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Lower GIT Haemorrhage

Lower GIT Haemorrhage. Prof/ Walid Elshazly. A prof of surgery. Lower gastrointestinal hemorrhage. Lower gastrointestinal hemorrhage refers to a spectrum of intestinal bleeding that arises distal to the ligament of Treitz. Incidence rate: 20/100,000/ year Disease of the elderly

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Lower GIT Haemorrhage

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  1. Lower GIT Haemorrhage Prof/ Walid Elshazly A prof of surgery

  2. Lower gastrointestinal hemorrhage • Lower gastrointestinal hemorrhage refers to a spectrum of intestinal bleeding that arises distal to the ligament of Treitz. • Incidence rate: 20/100,000/ year • Disease of the elderly • 200 fold increase from the 3rd to 9th decades of life • Mortality 2-4 % • 80 – 85 % bleeding stop spontaneously

  3. BLEEDING FRANK OCCULT SMALL BLEED MASSIVE BLEED (rare) ANAEMIA ٍٍٍSELF LIMITED ٍٍٍNON-SELF LIMITED

  4. Degrees of hemorrhage • Lower gastrointestinal bleeding presents with varying degrees of hemorrhage. • Minor and self-limited, • patient describe the passage of 100–250 mL of blood, possibly a few clots, and often mixed with mucous. 2) Major and self-limited • Patients experiencebrisk, copious bleeding 3) Major and ongoing ? • Patients present with massive and continuous hemorrhage associated with hypovolemia.

  5. Lower gastrointestinal hemorrhage • Massive lower intestinal hemorrhage is difficult to define. Patients often describe massive bleeding into their commode even when a small amount of blood discolors the water. • True massive intestinal hemorrhage typically include • Hematocrit less than 30%, • Transfusion requirements (up to 3–5 units of blood/blood products), or • Orthostasis requiring resuscitation.

  6. Etiologies • Common causes for lower gastrointestinal hemorrhage include • Diverticulosis (30 - 50%) • Angiodysplasia (20 - 30%) • Neoplastic (10- 15%) cancer, polyp • Inflammatory (15 - 20%) • Inflammatory bowel disease. • Ischemic colitis, and • Anorectal diseases (5-10 %) • Unusual causes include • Hemorrhage also stems from intestinal tumors or malignancies. • Nonsteroidal antiinflammatory drug (NSAID)-related nonspecific colitis, • Meckel’s diverticulum, and

  7. LGIBDiverticulosis(30 - 50%) • Prevalence of Diverticulosis • 5% to 10% before age 50 • 30% after age of 50 • 50% over age 70 • 66% over age 85

  8. Diverticular disease of the colon Pathogenesis • The start is disordered colonic motility • leads to segmentations of the colon into (bladders) • (bladders) separated by contraction rings with pressures reaching 90 mm Hg inside these bladders

  9. Diverticular disease of the colon Pathogenesis Segmentation causing high pressures and pulsion force responsible for diverticulosis

  10. Diverticular disease of the colon Pathogenesis

  11. Diverticular disease of the colon Pathogenesis Herniation of colonic mucosa through the circular muscle at the points where the blood vessels penetrate the colonic wall

  12. Diverticular disease of the colon Pathogenesis Herniation of colonic mucosa through the circular muscle at the points where the blood vessels penetrate the colonic wall

  13. LGIBDiverticulosis(30 - 50%) • 5 – 15 % of people with diverticula will have LGIB. • Bleeding is PAINLESS. • The bleeding • In most cases, bleeding ceases spontaneously • In 10 to 20 %of cases, the bleeding continues unabated in the absence of intervention

  14. LGIBDiverticulosis(30 - 50%) • The risk of rebleeding • After an episode of bleeding is approximately 25% • Increases to 50% among patients who have had two or more prior episodes of diverticular bleeding.

  15. LGIB Angiodysplasia (20 - 30%) • Angiodysplasia (20 - 30%) (or AVM, or Vascular Ectasias) • Composed of ectatic, dilated, thin-walled arteriovenous communications • located within the submucosa and mucosa of the intestine. • lined by endothelium alone.

