Lower GIT bleeding

Question 1

Definition of lower GIT bleeding

Answer 1

Gastrointestinal bleeding that occurs distal to ligament of Treitz

Question 2

How does massive lower GIT bleeding usually present

Answer 2

• Passage of large amounts of red or maroon blood per rectum (Haematochezia)
• Haemodynamic instability or shock
• An initial haemoglobin of 8 g/dl or less
• The need to transfuse more than 2 U of blood
• Bleeding that continues for three days
• Significant rebleeding within a week

Question 3

How do patients with chronic bleeding usually present

Answer 3

• Small amounts of blood in their stools

- Additionally they may present faecal occult blood postitivity or iron defiency anaemia

Question 4

What is occult LGIB

Answer 4

Patients show evidence of blood loss without any obvious signs or symptoms. It is detected with a postive faecal occult blood test

Question 5

Likely cause in younger patient with abdominal pain, diarrhea and rectal bleeding

Answer 5

inflammatory bowel disease

Question 6

Likely cause in older patient with weight loss and iron deficiency anaemia

Answer 6

large caecal tumour

Question 7

What proportion of patients will have acute bleeding that stops spontaneously

Answer 7

80 %

Question 8

Overall mortality of LGIB

Answer 8

2-4 %

Question 9

Most common causes of LGIB

Answer 9

• Diverticulosis
• Angiodysplasia
• colitis
• Neoplasia
• Haemorrhoids and other anorectal disorders
• Drug related

Question 10

What is diverticulosis and which part of the GIT does it usually affect

Answer 10

Presence of pouchlike herniations through the muscular layers of the colon. It most commonly affects the sigmoid colon but can affect the entire colon

Question 11

How does diverticula bleeding usually present

Answer 11

Usually presents with acute, painless, bright red bleeding

Question 12

What is angiodysplasia

Answer 12

Degenerative vascular malformations of the GIT characterized by fragile blood vessels leading to GIT and anaemia

Question 13

Which part of the GIT does angiodysplasia affect

Answer 13

Caecum and ascending colon

Question 14

What percentage of acute LGIB is due to angiodysplasia

Answer 14

5%

Question 15

How does ischaemic colitis usually present and which part of the GIT does it affect

Answer 15

• presents with abdominal pain associated with haematochezia
• it affects the watershed areas of the colon- the splenic flexure and rectosigmoid colon

Question 16

How does inflammatory bowel disease usually present

Answer 16

• Do not commonly cause massive LGIB but do cause bloody diarrhea that may lead to an iron deficiency anaemia

Question 17

What type of bleeding do polyps and carcinomas cause

Answer 17

The bleeding is usually low grade and often leads to iron deficiency anaemia

Question 18

What laboratory testing should one do for patients with LGIB

Answer 18

Full blood count with platelets. Clotting factors should be checked. Specimen taken to cross match in patients with an acute bleed

Question 19

When are plain abdominal X-rays useful

Answer 19

Rectal bleeding related to inflammatory bowel disease

Question 20

What is the bleeding rate required to detect bleeding on CT scan

Answer 20

CT scanning will pick up bleeding from 1 ml/minute

Question 21

What is the bleeding rate required for radioisotope scans to pick up bleeding

Answer 21

It will localize bleeding from 0.1 ml/ minute

Question 22

Which is the preferred method of interventional radiology?

Answer 22

Angioembolisation

Question 23

What is the primary diagnostic and therapeutic modality in LGIB?

Answer 23

Endoscopy- all patients presenting with LGIB Should have upper endoscopy performed to exclude any proximal cause of the bleeding

Question 24

What are the three phases of therapeutic approach to LGIB

Answer 24

• Resusciation
• localization of bleeding point
• haemostasis

Question 25

What methods are usually used to localize the bleeding

Answer 25

• colonoscopy is primary method
• If this is unsuccessful; ct scanning with angiography is the next step
• percutaneous angiographic techniques are reserved for use for interventional radiology
• tagged red cell scanning- stable patients where difficult to find the source of the bleeding

Question 26

Colonoscopy is usually the first modality used to stop the bleeding. What endoscopic interventions are available

Answer 26

• coagulation
• haemoclip application
• injection therapy

Question 27

If colonoscopy is unsuccesful in stopping LGIB, what is the next step?

Answer 27

Formal angiography should be done with a view to transcatheter embolization in the bleeding vessel

Question 28

When is surgery indicated in LGIB

Answer 28

If the patient is too unstable for angiography or if it is unavailable

Question 29

If the source of bleeding has not been found pre operatively what may be done to guide the resection?

Answer 29

On table colonoscopy