1. LGI BLEEDING A TEACHING CASE Miklosh Bala MD

2. PRESENTATION 47 YEARS OLD MALE PATIENT47 YEARS OLD MALE PATIENT RECTAL BLEEDING SEVERAL HOURS BEFORE ADMISION TO THE ERRECTAL BLEEDING SEVERAL HOURS BEFORE ADMISION TO THE ER

3. HISTORY ALWAYS HEALTHYALWAYS HEALTHY NON SMOKERNON SMOKER MILD CONSTIPATION FOR SEVERAL WEEKSMILD CONSTIPATION FOR SEVERAL WEEKS SEVERAL EPISODES OF PAINLESS PROFUSE RECTAL BLEEDING IN THE LAST MONTHSSEVERAL EPISODES OF PAINLESS PROFUSE RECTAL BLEEDING IN THE LAST MONTHS

4. WHAT ELSE DO YOU ASK ?

5. FAMILY HISTORY

6. FATHER CRC

7. EXAMINATION ALERT AND ORIENTEDALERT AND ORIENTED PULSE RATE 75 REGULARPULSE RATE 75 REGULAR BP 115/75BP 115/75 EKG NORMALEKG NORMAL HEART SOUNDS NORMALHEART SOUNDS NORMAL CHEST NormalCHEST Normal ABDOMEN SOFT NON TENDER NO MASSESABDOMEN SOFT NON TENDER NO MASSES

8. PR STREAKS OF BLOOD ON THE FINGERSTREAKS OF BLOOD ON THE FINGER

9. WHAT`S NEXT

10. LAB TESTS Hb 11.3Hb 11.3 WCC 9.800WCC 9.800 PLATELETS 190000PLATELETS 190000 PT AND PTT NORMAL RANGEPT AND PTT NORMAL RANGE ELECTROLITES NORMALELECTROLITES NORMAL

11. OTHER EXAMS ???

12. ANOSCOPYANOSCOPY RECTOSCOPYRECTOSCOPY FLEX SIGFLEX SIG

13. DIAGNOSIS

14. LOWER GI BLEEDDING

15. DISCHARGE ??

16. RECOMMENDATIONS LOWER GI STUDIESLOWER GI STUDIES TREATMENT ??TREATMENT ??

17. COLONOSCOPYCOLONOSCOPY Barium Enema +FLEX SIGBarium Enema +FLEX SIG VISIT A GASTROENTEROLOGISTVISIT A GASTROENTEROLOGIST VISIT A PROCTOLOGISTVISIT A PROCTOLOGIST

18. VISITS A PROCTOLOGY TWO WEEKS LATTER STILL COMPLAINS OF MILD BLEEDING AND CONSTIPATION. LATTELY OF LEFT ABDOMINAL PAIN. ANOSCOPY 2-3RD.DEGREE hemorrhoidesANOSCOPY 2-3RD.DEGREE hemorrhoides RECTOCOPY UP TO 25 cm:NORMALRECTOCOPY UP TO 25 cm:NORMAL

19. A LITTLE ABOUT RECTAL BLEEDING A LITTLE ABOUT RECTAL BLEEDING

20. In one study of 308 patients referred to Hospital for Rectal Bleeding In one study of 308 patients referred to Hospital for Rectal Bleeding hemorrhoides 54% anal fissure 18% colorectal cancer 4% another perianal lesion 7% ulcerative colitis 4% Crohn`s disease 1% no cause found 3% hemorrhoides 54% anal fissure 18% colorectal cancer 4% another perianal lesion 7% ulcerative colitis 4% Crohn`s disease 1% no cause found 3%

21. HEMORRHOIDS(Piles) Bleeding and prolapse are the cardinal symptoms of hemorrhoids.Blood appears as a bright red streak or spot on the toilet tissue or on the surface of the stool, spurts at the height of straining, or drips from the anus after the stool has been expelled.Chronic blood loss may cause iron deficiency anemia.

