Lower GI Bleeds

Question 1

What are the causes of a lower GI bleed?

Differentiate them based off of age, pain and size of bleed

Answer 1

Elderly – Diverticulitis, Colorectal Cancer, Angiodysplasia (vascular malformation in the gut), Ischaemic Colitis/Acute mesenteric ischemia
Younger – Inflammatory Bowel Disease
Both – Haemorrhoids, Rectal Varices, Infection, C. diff, Rectal Varices, Severe Upper GI bleed

Painful – Haemorrhoids (Local Pain/Itching), Upper GI bleed (Epigastric pain), Inflammatory Bowel Disease (Abdominal Pain), Anal Fissure (Local Pain), Acute mesenteric ischaemia Colitis (severely painful), Ischaemic colitis (Moderate flank pain), Infection (generalised abdominal discomfort)
Painless - Diverticulitis, Colorectal cancer, Angiodysplasia, Rectal Varices

Large Bleed – Diverticulitis, Upper GI bleed, Rectal Varices, Acute mesenteric ischaemia
Small Bleed – Haemorrhoids, Colorectal cancer, Anal Fissure, Infection, Ischaemic Colitis
Variable – Inflammatory Bowel Disease, Angiodysplasia

Question 2

What are the symptoms of a lower GI Bleed?

Answer 2

Symptoms:
Haematochezia (Fresh Blood) – Normally Seen in lower GI bleed, but can be seen in profuse upper GI bleed
Anaemia - Chronic Bleeds
Shock – Fainting or postural dizziness

Specific Questions to ask:
Colorectal cancer – Change in bowel habit, weight loss, anorexia
Rectal Varices – History of alcoholism/Liver disease
Ischaemic Colitis/Acute mesenteric Ischaemia - Cardiovascular risk factors

Question 3

What will you find on examination of a lower GI bleed?

Answer 3

What is the degree of anaemia/shock 
End of the bed:
Reduced skin turgidity - Hypovolaemia
Pale – Hypovolaemia
Low urine output – Hypovolaemia
Hands:
Increased capillary refill – Hypovolaemia
Weak Peripheral pulses – Hypovolaemia
Cold peripheries – Hypovolaemia
Hypotension - Hypovolaemia
Tachycardia - Hypovolaemia
Face:
Dry Mucous membranes - Hypovolaemia
Abdomen:
Bruit – May indicate ischemic colitis or mesenteric ischemia 
Mass – Colorectal cancer 
Legs:
Weak Peripheral pulses – Hypovolaemia
Cold peripheries – Hypovolaemia
PR:
Visible Anorectal cancer
Establish presence of blood/melaena

Question 4

What investigations will you order in a lower GI bleed?

Answer 4

Bedside:
Stool cultures (send multiple samples)– Only if infection suspected, to rule out infective causes.
Test any stool sent for C. Diff
Full set of observations

Bloods:
FBC - To assess severity of bleed with Hb levels and to look for infection (WCC
U&E - A raised urea comparative to creatinine is classical of an upper GI bleed. May also see dehydration if lots of blood loss
LFT’s – Liver disease can predispose to rectal varices and reduced clotting levels
Clotting - They are bleeding, especially important in patients with signs of chronic liver disease and those on anticoagulants
Cross Match – Between 2 and 6 units depending on the severity of the bleed
Total Iron Binding Capacity/Ferritin - Looking for Iron deficiency due to a chronic bleed

Imaging:
Abdominal X-Ray - To see any signs of colitis (oedema/thumb printing)
Erect CXR – Looking for any perforation
Colonoscopy - After patient stabilised and within 24 hours of admitting
CT Scan – If no cause found
Angiography – If no cause found, can help to localise site of bleeding

Question 5

What is the immediate management of a lower GI Bleed?

Answer 5

What is the Treatment: (Indication for admission (>60, haemodynamic instability, still bleeding, NSAIDS/Anti coagulants, Severe Co-morbidity)
Resuscitation:
A-E approach
Get IV Access (2 wide bore cannulas)/Give O2 to maintain sats of 94+ /Attach 12 lead ECG
Make sure not to use saline in liver disease
Insert Urinary Catheter
Assessment with AMPLE history and brief examination
Get help - Medical reg on call/consider ITU if large bleed
Frequent Observations - Constant or 15 minutely
Transfusion with O- Blood or Cross matched blood if Hb<70
Transudes with Platelets if platelet count >50
Keep patient bedbound, they may feel the need to pass a large stool, but this could be another GI bleed resulting in collapse.
Get advice from consultant/haematology on anticoagulation – Use FFP in patient with INR >1.5 and use PCC in actively bleeding patients taking warfarin. Factor VIIa can be used if either of these do not work. Stop any warfarin and talk to specialist about other blood thinners. Stop any NSAIDS in acute phase if possible.
Keep Nil by Mouth
Arrange urgent colonoscopy - Immediately in severe bleeds, within 24 hours of all bleeds

Medical: Treatment for massive bleeds (Other bleeds will likely not require specific treatment to stop the blood loss, simply treat the underlying cause)
General Management - Colonoscopy coagulation and injection with vasoconstrictors or sclerosing agents of any bleeding sites
Diverticulitis - Colonoscopy with bipolar coagulation, adrenaline injection or metallic clips
Angiodysplasia - Colonoscopy Thermal Therapy with Argon
Rectal Varices – Colonoscopy Endoscopic Injection Sclerotherapy
Ischaemic Colitis - Nil by Mouth and IV hydration

Surgery:
In Recurrent Bleeds - Resection of affected bowel