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Finding Sources of Obscure Lower GI Bleeding

Finding Sources of Obscure Lower GI Bleeding. William Kwan. Causes of Hematochezia. COLONIC BLEEDING (95%) SMALL BOWEL BLEEDING (5%) Diverticular disease 30-40 Angiodysplasias Ischemia 5-10 Erosions or ulcers (K, NSAIDs) Anorectal disease 5-15 Crohn's disease

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Finding Sources of Obscure Lower GI Bleeding

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  1. Finding Sources of Obscure Lower GI Bleeding William Kwan

  2. Causes of Hematochezia • COLONIC BLEEDING (95%) SMALL BOWEL BLEEDING (5%) • Diverticular disease 30-40 Angiodysplasias • Ischemia 5-10 Erosions or ulcers (K, NSAIDs) • Anorectal disease 5-15 Crohn's disease • Neoplasia 5-10 Radiation • Infectious colitis 3-8 Meckel's diverticulum • Postpolypectomy 3-7 Neoplasia • IBD 3-4 Aortoenteric fistula • Angiodysplasia 3 • Radiation colitis/proctitis1-3 • Other 1-5 • Unknown 10-25

  3. Causes of Hematochezia • Diverticulosis • Bleeding occurs in only 3-5% • Left-sided source more common when diagnosed by colonoscopy • Right-sided source more common when diagnosed by angiography • Angiodysplasia • Most common in cecum and ascending colon • When in the small bowel, presents as iron deficiency anemia and rarely as hematochezia

  4. Causes of Hematochezia • Hemorrhoids • Ischemic colitis • Neoplasms • NSAID-induced injury in terminal ileum and proximal colon • IBD • 10-15% of hematochezia caused by upper GI bleed

  5. History • NSAIDs & ASA strongly associated with lower GI bleeding just as with upper GI bleeding • Stercoral ulcers caused by severe constipation • Recent polypectomy • Hypovolemia preceding bleed suggests ischemic colitis

  6. Going Hunting

  7. Going Hunting • Bleeding source not found in 25% • KUB to look for perforation or obstruction • NG aspirate • Colonoscopy • No agreement over whether prep is needed because of increased risk of perforation with unpreped colon • Radionuclide imaging • Can detect slow bleeds at 0.1-0.5ml/min • More sensitive but less specific than angiography

  8. Going Hunting • Angiography • Requires bleeding of at least 1ml/min • Very specific but not very sensitive • May cause bowel infarction, renal failure • Small bowel evaluation • Push enteroscopy can allow evaluation of the first 60cm of jejunum • Video capsule to evaluate the remainder • Meckel scan

  9. Strategy with Lower GI bleeding • If persistently unstable and major bleeding, proceed to surgery • If colonic source, subtotal colectomy with ileorectal anastomosis • If small bowel source, resection • If no identified source, intraoperative enteroscopy followed by resection • If stable and major bleeding • Tagged red cell scan • If positive, follow with angiography • If negative, capsule endoscopy, enteroclysis, enteroscopy

  10. Strategy with Lower GI bleeding • If stable and minor bleeding • Colonoscopy • If negative, capsule endoscopy, enteroclysis, enteroscopy • If all studies negative • Colonoscopy if rebleeding

  11. Don’t Forget • In addition to basic labs (CBC, Chemistries, Coags), obtaining type and cross • Two large bore peripheral IV’s • Rectal exam as up to 40% of rectal cancers can be detected this way

  12. References • Bounds, BC and PB Kelsey. Lower Gastrointestinal Bleeding. Gastrointestinal Endoscopy Clinics of North America. 2007: 17, 273-88. • Townsend: Sabiston Textbook of Surgery. 18th ed.

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