University of FlorenceUniversity of FlorenceDepartment of Medical and Surgical Department of Medical and Surgical

Critical CareCritical Care

Lower Gastrointestinal Lower Gastrointestinal Bleeding:DefinitionsBleeding:Definitions

C.FuciniC.Fucini

Turin 2006 Turin 2006

…….any bleeding located .any bleeding located throughout the GI tract throughout the GI tract

distal to the legament of distal to the legament of Treitz..Treitz..

Jejuno-ileal bleedingJejuno-ileal bleeding

Colonic bleedingColonic bleeding

Rectal bleedingRectal bleeding

Anal bleedingAnal bleeding

Blood in the Stools Blood in the Stools

MelenaMelenaBlack tarry Black tarry usually from proximal to Treitzusually from proximal to Treitz Reddish purple Reddish purple Dark red Dark red usually from ileocolic areausually from ileocolic area

Bright red Bright red usually from left colon/anorectumusually from left colon/anorectum

The color of the blood is The color of the blood is unreliable because of unreliable because of

variability in its degradation variability in its degradation and transit timeand transit time

Incidence:25 cases per 100000Incidence:25 cases per 100000

(possibly understimated)(possibly understimated)

Lower gastrointestinal bleedingLower gastrointestinal bleeding

AcuteAcute

ChronicChronic

Severe(Hematochezia)Severe(Hematochezia)

ModerateModerate

SlowSlow

OccultOccult

Other symptomsOther symptoms

-abdominal pain-abdominal pain

-rectal pain-rectal pain

-anal pain-anal pain

-painless-painless

Small bowel is the source of Small bowel is the source of

bleeding in 5-20% of the casesbleeding in 5-20% of the cases

Vernava AM et al…1997Vernava AM et al…1997

Chao CC et al..2005 Chao CC et al..2005

The colon and anorectum are The colon and anorectum are the source in 70-90%of the the source in 70-90%of the

casescases

Acute lower gastrointestinal Acute lower gastrointestinal bleeding(ALGIB):bleeding(ALGIB):

abrupt onset of recurrent abrupt onset of recurrent hematocheziahematochezia

*0.7% of all hospital admission*0.7% of all hospital admission

*Average patients age 71 *Average patients age 71±14 yrs±14 yrs

……Although the vast majority Although the vast majority of patients will cease of patients will cease

bleeding spontaneously it bleeding spontaneously it can be a greater diagnostic can be a greater diagnostic and therapeutic challenge and therapeutic challenge

than bleeding from the than bleeding from the upper gut.upper gut.

The conundrum of lowerThe conundrum of lowergastrointestinal bleedinggastrointestinal bleeding

Billingham RP. Billingham RP. 19971997

10-15% of patients require 10-15% of patients require urgent diagnostic and urgent diagnostic and

therapeutic procedurestherapeutic procedures

8-12 % of patients fail to have 8-12 % of patients fail to have the precise origin and location the precise origin and location of bleeding identified before an of bleeding identified before an

operationoperation

In 10% of the patients with In 10% of the patients with hematochezia the source of hematochezia the source of bleeding is gastroduodenalbleeding is gastroduodenal

Severe acute lower Severe acute lower gastrointestinal gastrointestinal

bleeding(SALGIB)bleeding(SALGIB)(15-22% of ALGIB)(15-22% of ALGIB)

*significant hemodynamic compromise*significant hemodynamic compromise

*decrease in hemoglobin 2-4 g/dl*decrease in hemoglobin 2-4 g/dl

*transfusion requirement>/= 2-4 blood *transfusion requirement>/= 2-4 blood unitsunits

Mortality related to lower GI Mortality related to lower GI

bleeding has been reported to bleeding has been reported to

occur in 4 to 15% of patientsoccur in 4 to 15% of patients

Bender et al.1991Bender et al.1991

Makela JT et al…1993Makela JT et al…1993

Undirected surgery may be necessary Undirected surgery may be necessary whenwhen::

-more than 1500 ml of blood is necessary to -more than 1500 ml of blood is necessary to resuscitate the patients and bleeding continuesresuscitate the patients and bleeding continues

-2000 ml of blood is necessary to maintain vital -2000 ml of blood is necessary to maintain vital signs during a 24-hour periodsigns during a 24-hour period

-Bleeding continues for 72 hours-Bleeding continues for 72 hours

-Rebleeding(significant) occurs within one week -Rebleeding(significant) occurs within one week of initial cessationof initial cessation

Colonic originColonic origin

< 60 years< 60 years

Right/left diverticulaRight/left diverticula

IBDIBD

NeoplasmNeoplasm

> 60 years> 60 years

AngiodysplasiaAngiodysplasia(right (right sided)sided)

Right/left diverticulaRight/left diverticula

NeoplasmNeoplasm

Diverticulosis accounts for 50% of all lower Diverticulosis accounts for 50% of all lower gastrointestinal bleedingsgastrointestinal bleedings

60% of bleeding episodes arise from 60% of bleeding episodes arise from diverticula proximal to the splenic flexurediverticula proximal to the splenic flexure

Bleeding spontaneously ceases in 80-90% Bleeding spontaneously ceases in 80-90% of patientsof patients

Risk of rebleeding is approximately 25%Risk of rebleeding is approximately 25%

(Cohen J.L..1996)(Cohen J.L..1996)

AngiodysplasiaAngiodysplasia(Arterovenous malformations,Vascular ectasias,Angiomas)(Arterovenous malformations,Vascular ectasias,Angiomas)

Real or overstimated problem??Real or overstimated problem??