  16. LGIB Angiodysplasia (20 - 30%) • No one is quite certain precisely why angiodysplasias occur. • Current hypotheses suggest • a loss of vascular integrity related to loss of transforming growth factor (TGF) β signaling cascade or • a deficiency in mucosal type IV collagen.

  17. Adults Angiodysplasia (20 - 30%) • Risk Factors • Older (65 y.o.) > Younger • End stage renal disease • Von Willebrand's disease • Aortic stenosis? (Heyde’s syndrome), • Hereditary hemorrhagic telangiectasias (Osler-Weber-Rendu) • Low fiber diet • Obesity

  18. LGIB Angiodysplasia (20 - 30%) • LGIB (VENOUS) is usually occult and PAINLESS. • Located within • Cecum 37%, • Sigmoid 18%, • Ascending 17%, • Rectum 14%, • Transverse and Descending 7%.

  19. LGIBNeoplastic (10- 15%) Polyps Cancer

  20. LGIBInflammatory (15 - 20%) • Radiation • Intestinal damage due to fibrosis and ischemia. • IBD • Ulcerative • Crohn’s Disease Radiation colitis Sever Crohn’s Disease Ulcerative colitis

  21. LGIBInflammatory (15 - 20%) • Infectious (E. Coli, C. Difficile, C. Jejuni …) • Ischemic (Hypoperfusion and Vasoconstriction) • Hypotension, Heart Failure, Arrhythmia • Vasculitis Infective colitis Ischemic colitis

  22. LGIBInflammatory (15 - 20%) • Pseudomembransous Colitis • Complication of antibiotic therapy that causes severe inflammation, irritation and swelling of the colon mucosa. • Almost any antibiotic can cause this condition. • Clostridium difficile, which occurs normally in the intestine, overgrows when antibiotics are taken. This bacterium releases a powerful toxin which causes the symptoms.

  23. LGIBInflammatory (15 - 20%) • Pseudomembransous Colitis • Ampicillin is the most common cause of this condition in children. • Stopping the antibiotic with rehydration therapy and metronidazole is usually used to treat the disorder.

  24. LGIBAno-rectal causes (5 – 10%) • Hemorrhoids (< 50 y.o. most common) • Anal fissures (most common in child) • Anal fistulas • Proctitis • Gonorrheal or mycoplasmal infections • Rectal trauma • Foreign objects • Rectal CA • Rectal polyp

  25. LGIBOthers (5 – 10%) • Small intestinal tumors, known also as gastrointestinal stromal tumors (GIST). • These lesions enlarge and surpass their blood supply. • In that event, the ischemia in the tumor will ulcerate and may cause a localized hemorrhage. • Post-polypectomy bleeding • Aortoenteric fistula • Coagulation deficiency

  26. LGIB Others (5 – 10%) • Finally, NSAID-associated intestinal hemorrhage occurs most frequently in the terminal ileum and cecum. • Diaphragm-like strictures are pathognomonic for NSAID injuries and • may result from a healing ridge related to repeated injuries from the agents.

  27. LGIB Others (5 – 10%) • Intussusception • Most common abdominal emergency to affect children under 2 years of age. • Boys = 2 X Girls, in frequency • Meckel’s Diverticulum (embryonic diverticulum) • Rule of 2's: • 2% of the population • 2% of cases are symptomatic • 2 feet from the ileocecal valve • 2 inches in length • Often present within 2 years of age

  28. Children and Young Adults LGIB • Anal Fissure • Most often the result of hard stool and prolonged constipation. • After forced hard bowel movement. • Infectious Colitis • IBD • Crohn’s Disease • Ulcerative Colitis • Polyps • Intussusception • Meckel’s Diverticulum (embryonic diverticulum) • Pseudomembransous Colitis

  29. Management • Resuscitation for major bleeds • Find site (localization) • Treat the cause

  30. Resuscitation for major bleeds • Placement of vascular access with large bore intravenous fluids. • Further hemodynamic monitoring requires • Cardiac rhythm monitoring and • placement of a urinary catheter. • A nasogastric tube placed will screen for the presence of upper gastric sources for bleeding.

