Lower GI bleed

Question 1

Colour of lower GI bleeds?

Answer 1

Typically bright red or dark red blood

Colonic bleeding rarely presents as meaena type stool, this is because blood in the colon has a powerful laxative effect and is rarely retained long enough and because digestive enzymes present in the small bowel are not present in the colon.

General rule : right sided bleeds tend to present with darker coloured blood than left-sided bleeds.

Haemorrhoidal bleeding - typically presents as bright red rectal bleeding that occurs post defecation either onto toilet paper or into the toilet. Very unusual for haemorrhoids alone to cause any degree of haemodynamic compromise.

Question 2

Causes of lower GI bleeds?

Answer 2

Colitis

Diverticular disease

Cancer

Haemorrhoidal bleeding

Angiodysplasia

Question 3

Nature of bleeding due to colitis?

Answer 3

Bleeding may be brisk in advanced cases, diarrhoea is commonly present. Abdominal X-ray may show featureless colon

Question 4

Nature of diverticular disease bleeding?

Answer 4

Acute diverticulitis often is not complicated by major bleeding and diverticular bleeds often occur sporadically. 75% all will cease spontaneously within 24-48 hours. Bleeding is often dark and of large volume

Question 5

Nature of bleeding due to colonic cancer?

Answer 5

often bleed and for many patients this may be the first sign of the disease

major bleeding from early lesions is uncommon

Question 6

Nature of haemorrhoidal bleeding?

Answer 6

typically bright red bleeding occurring post defecation

Question 7

Nature of bleeding due to angiodysplasia

Answer 7

apart from bleeding, which may be massive, these arteriovenous lesions cause little in the way of symptoms.

The right side of the colon is more commonly affected

Question 8

Management of lower GI bleeds?

Answer 8

• correction of any haemodynamic compromise is required. unlike upper GI bleeding, first line management is usually supportive because in the acute setting endoscopy is rarely helpful
• in the unstable patient the usual procedure would be an angiogram (either CT or percutaneous)
• in others who are more stable - standard procedure would be a colonoscopy in the elective setting. In patients undergoing angiography attempts can be made to address the lesion in question such as coiling. otherwise surgery will be necessary
• in patients with UC who have significant haemorrhage, standard approach would be a sub total colectomy, particularly if medical management has already been tired and is not effective.

Question 9

Indications for surgery:

Answer 9

Patients > 60 years

Continued bleeding despite endoscopic intervention

Recurrent bleeding

Known cardiovascular disease with poor response to hypotension