LGI BLEEDINGLGI BLEEDING

A TEACHING CASEA TEACHING CASE

Miklosh Bala MDMiklosh Bala MD

PRESENTATIONPRESENTATION

• 47 YEARS OLD MALE PATIENT47 YEARS OLD MALE PATIENT

• RECTAL BLEEDING SEVERAL RECTAL BLEEDING SEVERAL HOURS BEFORE ADMISION TO HOURS BEFORE ADMISION TO THE ERTHE ER

HISTORYHISTORY

• ALWAYS HEALTHYALWAYS HEALTHY• NON SMOKERNON SMOKER• MILD CONSTIPATION FOR SEVERAL MILD CONSTIPATION FOR SEVERAL

WEEKSWEEKS• SEVERAL EPISODES OF PAINLESS SEVERAL EPISODES OF PAINLESS

PROFUSE RECTAL BLEEDING IN THE PROFUSE RECTAL BLEEDING IN THE LAST MONTHSLAST MONTHS

WHAT ELSE DO WHAT ELSE DO YOU ASK ?YOU ASK ?

FAMILY HISTORYFAMILY HISTORY

FATHER CRCFATHER CRC

EXAMINATIONEXAMINATION• 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 ABDOMEN SOFT NON TENDER NO

MASSESMASSES

PRPR

• STREAKS OF BLOOD ON THE STREAKS OF BLOOD ON THE FINGERFINGER

WHAT`S NEXTWHAT`S NEXT

LAB TESTSLAB TESTS

•Hb 11.3Hb 11.3•WCC 9.800WCC 9.800•PLATELETS 190000PLATELETS 190000•PT AND PTT NORMAL PT AND PTT NORMAL

RANGERANGE•ELECTROLITES NORMALELECTROLITES NORMAL

OTHER EXAMS ???OTHER EXAMS ???

•ANOSCOPYANOSCOPY

•RECTOSCOPYRECTOSCOPY

•FLEX SIGFLEX SIG

DIAGNOSISDIAGNOSIS

LOWER GI LOWER GI BLEEDDINGBLEEDDING

DISCHARGE ??DISCHARGE ??

RECOMMENDATIONSRECOMMENDATIONS

•LOWER GI STUDIESLOWER GI STUDIES

•TREATMENT ??TREATMENT ??

• COLONOSCOPYCOLONOSCOPY

• Barium Enema +FLEX SIGBarium Enema +FLEX SIG

• VISIT A GASTROENTEROLOGISTVISIT A GASTROENTEROLOGIST

• VISIT A PROCTOLOGISTVISIT A PROCTOLOGIST

VISITS A PROCTOLOGYVISITS A PROCTOLOGYTWO WEEKS LATTERTWO WEEKS LATTER

STILL COMPLAINS OF MILD STILL COMPLAINS OF MILD BLEEDING AND CONSTIPATION. BLEEDING AND CONSTIPATION. LATTELY OF LEFT ABDOMINAL PAIN .LATTELY OF LEFT ABDOMINAL PAIN .

• ANOSCOPY 2-3RD.DEGREE ANOSCOPY 2-3RD.DEGREE hemorrhoideshemorrhoides

• RECTOCOPY UP TO 25 cm:NORMALRECTOCOPY UP TO 25 cm:NORMAL

A LITTLE ABOUT RECTAL A LITTLE ABOUT RECTAL BLEEDINGBLEEDING

In one study of 308 patients referred to In one study of 308 patients referred to Hospital for Rectal Bleeding Hospital for Rectal Bleeding

hemorrhoides 54%hemorrhoides 54% anal fissure 18% anal fissure 18% colorectal cancer 4% colorectal cancer 4% another perianal lesion 7% another perianal lesion 7% ulcerative colitis 4% ulcerative colitis 4% Crohn`s disease 1% Crohn`s disease 1% no cause found 3% no cause found 3%

HEMORRHOIDS(Piles)HEMORRHOIDS(Piles)

