Lower GI Bleeding Dr. M. Ghanem

A less common reason for hospitalization 95%  from the colon Etiology usually age related

Presentation Hematochezia (bright red blood, clots) May present with melena Usually less severe than UGI

Etiology

Diagnosis

Colonoscopy Major bleeding interferes significantly with visualisation Successful in identifying the source of bleeding in up to 95% of cases

Radionuclide Scanning Most sensitive study Least accurate for localization of bleeding RBCs from the ptn r labeled with Tc99 and reinjected, images are collected Detect bleeding at a rate of 0.1cc/min Lack spatial resolution As a guide to the utility of angio

Angiography Detect hemorrhage at a rate of cc/min Therapeutic advantage (vasopressin inj., embolization) Invasive Complications include: – Hematoma – Areterial thrombosis – Contrast rxns – ARF

Video Capsule A video camera is swallowed Identifies the source of bleeding is 90% of cases Good in stable ptns Doesn’t have a treatment option

Push enteroscopy Can reach 70 cms from the ligament of treitz Successful in 40% of cases Video capsule is usually preferred

Diveticulosis The most common cause of LGIB (55%) >75% stop bleeding spontanously 10% rebleed within 1 year 50% rebleed within 10 years >50% of bleeds from Rt colon

Diveticulosis Diagnosis by colonscopy Tx by injecting epinephrine, cautery of clip with colonscopy Angio carries risk of ischemia

Angiodysplasia About 40% of LGIB Acquired degenerative lesions secondary to progressive dilation of normal blood vessels within the submucosa of the intestine Can occur anywhere in the bowel, cecum most common site Diagnosis by colonoscopy, angio Appear as red stellate lesions with a rim of pale mucosa

Angiodysplasia Tx with sclerotherapy or cautery (colonscopy), embolization by angio Rebleeding  consider surgery

Neoplasia Uncommon cause of significant LGIB The first to rule out!!! Polyps Diagnosis by colonscopy Tx depends whether it’s a tumor or polyp, pathology, etc…

Anorectal Disease Include internal hemorrhoids, fissures and colorectal neoplasia 5-10% of LGIB Bright-red blood per rectum that is seen in the toilet bowl and on the toilet paper Internal hemorrhoids: painless, a lump that reduces spontanously or by ptn Fissures: painful

Anorectal Disease Malignancy needs to be ruled out before assuming that the bleeding is due to hemorrhoids Tx of hemorrhoids: rubber band ligation, sclerotherapy, coagulatiom, surgery Tx of fissures: stool softeners, NG, Ca channel blockers

Meckels Diverticulum A true diverticulum Remnant of the omphalomesentric duct Caused by acid production by ectopic musocsa Diagnosis by nuclear imaging, angio Tx is surgical