1. MAJOR LOWER GASTRO-INTESTINAL BLEEDING
John Hartley
The Academic Surgical Unit, University of Hull, Castle Hill Hospital, Hull, U.K.

2. Lower gastrointestinal bleeding
Modes of Presentation
Occult or obscure bleeding
Iron deficiency anaemia
FOB’s positive
Overt bleeding – visible blood PR
Intermittent – self limiting
Significant haemorrhage
Large amounts frank blood
Haemodynamic compromise

3. Lower GI Bleeding - Etiology
Angiodysplasia
The Others
Neoplasms
Colitis
Ileal & Colonic varices
Meckels’ diverticulum
Haemorrhoids
40%
20% Others
40%
Diverticulosis

4. Lower GI bleeding - Angiodysplasia
Acquired vascular ectasia
Degenerative
Elderly population
Multiple

5. Lower GI bleeding - Angiodysplasia
Uncommon in healthy individuals
Benign course with low risk of re-bleeding
Endoscopic therapy non- bleeding lesions not necessary
Foutch PG et al. Am J Gastroenterol 1995

6. Lower GI bleeding – diverticular disease
Non-inflamed tics
Ruptured vasa recta

7. Lower GI bleeding – diverticular disease

8. Lower GI bleeding – diverticular disease
50% of > 60 yrs
Up to 20% bleed
5% massive
(mainly right side)
Non-inflamed
Recurs in 25%
McGuire HH et al. Ann Surg 1972; 175:

9. Lower GI bleeding – diverticular disease
Potential for therapeutic colonoscopy

10. Lower GI bleeding – cancer
Major bleeding uncommon % of significant bleeds

11. Lower GI bleeding – polyps
Uncommon cause
Of massive bleeding
(<10%)

12. Lower GI bleeding – ischaemic colitis
Abdo pain ++
Bleeding common
Usually limited
21 of 311 pts with
Major bleed
Rossini et al. World J
Surg 1989;13:

13. Lower GI bleeding – the catch!!
Adequate anorectal
Examination
MANDATORY

14. Lower GI bleeding - clinical
Bleeding per rectum 3-6 units transfusion within 24hrs
Hb drop to < 10g
Blood – cathartic
Bright red or plum coloured
Usually painless
+/- signs of shock

15. Lower GI bleeding - clinical
Management
Characterise
Resuscitate
Differentiate
Localise
(Treat)

16. Lower GI bleeding - clinical
Resuscitation
Large bore cannulae
Volume and blood replacement
Blood products
Monitoring
85% WILL STOP THEREAFTER

17. Major Lower GI Bleeding Endoscopic & Radiological Procedures
Diagnostic
Sigmoidoscopy ☺
Scintiscans
Colonoscopy
Angiography ☺
Barium Enema
Enteroclysis
Operative Endoscopy
Therapeutic
Colonoscopy
Electrocautery
Laser
Polypectomy
Angiography ☺
Vasopressin
Embolisation ☺

18. Lower GI bleeding - Management
Resuscitation
+ve
(NG Aspirate)
OGD
-ve
Proctoscopy & Sigmoidoscopy
Colonoscopy
Angiography
Radionucleotide scan

19. Lower GI Bleeding - Bleeding Scans

20. Lower GI Bleeding - Bleeding Scans
Tech. labelled red cell scan
Sensitivity 97%
Specificity 85%
48 of 50 patients had bleeding site identified preop
One patient TAC for failure to localise
No postop bleeding
Nicholson et al Br J Surg 1989;76:

21. Massive bleeding – acute colonoscopy
An alternative view
Urgent prep via NG (1-2hrs)
Site identified in approx. 76%
Access for therapy 85% will stop anyway
? best performed electively

22. Lower GI bleeding - clinical

23. Lower GI Bleeding - Angiography
Both diagnostic and therapeutic potential
Needs active bleeding
haemodynamically unstable patient
Highly operator dependant
Can be repeated
leave sheath in place
Embolise if source identified

24. Lower GI Bleeding Transcatheter coil embolotherapy
Extension of diagnostic angiography (Bookstein et al 1977)
Immediate haemostasis
Risk of colonic ischaemia and infarction (Bookstein et al 1982)

25. Colonic angiography and embolisation
Superselective embolisation
Avoid ischaemic complications

26. Mrs AB 75 yrs CVA 6yrs => dysphasic + hemiplegic
Admitted 10/7 pr bleed
normal UGI + LGI endoscopy => discharged
Readmitted pr bleed
bp 100/60 pulse 100
resuscitated => bp in lab

30. Angiography for major colonic bleeding
Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

31. Lower GI Bleeding - Embolotherapy
Results
13 patients (8 female)
Mean age 81yrs (71-87 yrs)
Mean systolic BP 76 mmHg (unrecordable in 2 patients)
Mean Hb 7.1 g/dl (4-10 g/dl)
Mean transfusion vol. 6.0 units (2-8 units)
Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

32. Lower GI Bleeding - Embolotherapy
Summary
Bleeding point embolised in 13/38 patients (r = 1 for systolic BP < 100mmHg)
Embolisation achieved haemostasis in 11/13 patients
Ischaemic complications in 3 patients managed conservatively
Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

33. Lower GI Bleeding - Embolotherapy
26 pts, positive angiograms
Mean transfusion 7 units (+/- 1.43)
16 pts attempted embolisation
Immediate haemostasis 14 pts (82%)
Rebleeding in 3 (one rpt embolisation)
2 pts required surgery
one colonic necrosis
one for bleeding
Luchtefeld MA et al. Dis Colon Rectum 2000;43:532-4.

34. Lower GI Bleeding - Coil embolotherapy
In the emergency control of major colonic haemorrhage:
Safe
both early and late problems appear minimal
coils should be placed beyond marginal artery
Efficacious
Reduces the requirement for emergency surgery
complete cessation of bleeding in some
may permit planned surgery in others
Nicholson AA, Ettles DF, Hartley JE et al. Gut 1998;43:4-5.

35. Lower GI Bleeding -Surgery
Make sure the cause is not anorectal
haemorrhoids
rectal cancer or proctitis
Only one bite of the cherry!
total colectomy is the procedure of choice
avoid segmental colectomy unless definite cause
probably avoid primary anastomosis

36. Lower GI bleeding - surgery
Ensure cause not anorectal
Only one bite at cherry!
Avoid segmental colectomy unless definite cause
Probably avoid primary anastomosis

37. Major low GI bleeding Unusual Alarming !!! Challenging:
- diagnosis - management
Multidisciplinary approach - characterise - localise
- treat