22. HEMORRHOIDS CLASSIFICATION FIRST DEGREEFIRST DEGREE SECOND DEGREESECOND DEGREE THIRD DEGREETHIRD DEGREE FOURTH DEGREEFOURTH DEGREE

23. TREATMENTS 1 ST DEGREE – CONSEVATIVE TREATMENT1 ST DEGREE – CONSEVATIVE TREATMENT 2 ND DEGREE - CONSERVATIVE OR ACTIVE2 ND DEGREE - CONSERVATIVE OR ACTIVE TREATMENT TREATMENT 3 RD DEGREE – ACTIVE TRATEMENT3 RD DEGREE – ACTIVE TRATEMENT 4 TH DEGREE - SURGERY4 TH DEGREE - SURGERY

24. CONSERVATIVE TREATMENT Measures to Reduce Downward Pressure HIGH FIBER DIETHIGH FIBER DIET BULK FORMING AGENTSBULK FORMING AGENTS

25. NON SURGICAL TREATMENTS Fixation Methods RUBBER BAND LIGATIONRUBBER BAND LIGATION SCLEROTHERAPYSCLEROTHERAPY INFRARED COAGULATIONINFRARED COAGULATION

26. WHAT`S NEXT

27. TO PERFORM A GI STUDY? TO TREAT?? DON`T FORGET THE PATIENT’S FAMILY HISTORYDON`T FORGET THE PATIENT’S FAMILY HISTORY

28. A COLONOSCOPY IS PERFORMEDA COLONOSCOPY IS PERFORMED REVEALS MILD DIVERTICULOSIS OF SIGMOID WITH NO OTHER ABNORMALITYREVEALS MILD DIVERTICULOSIS OF SIGMOID WITH NO OTHER ABNORMALITY

29. THE PATIENT FEELS BETTER AND WITHOUT CONSTIPATIONTHE PATIENT FEELS BETTER AND WITHOUT CONSTIPATION

30. TEN DAYS LATTER THE PATIENT IS FOUND UNCONSIOUSTEN DAYS LATTER THE PATIENT IS FOUND UNCONSIOUS A PARAMEDICAL TEAM ARRIVESA PARAMEDICAL TEAM ARRIVES PATIENT WITH DIZZINESSPATIENT WITH DIZZINESS BP 90/60BP 90/60 PULSE RATE 130PULSE RATE 130

31. ARRIVES TO THE ER AFTER BEEING RESUCITATED WITH CRISTALOIDSARRIVES TO THE ER AFTER BEEING RESUCITATED WITH CRISTALOIDS IS AFFECTED BY A MASSIVE RECTAL BLEEDING WITH DARK BLOOD AND CLOTS.IS AFFECTED BY A MASSIVE RECTAL BLEEDING WITH DARK BLOOD AND CLOTS.

32. YOU ARE CALLED WHAT`S YOUR NEXT STEP

33. LAB TESTS HGB 8.9HGB 8.9 HCT 27HCT 27 WC 12,000WC 12,000 PLT 300,000PLT 300,000 PT & PTT NORMALPT & PTT NORMAL SMA NORMAL RANGESMA NORMAL RANGE

34. YOUR NEXT STEP YOUR NEXT STEP

35. NGTNGT PROCTOSCOPYPROCTOSCOPY

36. LOWER GI BLEEDING

38. Tc Red Cell Scan Bleeding rate 0.1 ml/min can be detectedBleeding rate 0.1 ml/min can be detected Images at distinct intervals after injectionImages at distinct intervals after injection If the bleeding is present it can accurate identify in 85%If the bleeding is present it can accurate identify in 85%

40. Selective angiography Bleeding rate 0.5 ml/min or greaterBleeding rate 0.5 ml/min or greater Identifies 45% to 75% in active bleedingIdentifies 45% to 75% in active bleeding Possibility of controlling bleedingPossibility of controlling bleeding Complications 10%Complications 10%

42. LOWER GI BLEEDING

44. CAUSES OF LGI BLEEDING

45. Diverticular disease

46. Diverticular disease is the most common cause of acute lower gastrointestinal bleeding.Diverticular disease is the most common cause of acute lower gastrointestinal bleeding. Sixty to 80% of bleeding diverticula are located in the right colon. Ninety percent of all diverticula are found in the left colonSixty to 80% of bleeding diverticula are located in the right colon. Ninety percent of all diverticula are found in the left colon Diverticular bleeding tends to be massive, but it stops spontaneously in 80% of patients, and the rate of rebleeding is only 25%.Diverticular bleeding tends to be massive, but it stops spontaneously in 80% of patients, and the rate of rebleeding is only 25%.

47. Angiodysplasia

48. Angiodysplasia Lesions are small vascular tufts that are formed by capillaries, veins, and venules, appearing as red dots or spider-like lesions 2 to 10 mm in diameterLesions are small vascular tufts that are formed by capillaries, veins, and venules, appearing as red dots or spider-like lesions 2 to 10 mm in diameter Lesions develop secondary to chronic colonic distention, and they have a prevalence rate of 25% in elderly patientsLesions develop secondary to chronic colonic distention, and they have a prevalence rate of 25% in elderly patients Even though angiodysplasia may be present throughout the entire colon, the most common site of bleeding is the right colon.Even though angiodysplasia may be present throughout the entire colon, the most common site of bleeding is the right colon. Recurrent minor bleeding; however, massive bleeding is not uncommon.Recurrent minor bleeding; however, massive bleeding is not uncommon.

