Lower GI Bleed

LOWER Gl BLEED
Elderly lady presents with rectal bleed.

 Was a single polyp.
 Asked for long-term management and family management.
 Approach first with ABCs, etc as many of these will be management stations!
Approach:
 My approach to LGIB is anatomical (diverticulosis) vs vascular vs inflammatory vs neoplastic vs

other. I’d start with ABC, Vitals, IV, O2, Monitor, then proceed to history.
Differential Diagnosis of LGIB

Anatomical  Diverticulosis
Neoplastic  Polyp
 Carcinoma
Inflammatory  Infectious colitis

 IBD
Vascular  Angiodysplasia
 Bowel ischemia
 Radiation-induced colitis
Other  Hemorrhoids
 Anal Fissure/Ulcer
 Bleeding diathesis
History:
 Symptoms – diarrhea (duration, frequency, volume, blood, floating in toilet bowl,

aggravating factors like diet and stress)
 Travel before the onset of illness, exposure to potentially contaminated food or water
and illness in other family members
 Abdominal pain (characterize), fever, jaundice, nausea, vomiting, weight loss, chills,
sweats, confusion, rashes, ↓ urine output
 Nocturnal symptoms (pain, stooling)
 Urgency, tenesmus, fecal incontinence
 Previous episodes of the same  cause, diagnosis, treatment (including procedures)
 Past Medical/Surgical history – DM, IBD, abdominal surgery, malignancy, previous
endoscopy, previous radiation, vascular risk factors
 Family history – malignancy, IBD, IBS
 Medications (immunosuppressives)/allergies
 Social history – EtOH, drugs, sexual history
Physical Exam
(examine for hypovolemia/large volume blood loss, see UGIB scenario for jama summary)
 Perform full general exam, including body weight, and vitals
 Hands and Legs

o Capillary refill time, skin turgor (signs of volume depletion)
o Rashes (PG, EN), active joints
 Head & Neck

o Lymphadenopathy
o Eyes/Ear/Nose/Oropharynx
o Uveitis, episcleritis, aphthous ulcers
 Respiratory
o Work of breathing, oxygenation (w/o supplemental O2)
 Cardiovasular
o JVP, murmurs, signs of ischemia
 Abdominal
o Inspection (observe patient breath at rest, maximal inspiration)
 General level of comfort and health

 Abdominal scars
 Asymmetry, obesity
o Palpation
 Tenderness
 Organomegaly
 Peritoneal findings (perforation)
o Percussion
 Resonance vs. Dullness

 Presence of Ascites
o Auscultation
 Bowel sounds
 Friction rub (hepatic/splenic)
o DRE
 Bleeding (FOBT), masses, stool color/consistency

Investigations:
 CBC, lytes, renal, LFTS, Calcium profile, coags
 Abdomen 3 views (apple core, thumbprinting - edema of bowel wall, free air)
 Colonoscopy vs flex sig
 CT scan if suspecting perforation or other complications
 Barium enema (contra-indicated if suspect perforation)
 Bleeding scans – does not localize site of bleeding, highly sensitive, detects 0.1
ml/minute (if negative, procede with colonscopy)
 Arteriography - detects 0.5 ml/minute. Good for brisk bleed, unstable who needs quick
localization of bleed and embolization.
 OGD - if lower investigations all negative, must r/o UGI bleed.
 Lab investigations not routinely recommended in minimal LGIB
Treatment
 2 large bore IVs, fluid support and blood, NPO until definitive treatment (colonoscopy,
surgery)
 GI referral
Long term management:
Should be based on histology and whether there was complete removal of polyp as well as
number and size of polyps
 For patients with 1-2 polyps less than 1cm tubular adenomas with only low grade
dysplasia should have next c-scope 5-10yrs (exact timing based on clinical factors)
 For patients with any adenoma >1cm or with villous features or high grade dysplasia,
then next c-scope in 3 yrs
 Sessile adenomas removed piecemeal should have short interval f/u (2-6mo)
 Patients with Small rectal hyperplastic polyps should be considered to have normal
colonoscopies
_______________________________
Angiodysplasia:
Usually venous or capillary bleeding so present with weakness (not presyncope/syncope)
Most common lesions are in right colon and small intestine
Ass'd with:
 aortic stenosis (AVR --> angiodysplasia resolves!)
 radiation therapy to abdomen
 hereditary hemorrhagic telangectasia
 VWD
 chronic renal failure
 can also see variant with vascular ectasia in the antrum; "watermelon stomach"
Ix: small bowel – nee SB enteroscopy or nuclear / angio
Tx: endoscopic interventional (intrarterial vasopressin, laser/heater probe), hormonal Tx –
estrogen
Bleeding scans:
Sulphur colloid - Positive only when actively bleeding during or shortly after administration b/e
labelled sulphur is rapidly cleared by liver and spleen
Tch 99 - RBC scan - labelled erythrocytes. Can detect intermittent bleeding b/c label stays in the
vascular system. Can scan repeatedly. Detects 0.1 ml/minute.
Diverticular bleeding:
Occurs in only 5% of patients with diverticular disease.
Diverticuli develop where vessels penetrate the muscular layers of the colon. Pressure on the
artery leads to necrosis of the inner wall. Bleeding is arterial. Often right sided. If bleeding stops
spontaneously, 25% chance that they will rebleed.
25 M, RLQ pain, melena and BRBPR on DRE. Tachy, BP 105 syst.

 After acute management, hx and px, asked about DDx and specifically any
congenital causes of GI bleed.
 I said av malformation, they asked what else. Someone thought of Meckel's. Hb 90,
BP improves with fluids.
 Call GI - upper and lower scope are both negative! Where do you think the bleed
is. I said small bowel.
 What next? I said angiography/embolization if still bleeding. Someone suggested
surgery, they pushed for alternatives
For obscure GI bleeds with –ve scope green book says:

First do EGD with push enteroscopy (small bowel follow through) while active bleeding, if –ve
do video capsule endoscopy, if still –ve consider 99mTc-pertechnetate scan (Meckel’s scan),
double balloon enteroscopy, tagged RBC scan, and arteriography

Lower GI Bleed

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LOWER Gl BLEED

Elderly lady presents with rectal bleed.

 My approach to LGIB is anatomical (diverticulosis) vs vascular vs inflammatory vs neoplastic vs

Differential Diagnosis of LGIB

Inflammatory  Infectious colitis

 Symptoms – diarrhea (duration, frequency, volume, blood, floating in toilet bowl,

 Perform full general exam, including body weight, and vitals

 Hands and Legs

 Head & Neck

 General level of comfort and health

 Resonance vs. Dullness

 Bleeding (FOBT), masses, stool color/consistency

Long term management:

25 M, RLQ pain, melena and BRBPR on DRE. Tachy, BP 105 syst.

For obscure GI bleeds with –ve scope green book says:

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