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

HEMORRHOIDSHEMORRHOIDSCLASSIFICATIONCLASSIFICATION

• FIRST DEGREEFIRST DEGREE• SECOND DEGREESECOND DEGREE• THIRD DEGREETHIRD DEGREE• FOURTH DEGREEFOURTH DEGREE

TREATMENTSTREATMENTS

• 11ST ST DEGREE – CONSEVATIVE TREATMENTDEGREE – CONSEVATIVE TREATMENT

• 22ND ND DEGREE - CONSERVATIVE OR ACTIVEDEGREE - CONSERVATIVE OR ACTIVE

TREATMENTTREATMENT

• 33RD RD DEGREE – ACTIVE TRATEMENTDEGREE – ACTIVE TRATEMENT

• 44TH TH DEGREE - SURGERYDEGREE - SURGERY

CONSERVATIVE CONSERVATIVE TREATMENT Measures to TREATMENT Measures to

Reduce Downward Reduce Downward PressurePressure

• HIGH FIBER DIETHIGH FIBER DIET

• BULK FORMING AGENTSBULK FORMING AGENTS

NON SURGICAL NON SURGICAL TREATMENTSTREATMENTS

Fixation MethodsFixation Methods

• RUBBER BAND LIGATIONRUBBER BAND LIGATION

• SCLEROTHERAPYSCLEROTHERAPY

• INFRARED COAGULATIONINFRARED COAGULATION

WHAT`S NEXTWHAT`S NEXT

TO PERFORM A GI TO PERFORM A GI STUDY?STUDY?

TO TREAT??TO TREAT??

• DON`T FORGET THE DON`T FORGET THE PATIENT’S FAMILY HISTORYPATIENT’S FAMILY HISTORY

• A COLONOSCOPY IS A COLONOSCOPY IS PERFORMEDPERFORMED

• REVEALS MILD REVEALS MILD DIVERTICULOSIS OF SIGMOID DIVERTICULOSIS OF SIGMOID WITH NO OTHER WITH NO OTHER ABNORMALITYABNORMALITY

• THE PATIENT FEELS BETTER THE PATIENT FEELS BETTER AND WITHOUT CONSTIPATIONAND WITHOUT CONSTIPATION

• TEN DAYS LATTER THE PATIENT TEN DAYS LATTER THE PATIENT IS FOUND UNCONSIOUSIS FOUND UNCONSIOUS

• A PARAMEDICAL TEAM ARRIVESA PARAMEDICAL TEAM ARRIVES• PATIENT WITH DIZZINESSPATIENT WITH DIZZINESS• BP 90/60BP 90/60• PULSE RATE 130PULSE RATE 130

• ARRIVES TO THE ER AFTER BEEING ARRIVES TO THE ER AFTER BEEING RESUCITATED WITH CRISTALOIDSRESUCITATED WITH CRISTALOIDS

• IS AFFECTED BY A MASSIVE IS AFFECTED BY A MASSIVE RECTAL BLEEDING WITH DARK RECTAL BLEEDING WITH DARK BLOOD AND CLOTS.BLOOD AND CLOTS.

YOU ARE CALLEDYOU ARE CALLEDWHAT`S YOUR NEXT WHAT`S YOUR NEXT

STEPSTEP

LAB TESTSLAB 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

YOUR NEXT STEPYOUR NEXT STEP

•NGTNGT

•PROCTOSCOPYPROCTOSCOPY

LOWER GI BLEEDINGLOWER GI BLEEDING

N GT -

PRO CT O S CO PY+

LOWER GI BLEEDINGLOWER GI BLEEDING

T c Labelled RBC S can

A ngiography? ? ? / Colonoscopy? ?

N GT -

PRO CT O S CO PY+

Tc Red Cell ScanTc Red Cell Scan

•Bleeding rate 0.1 ml/min can Bleeding rate 0.1 ml/min can be detectedbe detected

• Images at distinct intervals Images at distinct intervals after injectionafter injection

• If the bleeding is present it If the bleeding is present it can accurate identify in 85%can accurate identify in 85%

Selective Selective angiographyangiography

•Bleeding rate 0.5 ml/min or Bleeding rate 0.5 ml/min or greatergreater

• Identifies 45% to 75% in Identifies 45% to 75% in active bleedingactive bleeding

•Possibility of controlling Possibility of controlling bleedingbleeding

•Complications 10%Complications 10%

LOWER GI BLEEDINGLOWER GI BLEEDING

S table pat ient U nstable

N egat ive

S elect ive A ngiography

Posit ive

T c Labelled RBC S can

N GT -

PRO CT O S CO PY+

LOWER GI LOWER GI BLEEDINGBLEEDING

Colonoscopy

S table pat ient U nstable

N egat ive

Posit ive N egat ive

S elect ive A ngiography

Posit ive

T c Labelled RBC S can

N GT -

PRO CT O S CO PY+

CAUSESCAUSES OF LGI OF LGI BLEEDINGBLEEDING

DiverticularDiverticular diseasedisease

DiverticularDiverticular diseasedisease• Diverticular disease is the most common cause Diverticular disease is the most common cause

of acute lower gastrointestinal bleeding.of acute lower gastrointestinal bleeding.

• Sixty to 80% of bleeding diverticula are Sixty to 80% of bleeding diverticula are located in the right colonlocated in the right colon. . Ninety percent of all Ninety percent of all diverticula are found in the left colondiverticula are found in the left colon

• Diverticular bleeding tends to be massive,Diverticular bleeding tends to be massive, but but itit stops spontaneously in 80%stops spontaneously in 80% of patients, and of patients, and the rate of rebleeding is only 25%.the rate of rebleeding is only 25%.

