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LOWER GASTROINTESTIRAL BLEEDING

LOWER GASTROINTESTIRAL BLEEDING. Asoc. Prof. Dr.Orhan Yalçın Ministry of Health, Okmeydanı Education and Research Hospital, Turkey. Definition. Abnormal hemorrhage into lumen of the bowel from a source distal to ligament of Treitz. 30 % - 40 % diverticular disease Colitis

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LOWER GASTROINTESTIRAL BLEEDING

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  1. LOWER GASTROINTESTIRAL BLEEDING Asoc. Prof. Dr.Orhan Yalçın Ministry of Health, Okmeydanı Education and Research Hospital, Turkey

  2. Definition Abnormal hemorrhage into lumen of thebowel from a source distal to ligament of Treitz.

  3. 30 % - 40 % diverticular disease • Colitis • Colorectal neoplasia • Benign anorectal disease • Coloni arteriovenous malformation • Small bowel origin Despite all of the diagnostic modalities in 8 % to12 % of patients the source of bleeding cannot be found. In 10 % of hemotochesia cases, the source is from upper GI tract.

  4. There are three steps 1- Hemodynamic stabilization 2- Bleeding site localization 3- Therapy History -Nature and duration of bleeding -Associated symptoms ( pain, weight loss ) -Past medical events ( Injuries, surgical procedures, endoscopy, IBD, etc.) -Medications ( NSAİD, anticoagulants ) -Physical examination / Vital signs -Laboratory: Hemogrom, PT, PTT -And resussication

  5. BLEEDING SITE LOCALIZATION Which modality will be used. This depends on: -Hemodynamic stability -Bleeding rate -Comorbid conditions -Hospital expertise MODALITIES -Colonoscopy -Radiolabeled red blood cell scanning -Angiography -Multidetecter Row Helical CT

  6. COLONOSCOPY - Procedure of choice as initial investigation - Accuracy for localization 53 % - 97 % - The distal ileum should be entubated - It has both diagnostic and therapeutic effect - Has ability to identify bleeding source regardless offrate and presence of bleeding. - It is safe

  7. COLONOSCOPY DISADVANTAGES - Requires bowel preparation - It is invasive procedure - Prevalence of stigmata of hemorrhage is low - Complication rate is low ( 0,5- 1,5 % ) but major complications ( Perforation ) - Can not show upper GI and small bowel bleeding

  8. RAPIOLABELED RED BLOOD CELL SCANNING It detects at rates as slow 0,1- 0,4 ml/min bleeding - Two agents are used A- 99 m Tc-labeled sulfur colloid - Requires no preparation time - But it’s absorbsion is rapid by liver and spleen - This condition hinder accurate localization of bleeding B- 99 m Tc – labeled RBC s -Requires some preparation time -It is not hinder by liver and spleen -Much longer half time ( 24- 48 hours )

  9. RADIOLABELED RED BLOOD CELL SCANNING CONT. - Accurate localization rate for bleeding is between 42 % -85 % - Major complication is rare - Has no therapeutic intervention capability - It is useful especially in non life threating bleeding to confirm active bleeding and a guide to mesenteric angiography

  10. ANGIOGRAPHY - It is detects at rate as slow as 1- 1,5 ml/min - Detection rate is between 27 %- 67 % - It has both diagnostic and therapeutic effects - Major complication rate 2 % - 50 ( renal failure, bleeding from arterial puncture, embolism from dislodged thrombus ) - Therapeutic vasopressin infusion or embolization - It should be used if colonoscopy fails

  11. PROVOCATIVE ANGIOGRAPHY • In some patients despite continuous obscure bleeding, bleeding point can not be found - In this patients use of short acting anticoagulant agents ( including vasodilators, thrombolytics ) - When bleeding point is localized, IV methylen blue and laparotomy.

  12. MULTI- DETECTOR ROW HELICAL CT. - In this modality on arterial phase active bleeding is identified as a focal area of high attentuation within the bowel lumen - Accuracy for localization 24 %- 94 % ( All GI bleeding ) -Major complication rate is 0 %- 11 %

  13. THERAPY - Endoscopic therapy - Angiographic therapy - Surgical therapy

  14. ENDOSCOPIC THERAPY • Electrocauterization • Vasoconstrictor Injections • Thermal contacts • Sclero Therapy • Laser

  15. ANGIOGRAPHIC THERAPY A- - Vasopressin infusion 0,2 – 0,4 U/min - Success rate 60 %- 100 % - Complication rate 10 %- 20 % - Re-bleeding rate 50 % B- - Transcatheter embolization - Microcoil, gelatin sponge, polyvinyl alcohol particles - Success rate 90 %

  16. SURGICAL THERAPY Indications - 4 units of RBC in 24 hours - Re bleeding after cessation of hemorrhage in one week - Ongoing bleeding after 72 hours

  17. If possible • Bleeding site should be localized before operation • If angiography shows but can not stop bleeding, methylen blue injected shortly before operation • If preoperative is not possible on operating table every effort should be made to localize bleeding source before resection • Blind resection should be avoided

  18. INTRAOPERATIVE ADJUNCTIVE MANEUVERS • On table colonoscopy • Per oral trans luminal enteroscopy • At the end subtotal colectomy

  19. THANK YOU

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