University of Florence Department of Medical and Surgical Critical Care Lower Gastrointestinal Bleeding:Definitions C.Fucini Turin 2006 Turin 2006

….any bleeding located throughout the GI tract distal to the legament of Treitz..

Jejuno-ileal bleeding Colonic bleeding Rectal bleeding Anal bleeding Jejuno-ileal bleeding Colonic bleeding Rectal bleeding Anal bleeding

Blood in the Stools Melena Black tarry usually from proximal to Treitz Reddish purple Dark red usually from ileocolic area Bright red usually from left colon/anorectum

The color of the blood is unreliable because of variability in its degradation and transit time

Incidence:25 cases per (possibly understimated)

Lower gastrointestinal bleeding Acute Acute Chronic Chronic Severe(Hematochezia) Moderate ModerateSlowOccult

Other symptoms -abdominal pain -abdominal pain -rectal pain -rectal pain -anal pain -anal pain -painless -painless

Small bowel is the source of bleeding in 5-20% of the cases Vernava AM et al…1997 Chao CC et al..2005

The colon and anorectum are the source in 70-90%of the cases

Acute lower gastrointestinal bleeding(ALGIB): abrupt onset of recurrent hematochezia

*0.7% of all hospital admission *Average patients age 71±14 yrs

…Although the vast majority of patients will cease bleeding spontaneously it can be a greater diagnostic and therapeutic challenge than bleeding from the upper gut.

The conundrum of lower gastrointestinal bleeding Billingham RP. 1997

10-15% of patients require urgent diagnostic and therapeutic procedures 8-12 % of patients fail to have the precise origin and location of bleeding identified before an operation

In 10% of the patients with hematochezia the source of bleeding is gastroduodenal

Severe acute lower gastrointestinal bleeding(SALGIB) (15-22% of ALGIB) *significant hemodynamic compromise *significant hemodynamic compromise *decrease in hemoglobin 2-4 g/dl *transfusion requirement>/= 2-4 blood units

Mortality related to lower GI bleeding has been reported to occur in 4 to 15% of patients Bender et al.1991 Makela JT et al…1993

Undirected surgery may be necessary when: -more than 1500 ml of blood is necessary to resuscitate the patients and bleeding continues ml of blood is necessary to maintain vital signs during a 24-hour period -Bleeding continues for 72 hours -Rebleeding(significant) occurs within one week of initial cessation

Colonic origin < 60 years < 60 years Right/left diverticula IBDNeoplasm > 60 years > 60 years Angiodysplasia (right sided) Right/left diverticula Neoplasm

Diverticulosis accounts for 50% of all lower gastrointestinal bleedings 60% of bleeding episodes arise from diverticula proximal to the splenic flexure Bleeding spontaneously ceases in 80-90% of patients Risk of rebleeding is approximately 25% (Cohen J.L..1996)

Angiodysplasia (Arterovenous malformations,Vascular ectasias,Angiomas) Real or overstimated problem?? Real or overstimated problem?? Precise incidence unknown:<1-30% subjects Lower GI bleeding:2-60% Only 15% with bleeding will experience severe episodes

Rectal outlet bleeding Intermittent passage of scant to modest amounts of blood and clots,not associated(usually) with a significant drop in the hemoglobin or hematocrit and arising from anorectal conditions. Intermittent passage of scant to modest amounts of blood and clots,not associated(usually) with a significant drop in the hemoglobin or hematocrit and arising from anorectal conditions.

Chronic bleeding -In 10% of subjects aged % benign anorectal diseases (Hemorroids,fissure, solitary ulcer/prolapse,radiation proctitis etc…..) -present in 70% of pts.with anorectal symptoms. but……………. ……………………….

….11% of patients(mostly of them <50 years) with significant lower gastrointestinal bleeding have a benign anorectal source of bleeding. (Hoedema R.E. et al… 2005)

Chronic bleeding -common also in angiodyplasia,neoplasms -Usually slow and minor at times revealed by unexplained anemia

Chronic bleeding (occult bleeding) Biochemical test(Guajak) Immunological test

Acute GI hemorrhages in patients with coagulopathy or under antiaggragation/anticoagulation treatment 50% of pts.with leukemia and platelet<20,000 mm 3 suffer significant GI bleeding 26-30% of geriatric patients with lower bleeding are antiaggregated/anticoagulated Spontaneous hemorrage is unlikely!!! Spontaneous hemorrage is unlikely!!! (Coon WW,1974 (Coon WW,1974 Mittal R et al..1985) Mittal R et al..1985)

The first important step,after resuscitation,is to establish whether the patient is actively bleeding or has ceased by the time of presentation.

To apply an efficient,disciplined and orderly approach in choosing among several sophisticated diagnostic tools

Aim To identify the etiology of bleeding

A team approach for the correct algorithm to follow in lower gastrointestinal bleeding

Lower GI Hemorrhage (Sources ) Colorectal Colorectal Diverticular disease Diverticular disease Angiodysplasia Angiodysplasia Neoplasm Neoplasm IBD IBD Ischemic colitis Ischemic colitis Infectious colitis Infectious colitis Radiation proctitis Radiation proctitis Anorectal (Hemorroids,fissure ) Anorectal (Hemorroids,fissure ) Iatrogenic Iatrogenic Varices Varices Small bowel Small bowel Arteriovenous malformation Arteriovenous malformation Meckel’s diverticulum Meckel’s diverticulum IBD IBD Neoplasia Neoplasia Vasculitis Vasculitis

Moderate Lower GI bleeding When and where the admission ???

Nearly 20% of emergency department patients with a chief complaint of lower gastrointestinal bleeding will prove either to have no bleeding at all or to have bleeding from a non gastrointestinal source(eg,nose,pulmonary tree,vagina) (Law DH,1979)

Urgent colonoscopy vs.standard approach

Diagnostic tools History Nasogastric tube Anorectal inspection,digital rectal examination Proctoscopy,Colonoscopy/sigmoidoscopyEnteroscopy technetium-labeled rbc scan technetium-labeled rbc scan Radionuclide scintigraphy technectium-99 sulfur colloid technectium-99 sulfur colloid Selective mesenteric angiography Wireless capsule endoscopy Helical CT scan