AngiodysplasiaAngiodysplasia

AngiodysplasiaAngiodysplasia• Lesions are small vascular tufts that are Lesions are small vascular tufts that are

formed by capillaries, veins, and venules, formed by capillaries, veins, and venules, appearing as red dots or spider-like lesions appearing as red dots or spider-like lesions 2 to 10 mm in diameter2 to 10 mm in diameter

• Lesions develop secondary to chronic Lesions develop secondary to chronic colonic distention, and they have a colonic distention, and they have a prevalence rate of 25% in elderly patientsprevalence rate of 25% in elderly patients

• Even though angiodysplasia may be present Even though angiodysplasia may be present throughout the entire colon, the most throughout the entire colon, the most common site of bleeding is the right colon. common site of bleeding is the right colon.

• Recurrent minor bleeding; however, Recurrent minor bleeding; however, massive bleeding is not uncommon.massive bleeding is not uncommon.

Colon polyps and colon Colon polyps and colon cancerscancers

Colon polyps and colon Colon polyps and colon cancerscancers

• These disorders rarely cause significant These disorders rarely cause significant acute LGI hemorrhage.acute LGI hemorrhage.

• Left-sided and rectal neoplasms are more Left-sided and rectal neoplasms are more likely to cause gross bleeding than right likely to cause gross bleeding than right sided lesionssided lesions

• Right sided lesions are more likely to Right sided lesions are more likely to cause anemia and occult bleeding.cause anemia and occult bleeding.

• Diagnosis and treatment consists of Diagnosis and treatment consists of colonoscopic excision or surgical resection.colonoscopic excision or surgical resection.

Inflammatory bowel Inflammatory bowel diseasedisease

Inflammatory bowel Inflammatory bowel diseasedisease

• Ulcerative colitis can occasionally Ulcerative colitis can occasionally cause severe GI bleeding associated cause severe GI bleeding associated with abdominal pain and diarrhea.with abdominal pain and diarrhea.

• Colonoscopy and biopsy is diagnosticColonoscopy and biopsy is diagnostic• Therapy consists of medical Therapy consists of medical

treatment of the underlying disease;treatment of the underlying disease; operation is required on rareoperation is required on rare occasionsoccasions

Ischemic colitisIschemic colitis

Ischemic colitisIschemic colitis• This disorder is seen in elderly patients with This disorder is seen in elderly patients with

known vascular disease; abdominal pain may be known vascular disease; abdominal pain may be postprandial and associated with bloody diarrhea postprandial and associated with bloody diarrhea or rectal bleeding. Severe blood loss is unusual or rectal bleeding. Severe blood loss is unusual but can occur.but can occur.

• Abdominal films may reveal Abdominal films may reveal ""thumbprintingthumbprinting"", , causedcaused by submucosal edema. Colonoscopy by submucosal edema. Colonoscopy reveals areveals a well-demarcated area of hyperemia, well-demarcated area of hyperemia, edema, andedema, and mucosal ulcerations.mucosal ulcerations. TheThe splenic splenic flexure andflexure and descending colondescending colon are the most are the most common sites.common sites.

HemorrhoidsHemorrhoids

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.

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

Obscure GI BleedingSmall 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

Small Bowel BleedingRare 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

Obscure GI BleedingEvaluation

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

If Surgery is neededIf Surgery is needed

•Localized without control Localized without control or rebleedingor rebleeding

•What's your treatment?What's your treatment?

LocalizedLocalized

•Resection of affected areaResection of affected area

SurgerySurgery

•Severe hemorrhage without Severe hemorrhage without localizationlocalization

•WHAT`S YOUR NEXT STEP?WHAT`S YOUR NEXT STEP?

In an Unstable Patient In an Unstable Patient withwith

No localized site of No localized site of bleedingbleeding

• Introperative CleansingIntroperative Cleansing• Intraoperative Intraoperative

ColonoscopyColonoscopy•TransiluminationTransilumination•ColotomyColotomy•Subtotal colectomySubtotal colectomy

Returning to our Returning to our casecase

A Colonoscopy was A Colonoscopy was performedperformed

Diagnosis was madeDiagnosis was made

• POST RBL BLEEDINGPOST RBL BLEEDING

• MISSED AT PRIMARY INVESTIGATIONMISSED AT PRIMARY INVESTIGATION

• A SIMPLE ANOSCOPY WITH GOOD A SIMPLE ANOSCOPY WITH GOOD SUCTION OF BLOOD CLOTS WOULD HAVE SUCTION OF BLOOD CLOTS WOULD HAVE HELPHELP