Lower GI bleeding Flashcards
What’s the definition of lower GI bleeding? (landmark)
Lower GI bleed = any bleeding distal to the ligament of Treitz
*ligament of Treitz: connects duodenum to the diaphragm and divides it from jejunum
The differential diagnosis for lower GI bleed
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
Assessment of pts with lower GI
- ABCD
- abdominal exam -> tenderness/ masses/ guarding/ rigidity
Resuscitation of the patient with hypotension (if there is a bleed)
Blood transfusion
What further investigations to perform in a patient with lower GI bleed who is shocked?
- FBC
- U&E
- coagulation profile
- x-match
- ABGs
Stages of shock (the names of categories) (3)
Stage I -> compensated, or nonprogressive
Stage II -> decompensated or progressive
Stage III -> irreversible
What happens in stage I shock?
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
What happens at stage 2 shock?
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
What happens in stage III shock?
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.
What cannula do we insert into a shocked patient?
2x 16G cannulae
Is there a scoring system for lower GI bleed?
no validated scoring system for lower GI bleed
When can we discharge a patient with a lower GI bleed?
If a patient:
- isn’t shocked
- haemoglobin is normal
- not on anticoagulants
What do we need to remember in terms of medication a pt is on when they come in with GI bleed
stop anti-coagulant medication
What’s the commonest cause of lower GI bleed?
- diverticular disease (40-60%)
- rare: cancer/neoplasm
- piles (large volume of bright red blood in the pans)
Why do we use NG tube in the investigation of lower GI bleed?
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
Investigations in acute lower GI bleed
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
What if the pt has a Hx of aortic intervention and comes in with GI bleed?
*aortic intervention e.g. aneurysm repair
Urgent/Immediate CT angiography and vascular referral
What can be done while colonoscopy if the source of lower GI bleed is identified?
- adrenaline
- coagulation
- haemoclipping
What can we see on CT angioography in a lower GI bleed into the bowel?
Blood with contrast goes into the bowel lumen
Selective Mesenteric Angiography
- what is required
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
Radionuclide Scintigraphy
Advantages/ disadvantages
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
Capsule endoscopy
- is it commonly used?
- use
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
Indication for the surgery in a lower GI bleed (1)
Haemodynamic instability despite aggressive resuscitation
Surgical techniques in lower GI bleed
- blind segmental large bowel resection -> a bit of bowel taken out if we suspect where the bleeding is
- emergency subtotal colectomy
Stepwise interventions for lower GI bleed
1: Colonoscopy +/- haemostatic techniques
2: embolisation
3: Surgery
( from the list invasive to most invasive)
What is the management if there is a lower GI bleeding but we cannot localise it?
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
How is post-polypectomy bleeding treated with?
- treated with repeated colonoscopy + cauterisation/ clipping
What’s the most common cause of small intestinal haemorrhage?
Angiodysplasia
- it is difficult to find and treat
- capsule endoscopy in elective setting (not done acutely)
How does lower GI bleed typically present?
bright red or dark red blood per rectum
Does colonic bleed often present with Malaena?
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
What’s hematochezia?
Passage of fresh blood through the anus (usually with stool)
*as contrasted with malena - blood is fresh
What’s the usual management in a patient with UC and who have
a significant lower GI haemorrhage?
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
When to consider admission in pt with lower GI bleed?
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
What investigation is preferred if haemorrhoids are the suspected source of lower GI bleed?
Proctosigmoidoscopy - as colonoscopy is time-consuming and usually useless in that case
What investigation to perform in an unstable, actively bleeding patient (lower GI bleed)
CT angiography - likely to show source of bleeding
