COLORECTAL BLEEDING: A MULTIDISCIPLINARY APPROACH Colon and Rectum : Benign Sources Luigi Bucci

Colon and Rectum: Benign Sources Radiation Colitis/Proctitis

Difficult to describe the real incidence Evaluation of patients with lower gastrointestinal haemorrhage is variable and institution-specific –Age –Severity –Elective vs Urgency Admission –Institution availability of a bleeding team As many as 5.6 to 20% remain obscure These different results are related to “conventional examinations” Nature of bleeding influences its incidence and management as well

Colon and Rectum : Benign Sources 1Minor bleeding 2Chronic Intermittent bleeding 3Severe bleeding episodes with haemodynamic stability in between episodes 4Continual active bleeding

Differential Diagnosis of Colorectal Bleeding Diverticular disease Inflammatory Bowel Disease Infectious colitis Neoplasms Coagulopathy Arteriovenous malformations Radiation proctitis/enteritis Adults

Differential Diagnosis of Colorectal Bleeding Adults < 60 years> 60 years DiverticulosisVascular ectasias MalignancyDiverticulosis PolypsMalignancy Inflammatory Bowel Disease

Colon and Rectum: Benign Sources Farrell JJ, Friedman LS - Review article: the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther Jun 1;21(11): Review.

Differential Diagnosis of Colorectal Bleeding Intussusception Polyps and Polyposis Syndromes Inflammatory Bowel Disease Meckel diverticulum Children and Adolescents

Colon and Rectum: Benign Sources Diverticular Disease - A mean of 17% of patients with colonic diverticulosis experience bleeding - Diverticular bleeding may range from minor to life- threatening - Altough diverticular disease affects the left colon, bleeding from right colon is more common and usually severe - As many as 80 to 85% of diverticular haemorrhages stop spontaneusly

Colon and Rectum: Benign Sources Diverticular Disease The rate of recurrent bleeding is 9% at 1 year, 10% at 2 years, 19% at 3 years and 25% at 4 years (Longstrth GF, 1995) -The risk of re-bleeding after a second diverticular harmorrhage exceeds 50% - About 35% of patients require transfusion or invasive diagnostic/therapeutic evaluation - About 5% require emergency operation

Colon and Rectum: Benign Sources Arteriovenous malformations Moore’s classification - Type I Large bowel (ascending colon) Elderly patients - Type II Small bowel Young patients - Type III Multifocality Association with cutis and mucosae Children Rendu-Osler-Weber syndrome Related to age, angiographic findings and familiar history Camilleri based his classification on pathological findings

Colon and Rectum: Benign Sources Arteriovenous malformations - Arteriovenous malformations include vascular ectasias, angiomas, and angiodysplasias - Angiodysplasias are acquired abnormalities caused by chronic intermittent partial obstruction of submucosal veins from colonic muscle wall contraction - Angiodysplasias involve most commonly the right colon - There is an association between bleeding and calcific aortic stenosis, quality platetet abnormalities and dialisis

Colon and Rectum: Benign Sources Angiodysplasias - Massive hemorrhage occur in 15% of patients - Patients with colonic angiodysplasia may present with hematochezia (0-60%), melena (0-26%), hemoccult positive stool (4-47%) or iron deficiency anemia (0-51%) - Up to 90% of patients there is a spontaneous cessation of bleeding - Re-bleeding occur in 25-85% of patients

Colon and Rectum: Benign Sources Inflammatory bowel disease - Massive haemorrhage is unusual - Aestimates are 0.9-6% (Robert JR, 1991) - Bleeding stops spontaneously in about 50% of patients - About 35% of patients experience rebleeding after a spontaneous cessation - Rarely the rectum is the site of the main bleeding

Colon and Rectum: Benign Sources Ischemic colitis

Colon and Rectum: Benign Sources Rare causes Solitary rectal and colonic ulcer - Rectum  Related to digitation, stress, prolapse (?) - Colon  chronic drug abuse, HIV, peptic colon ulcer, colonic stasis, local ischemia, atherosclerosis, Strongyloidasis, portal hypertension (?)

Colon and Rectum: Benign Sources Portal colopathy

Colon and Rectum: Benign Sources Coagulopathy It is unclear whether spontaneous gastrointestinal bleeding occurs without identifiable lesions Platelet count of ≤ /mm 3 seems to be responsible for 50% of significant gastrointestinal bleeding in patients with acute leukemia Gastrointestinal haemorrhage in patients while taking heparin or warfarin had a similar distribution as general population Diagnostic algorythm is the same as patients with normal coagulation and include specific treatment of coagulation abnormality

Colon and Rectum: Benign Sources Rare causes Infectious colitis - Bacteria (Campylobacter, E. Coli, Myc. Tuberculosis) - Protozoa (Entoamoeba hystolitica) - Viruses (CMV) - Helmints (Scistosoma, Trichuris)