  31. Resuscitation for major bleeds • The treatment goals for resuscitation are to • Restore volume and, • Replete red blood cell deficiencies and their impact on oxygen delivery. • In addition, all coagulopathies require reversal. • Patients require laboratory profiles that include a • Complete blood count, • Serum electrolytes, • Coagulation profile, • and a type and cross match for packed red blood cells.

  32. Management Resuscitation for major bleeds Find site (localization) Treat the cause

  33. Find site (localization) • The initial specific diagnostic evaluation begins with • Digital anorectal examination and anoscopy. • A rigid proctosigmoidoscopy will allow the examiner • to evacuate the rectum of blood and clots. • A complete mucosal assessment serves to exclude internal hemorrhoids, anorectal solitary ulcers, neoplasms, and colitis.

  34. Find site (localization) • What is the first test to evaluate the cause of bleeding ? Currently, three tests are considered for the initial evaluation. These tests include • Colonoscopy, • Nuclear scintigraphy, and • Angiography.

  35. Find site (localization) • Colonoscopy and angiography offer therapeutic intervention whereas nuclear scanning is purely diagnostic. • Decisions as to which test to use depend on • The clinical judgment, • Local expertise, • Severity of the event, and • The current activity of the hemorrhage.

  36. Colonoscopy

  37. Colonoscopy

  38. Colonoscopy Advantages • Ability to provide a definitive localization of ongoing active bleeding the region of the intestine requires a tattoo to mark the site with India ink • The potential for therapy. • Thermal agents such as heater probes, bipolar coagulation, argon beam, and laser therapy • Injection therapy primarily uses topical and intramucosal epinephrine. • Mechanical therapy includes endoscopically applied clips.

  39. Colonoscopy Disadvantages Colon must be preparation is for visualization which require 24 hour Risks of sedation and anesthesia

  40. Argon beam arrest of AVM

  41. Radionuclide imaging

  42. Radionuclide imaging • The more frequently preferred agent for lower gastrointestinal hemorrhage radionuclide scanning is the 99mTc pertechnetate-tagged RBC scans. • The tagged RBC scans may cover a period of hours and allow for re-imaging within 24 hours.

  43. Radionuclide imaging Advantages Noninvasive Radionuclide imaging detects the slowest bleeding rates. It is able to detect rates of 0.1 – 0.5 mL/min. Thus, it is a technique that is more sensitive than angiography. Disadvantages the nuclear scanning cannot reliably localize the site of hemorrhage precisely. Requires active bleeding of > 0.1 ml/min Nuclear scintigraphy has variable results, suggesting that scan timing, technical skills, and experience may increase accuracy. Current reports suggest accuracies ranging from 24% to 91%.

  44. Selected images from a 99mTc-labeled RBC gastrointestinal bleeding study in a patient with known diureticulosis.Images acquired at 1 minute (A) and 14 minutes (B). Abnormal increased isotopic activity developed in the proximal transverse colon, which progressed antegrade to the descending colon.

  45. Technetium labelled RBC scan showing extravasation of radiolabelled blood in a loop of ileum (arrow(

  46. Angiography

  47. Angiography • Angiography is diagnostic and therapeutic in the treatment of intestinal hemorrhage. • The clinical judgment for choosing angiography involves three different types of hemorrhage. • First, acute, major hemorrhage with ongoing bleeding requires emergency angiography. • Second, patients with an early blush during nuclear scintigraphy may benefit from therapeutic angiography. • Finally, angiograms may define a potential source for hemorrhage in occult and recurrent gastrointestinal hemorrhage.

  48. Angiography • Advantages • Used with major sever bleeding the study requires a hemorrhage rate of > 1 mL/min. • Highly accurate localization of the site of bleeding . • Angiographic blush may suggest a specific etiology, but it lacks the accuracy of colonoscopy. • Angiography could used for treatment by either • Intra-arterial vasopressin infusion • Arterial embolization

  49. Diverticular hge in the caecum Extravasation hge in the caecum AVM

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