Precise incidence unknown:<1-30% subjectsPrecise incidence unknown:<1-30% subjects

Lower GI bleeding:2-60%Lower GI bleeding:2-60%

Only 15% with bleeding will experienceOnly 15% with bleeding will experience

severe episodessevere episodes

Rectal outlet bleedingRectal outlet bleeding

Intermittent passage of scant to Intermittent passage of scant to modest amounts of blood and modest amounts of blood and clots,not associated(usually) with clots,not associated(usually) with a significant drop in the a significant drop in the hemoglobin or hematocrit and hemoglobin or hematocrit and arising from anorectal conditions.arising from anorectal conditions.

Chronic bleedingChronic bleeding

-In 10% of subjects aged 25-65-In 10% of subjects aged 25-65-80% benign anorectal diseases -80% benign anorectal diseases

(Hemorroids,fissure, solitary ulcer/prolapse,radiation (Hemorroids,fissure, solitary ulcer/prolapse,radiation proctitis etc…..)proctitis etc…..)

-present in 70% of pts.with anorectal -present in 70% of pts.with anorectal symptoms.symptoms.

but……………. ……………………….but……………. ……………………….

…….11% of patients(mostly of .11% of patients(mostly of them <50 years) with them <50 years) with

significant significant lower lower gastrointestinal bleeding have gastrointestinal bleeding have a benign anorectal source of a benign anorectal source of

bleeding.bleeding.

(Hoedema R.E. et al… 2005)(Hoedema R.E. et al… 2005)

Chronic bleedingChronic bleeding

-common also in -common also in angiodyplasia,neoplasmsangiodyplasia,neoplasms

-Usually slow and minor at times -Usually slow and minor at times revealed by unexplained anemiarevealed by unexplained anemia

Chronic bleedingChronic bleeding(occult bleeding)(occult bleeding)

Biochemical test(Guajak)Biochemical test(Guajak)

Immunological testImmunological test

Acute GI hemorrhages in patients Acute GI hemorrhages in patients with coagulopathy or under with coagulopathy or under

antiaggragation/anticoagulation antiaggragation/anticoagulation

treatmenttreatment 50% of pts.with leukemia and platelet<20,000 mm50% of pts.with leukemia and platelet<20,000 mm3 3 suffer suffer

significant GI bleedingsignificant GI bleeding

26-30% of geriatric patients with lower bleeding are 26-30% of geriatric patients with lower bleeding are antiaggregated/anticoagulatedantiaggregated/anticoagulated

Spontaneous hemorrage is unlikely!!!Spontaneous hemorrage is unlikely!!!

(Coon WW,1974(Coon WW,1974

Mittal R et al..1985)Mittal R et al..1985)

The first important step,after The first important step,after resuscitation,is to establish resuscitation,is to establish

whether the patient is actively whether the patient is actively bleeding or has ceased by the bleeding or has ceased by the

time of presentation.time of presentation.

To apply an To apply an efficient,disciplined and efficient,disciplined and

orderly approach in choosing orderly approach in choosing among several sophisticated among several sophisticated

diagnostic toolsdiagnostic tools

AimAim

To identify the etiology of To identify the etiology of bleedingbleeding

A team approach for the A team approach for the correct algorithm to follow in correct algorithm to follow in

lower gastrointestinal bleedinglower gastrointestinal bleeding

Lower GI HemorrhageLower GI Hemorrhage(Sources(Sources))

ColorectalColorectal

Diverticular diseaseDiverticular disease AngiodysplasiaAngiodysplasia NeoplasmNeoplasm IBDIBD Ischemic colitisIschemic colitis Infectious colitisInfectious colitis Radiation proctitisRadiation proctitis Anorectal (Hemorroids,fissure Anorectal (Hemorroids,fissure

)) IatrogenicIatrogenic VaricesVarices

Small bowelSmall bowel

Arteriovenous Arteriovenous malformationmalformation

Meckel’s diverticulumMeckel’s diverticulum IBDIBD NeoplasiaNeoplasia VasculitisVasculitis

Moderate Lower GI bleeding Moderate Lower GI bleeding

When and where the admission ???When and where the admission ???

Nearly 20% of emergency Nearly 20% of emergency department patients with a chief department patients with a chief

complaint of lower gastrointestinal complaint of lower gastrointestinal bleeding will prove either to have bleeding will prove either to have

no bleeding at all or to have no bleeding at all or to have bleeding from a non bleeding from a non

gastrointestinal gastrointestinal source(eg,nose,pulmonary source(eg,nose,pulmonary

tree,vagina)tree,vagina)

(Law DH,1979) (Law DH,1979)

Urgent colonoscopy Urgent colonoscopy vs.standard approachvs.standard approach

Diagnostic toolsDiagnostic tools

HistoryHistory

Nasogastric tubeNasogastric tube

Anorectal inspection,digital rectal examinationAnorectal inspection,digital rectal examination

Proctoscopy,Proctoscopy,

Colonoscopy/sigmoidoscopyColonoscopy/sigmoidoscopy

EnteroscopyEnteroscopy

technetium-labeled rbc scantechnetium-labeled rbc scan

Radionuclide scintigraphyRadionuclide scintigraphy

technectium-99 sulfur colloid technectium-99 sulfur colloid

Selective mesenteric angiographySelective mesenteric angiography

Wireless capsule endoscopyWireless capsule endoscopy

Helical CT scanHelical CT scan