Lower GI bleeding

Question 1

What’s the definition of lower GI bleeding? (landmark)

Answer 1

Lower GI bleed = any bleeding distal to the ligament of Treitz

*ligament of Treitz: connects duodenum to the diaphragm and divides it from jejunum

Question 2

The differential diagnosis for lower GI bleed

Answer 2

Lower GI bleed - differentials

• neoplasm
• diverticular disease
• angiodysplasia - small vascular malformation of the gut
• ischaemic colitis
• radiation enteropathy - following radiation therapy for pelvic or abdominal Ca
• IBD
• peptic ulcer
• Meckel’s diverticulum
• anorectal disease
• Upper GI bleeding

Question 3

Assessment of pts with lower GI

Answer 3

• ABCD
• abdominal exam -> tenderness/ masses/ guarding/ rigidity

Question 4

Resuscitation of the patient with hypotension (if there is a bleed)

Answer 4

Blood transfusion

Question 5

What further investigations to perform in a patient with lower GI bleed who is shocked?

Answer 5

• FBC
• U&E
• coagulation profile
• x-match
• ABGs

Question 6

Stages of shock (the names of categories) (3)

Answer 6

Stage I -> compensated, or nonprogressive

Stage II -> decompensated or progressive

Stage III -> irreversible

Question 7

What happens in stage I shock?

Answer 7

Stage I of shock

Low blood flow (perfusion) is first detected -> a number of systems are activated in order to maintain/restore perfusion

• heart beats faster, vasoconstriction, the kidney works to retain fluid in the circulatory system.

All this serves to maximize blood flow to the most important organs and systems in the body.

• The patient in this stage of shock has very few symptoms, and aggressive treatment may slow progression

Question 8

What happens at stage 2 shock?

Answer 8

Stage II of shock

• methods of body’s compensation begin to fail -> systems of the body are unable to improve perfusion any longer
• Oxygen deprivation in the brain causes the patient to become confused and disoriented

Question 9

What happens in stage III shock?

Answer 9

Stage III of shock

• the length of time that poor perfusion has existed begins to take a permanent toll on the body’s organs and tissues
• the declining function of the heart, kidney failure
• cells in organs and tissues throughout the body are injured and dying
• the endpoint of Stage III shock is patient death.

Question 10

What cannula do we insert into a shocked patient?

Answer 10

2x 16G cannulae

Question 11

Is there a scoring system for lower GI bleed?

Answer 11

no validated scoring system for lower GI bleed

Question 12

When can we discharge a patient with a lower GI bleed?

Answer 12

If a patient:

• isn’t shocked
• haemoglobin is normal
• not on anticoagulants

Question 13

What do we need to remember in terms of medication a pt is on when they come in with GI bleed

Answer 13

stop anti-coagulant medication

Question 14

What’s the commonest cause of lower GI bleed?

Answer 14

• diverticular disease (40-60%)
• rare: cancer/neoplasm
• piles (large volume of bright red blood in the pans)

Question 15

Why do we use NG tube in the investigation of lower GI bleed?

Answer 15

To differentiate between upper & lower GI bleed

*if we can aspirate blood = upper GI bleed

We do not do it, everyone, depends on certainty of diagnosis for source of bleeding

Question 16

Investigations in acute lower GI bleed

Answer 16

Basics: ECG, CXR, NG tube

Identification of the site of bedding: endoscopy (upper and lower), CT angiography, digital subtraction angiography

*lower GI endoscopy acutely is not often performed - due to faeces being there = therefore difficult to visualise the source of bleeding

Question 17

What if the pt has a Hx of aortic intervention and comes in with GI bleed?

*aortic intervention e.g. aneurysm repair

Answer 17

Urgent/Immediate CT angiography and vascular referral

Question 18

What can be done while colonoscopy if the source of lower GI bleed is identified?

Answer 18

• adrenaline
• coagulation
• haemoclipping

Question 19

What can we see on CT angioography in a lower GI bleed into the bowel?

Answer 19

Blood with contrast goes into the bowel lumen

Question 20

Selective Mesenteric Angiography

• what is required

Answer 20

Selective Mesenteric Angiography

• active bleeding (at the time of the angiogram) is required in order to detect a bleed

*no bowel prep is needed for that

* serious complication - bowel ischaemia may occur (as we need to embolise the vessels) -11% risk

Question 21

Radionuclide Scintigraphy

Advantages/ disadvantages

Answer 21

Radionuclide scintigraphy

(blurred picture of the skeleton; shady areas where the bleed is on)

Advantages:

• sensitive to lowe rates of bleed
• no bowel prep needed
• easily repeated if needed

Disadvantage:

• it is slow
• may delay therapeutic intervention
• diagnosis must be confirmed with endoscopy/surgery

Question 22

Capsule endoscopy

• is it commonly used?
• use

Answer 22

Capsule endoscopy

• available in few centres (expect as a research technique)
• use: to identify small bowel bleeding sites or if CT and mesenteric angiography are negative

*not usually used in acute setting and clinical practice

Question 23

Indication for the surgery in a lower GI bleed (1)

Answer 23

Haemodynamic instability despite aggressive resuscitation

Question 24

Surgical techniques in lower GI bleed

Answer 24

• blind segmental large bowel resection -> a bit of bowel taken out if we suspect where the bleeding is
• emergency subtotal colectomy

Question 25

Stepwise interventions for lower GI bleed

Answer 25

1: Colonoscopy +/- haemostatic techniques

2: embolisation

3: Surgery

( from the list invasive to most invasive)

Question 26

What is the management if there is a lower GI bleeding but we cannot localise it?

Answer 26

Bleeding without localisation

*maximal access surgery - big laparotomy - if we can find the source of bleed, we take out that segment, if we cannot - then the whole colon is taken out

• perform throughout exploration
• intraoperative colonoscopy
• isolated colonic bleeding -> Mx is subtotal colectomy

Question 27

How is post-polypectomy bleeding treated with?

Answer 27

• treated with repeated colonoscopy + cauterisation/ clipping

Question 28

What’s the most common cause of small intestinal haemorrhage?

Answer 28

Angiodysplasia

• it is difficult to find and treat
• capsule endoscopy in elective setting (not done acutely)

Question 29

How does lower GI bleed typically present?

Answer 29

bright red or dark red blood per rectum

Question 30

Does colonic bleed often present with Malaena?

Answer 30

No. This is because colonic bleed has a laxative effect -> therefore the blood is often not retained long enough for the enzymes to act on it

Question 31

What’s hematochezia?

Answer 31

Passage of fresh blood through the anus (usually with stool)

*as contrasted with malena - blood is fresh

Question 32

What’s the usual management in a patient with UC and who have

a significant lower GI haemorrhage?

Answer 32

In patients with ulcerative colitis who have significant haemorrhage:

the standard approach -> subtotal colectomy

*particularly if medical management has already been tried and is not effective

Question 33

When to consider admission in pt with lower GI bleed?

Answer 33

Consider admission if:

* Over 60 years

* Haemodynamically unstable/profuse PR bleeding

* On aspirin or NSAID

* Significant co morbidity

Management

All patients should have a history and examination, PR and proctoscopy

Colonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding

Question 34

What investigation is preferred if haemorrhoids are the suspected source of lower GI bleed?

Answer 34

Proctosigmoidoscopy - as colonoscopy is time-consuming and usually useless in that case

Question 35

What investigation to perform in an unstable, actively bleeding patient (lower GI bleed)

Answer 35

CT angiography - likely to show source of bleeding