49. Colon polyps and colon cancers

50. These disorders rarely cause significant acute LGI hemorrhage.These disorders rarely cause significant acute LGI hemorrhage. Left-sided and rectal neoplasms are more likely to cause gross bleeding than right sided lesionsLeft-sided and rectal neoplasms are more likely to cause gross bleeding than right sided lesions Right sided lesions are more likely to cause anemia and occult bleeding.Right sided lesions are more likely to cause anemia and occult bleeding. Diagnosis and treatment consists of colonoscopic excision or surgical resection.Diagnosis and treatment consists of colonoscopic excision or surgical resection.

51. Inflammatory bowel disease

52. Ulcerative colitis can occasionally cause severe GI bleeding associated with abdominal pain and diarrhea.Ulcerative colitis can occasionally cause severe GI bleeding associated with abdominal pain and diarrhea. Colonoscopy and biopsy is diagnosticColonoscopy and biopsy is diagnostic Therapy consists of medical treatment of the underlying disease;Therapy consists of medical treatment of the underlying disease; operation is required on rare operation is required on rare occasions occasions

53. Ischemic colitis

54. This disorder is seen in elderly patients with known vascular disease; abdominal pain may be postprandial and associated with bloody diarrhea or rectal bleeding. Severe blood loss is unusual but can occur.This disorder is seen in elderly patients with known vascular disease; abdominal pain may be postprandial and associated with bloody diarrhea or rectal bleeding. Severe blood loss is unusual but can occur. Abdominal films may reveal "thumbprinting", causedby submucosal edema. Colonoscopy reveals awell-demarcated area of hyperemia, edema, andmucosal ulcerations.Thesplenic flexure anddescending colonare the most common sites.Abdominal films may reveal "thumbprinting", caused by submucosal edema. Colonoscopy reveals a well-demarcated area of hyperemia, edema, and mucosal ulcerations. The splenic flexure and descending colon are the most common sites.

55. Hemorrhoids

56. Obscure GI bleeding A previously healthy 64 year old female presented with clinical signs of active GI bleeding. Upper endoscopy was normal and colonoscopy showed transported blood from small bowel.

59. Pathological results showed GIST with low MIB-1 proliferation index of 1%. Small erosions are noted in the adjacent mucosa explained GI bleeding.

60. Obscure GI Bleeding Small Bowel Causes Grouped by Age Patient’s < 25 years old –Meckel’s Diverticula Patient’s between 30 – 50 years old –Tumors Patient’s > 50 years old –Vascular ectasias 60

61. Small Bowel Bleeding Rare Causes Hemobilia –Neoplasm, vascular aneurysm, liver abscess, trauma, liver biopsy Hemosuccus pancreaticus –Pancreatic pseudocysts, pancreatitis, neoplasms –Erosion into a vessel with communication with PD Infections –Cytomegalovirus, histoplasmosis, Tb 61

62. Obscure GI Bleeding Evaluation Repeat EGD and Colonoscopy (~ 35% yield) If negative Capsule Endoscopy ( ~ 60–70% yield) If negative Repeat Capsule Endoscopy ( ~ 35% yield) If negative Double Balloon Enteroscopy ( ~ 40% yield) If negative Intraoperative Enteroscopy in selected cases

63. If Surgery is needed

64. Localized without control or rebleedingLocalized without control or rebleeding What's your treatment?What's your treatment?

65. Localized Resection of affected areaResection of affected area

66. Surgery Severe hemorrhage without localizationSevere hemorrhage without localization WHAT`S YOUR NEXT STEP?WHAT`S YOUR NEXT STEP?

67. In an Unstable Patient with No localized site of bleeding In an Unstable Patient with No localized site of bleeding Introperative CleansingIntroperative Cleansing Intraoperative ColonoscopyIntraoperative Colonoscopy TransiluminationTransilumination ColotomyColotomy Subtotal colectomySubtotal colectomy

68. Returning to our case

69. A Colonoscopy was performed

70. Diagnosis was made

75. POST RBL BLEEDINGPOST RBL BLEEDING MISSED AT PRIMARY INVESTIGATIONMISSED AT PRIMARY INVESTIGATION A SIMPLE ANOSCOPY WITH GOOD SUCTION OF BLOOD CLOTS WOULD HAVE HELPA SIMPLE ANOSCOPY WITH GOOD SUCTION OF BLOOD CLOTS WOULD HAVE HELP