1. LOWER GASTROINTESTIRAL BLEEDING Asoc. Prof. Dr.Orhan Yalçın Ministry of Health, Okmeydanı Education and Research Hospital, Turkey

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3. 3 Definition Abnormal hemorrhage into lumen of the bowel from a source distal to ligament of Treitz. Abnormal hemorrhage into lumen of the bowel from a source distal to ligament of Treitz.

4. 4 30 % - 40 % diverticular disease 30 % - 40 % diverticular disease Colitis Colitis Colorectal neoplasia Colorectal neoplasia Benign anorectal disease Benign anorectal disease Coloni arteriovenous malformation Coloni arteriovenous malformation Small bowel origin Small bowel origin Despite all of the diagnostic modalities in 8 % to 12 % of patients the source of bleeding cannot be found. In 10 % of hemotochesia cases, the source is from upper GI tract.

5. 5 There are three steps 1- Hemodynamic stabilization 2- Bleeding site localization 3- Therapy History - Nature and duration of bleeding -Associated symptoms ( pain, weight loss ) -Past medical events ( Injuries, surgical procedures, endoscopy, IBD, etc.) -Medications ( NSAİD, anticoagulants ) -Physical examination / Vital signs -Laboratory: Hemogrom, PT, PTT -And resussication

6. 6 BLEEDING SITE LOCALIZATION Which modality will be used. This depends on: -Hemodynamic stability -Bleeding rate -Comorbid conditions -Hospital expertise MODALITIES -Colonoscopy -Radiolabeled red blood cell scanning -Angiography -Multidetecter Row Helical CT

7. 7 COLONOSCOPY - Procedure of choice as initial investigation -Accuracy for localization 53 % - 97 % -The distal ileum should be entubated -It has both diagnostic and therapeutic effect -Has ability to identify bleeding source regardless off rate and presence of bleeding. -It is safe

8. 8 COLONOSCOPY DISADVANTAGES - Requires bowel preparation -It is invasive procedure -Prevalence of stigmata of hemorrhage is low -Complication rate is low ( 0,5- 1,5 % ) but major complications ( Perforation ) -Can not show upper GI and small bowel bleeding

9. 9 RAPIOLABELED RED BLOOD CELL SCANNING It detects at rates as slow 0,1- 0,4 ml/min bleeding - Two agents are used A- 99 m Tc-labeled sulfur colloid - Requires no preparation time - But it’s absorbsion is rapid by liver and spleen - This condition hinder accurate localization of bleeding B- 99 m Tc – labeled RBC s -Requires some preparation time -It is not hinder by liver and spleen -Much longer half time ( 24- 48 hours )

10. 10 RADIOLABELED RED BLOOD CELL SCANNING CONT. - Accurate localization rate for bleeding is between 42 % -85 % - Major complication is rare - Has no therapeutic intervention capability - It is useful especially in non life threating bleeding to confirm active bleeding and a guide to mesenteric angiography

11. 11 ANGIOGRAPHY - It is detects at rate as slow as 1- 1,5 ml/min - Detection rate is between 27 %- 67 % - It has both diagnostic and therapeutic effects - Major complication rate 2 % - 50 ( renal failure, bleeding from arterial puncture, embolism from dislodged thrombus ) - Therapeutic vasopressin infusion or embolization - It should be used if colonoscopy fails

12. 12 PROVOCATIVE ANGIOGRAPHY - In some patients despite continuous obscure bleeding, bleeding point can not be found - In this patients use of short acting anticoagulant agents ( including vasodilators, thrombolytics ) - When bleeding point is localized, IV methylen blue and laparotomy.

13. 13 MULTI- DETECTOR ROW HELICAL CT. - In this modality on arterial phase active bleeding is identified as a focal area of high attentuation within the bowel lumen - Accuracy for localization 24 %- 94 % ( All GI bleeding ) -Major complication rate is 0 %- 11 %

14. 14 THERAPY - Endoscopic therapy - Angiographic therapy - Surgical therapy

15. 15 ENDOSCOPIC THERAPY Electrocauterization Electrocauterization Vasoconstrictor Injections Vasoconstrictor Injections Thermal contacts Thermal contacts Sclero Therapy Sclero Therapy Laser Laser

16. 16 ANGIOGRAPHIC THERAPY A- - Vasopressin infusion 0,2 – 0,4 U/min - Success rate 60 %- 100 % - Complication rate 10 %- 20 % - Re-bleeding rate 50 % B- - Transcatheter embolization - Microcoil, gelatin sponge, polyvinyl alcohol particles - Success rate 90 %

17. 17 SURGICAL THERAPY Indications - 4 units of RBC in 24 hours - Re bleeding after cessation of hemorrhage in one week - Ongoing bleeding after 72 hours

18. 18 If possible Bleeding site should be localized before operation Bleeding site should be localized before operation If angiography shows but can not stop bleeding, methylen blue injected shortly before operation If angiography shows but can not stop bleeding, methylen blue injected shortly before operation If preoperative is not possible on operating table every effort should be made to localize bleeding source before resection If preoperative is not possible on operating table every effort should be made to localize bleeding source before resection Blind resection should be avoided Blind resection should be avoided

19. 19 INTRAOPERATIVE ADJUNCTIVE MANEUVERS On table colonoscopy On table colonoscopy Per oral trans luminal enteroscopy Per oral trans luminal enteroscopy At the end subtotal colectomy At the end subtotal colectomy

20. 20 THANK YOU THANK YOU