,platelete count 200,000u/l with normal electrolytes
 Imaging: CT angiography, colonoscopy-scheduled
Questions 1.What is most likely DX

References
 Manning-Dimmitt LL, Dimmitt SG, Wilson GR. Diagnosis of
Gastrointestinal Bleeding in Adults. American Family Physician. American
Academy of Family Physicians. April 2005. Available at
http://www.aafp.org/afp/2005/0401/p1339.html.
 Barnert J, Messmann H. Diagnosis and management of lower gastrointestinal
bleeding. Nature Reviews. Medscape CME. November 2009. Available at
http://www.nature.com/nrgastro/journal/v6/n11/full/nrgastro.2009.167.htHarr
ison’s Principles of Internal Medicine 14th edition

 Gastrointestinal Atlas.com endoscopy photos

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LOWER GIT BLEEDING

 Define lower git bleeding

 Classical signs and symptoms of lower GITB

 Etiology of lower GITB

 Acute Vs chronic bleeding

 Overt Vs Covert (occult)

Regardless of the classification the principles of initial management

“The suspensory muscle of duodenum is a thin muscle

 LGIB accounts for approximately 20%- 30% of all major GI bleeds.

 Annual incidence 21 cases per 100,000.

 Increased in males and in older patients (mean age at presentation of 63 to 77

 Occult blood in stool ( GUAIAC TEST usually positive).

 Melena 10% ( 90% in Upper GITB). “Passage of black tarry

 NGT Aspirate usually clear.

 Small bowel (small intestines)or Large bowel (colon).

 Etiological factors can be categorized into two i.e

 Benign causes and Malignant causes.

hemodynamic instability or large volume of blood loss.

Possible causes of rectal ulcers are :

 Lesions are often multiple, and frequently involve

 Only about 15% of patients with vascular ectasia

 The incidence in most recent studies is only 3%

 Acute hemorrhage occurs 0.9-6%.

 Malignant lesion must be considered in patient with long standing history of

OTHERS ARE: Infectious colitis or enteritis :Radiation colitis/proctitis,Trauma,

 Although colorectal cancer is most commonly associated with

 CR-cancers are source of LGIB in 9-13% of patients.

 Vascular-enteric fistulas e.g Aorto-enteric fistula

 Intestinal ulcers (NSAIDS)

 CBC (leukocytosis with a left shift –neutrophilia).

 Platelets (Thrombocytosis-Secondary thrombocythemia)

 Red blood cells (hematocrit count reduced and a reduction in Hb)

 Gross. (Red color-LGITB, Black-UGITB)

 Microscopic. (ova and cysts, live parasites-infestation, RBCs-

 Chemical. (pH low –acidic)

 NG tube aspirate- Negative

 The management depend on the cause of bleeding.

 It involves both supportive and definitive management.

 Supportive management include, oxygen administration, fluid resuscitation,

 Definitive management involves surgery(open or laparoscopy) more so when it comes

 Toxic mega colon in transverse colon

 Abdominal examination-tender in lower quadrants

 Rectal exam-bright red blood

 Lab-HB-10g/dl,hematocrit-30%,platelete count 200,000u/l with normal electrolytes

 Imaging: CT angiography, colonoscopy-scheduled

Questions 1.What is most likely DX

Gastrointestinal Bleeding in Adults. American Family Physician. American

Academy of Family Physicians. April 2005. Available at

bleeding. Nature Reviews. Medscape CME. November 2009. Available at

ison’s Principles of Internal Medicine 14th edition

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