LGIB definition
bleeding from the gut distal to ligament of treitz
per rectal bleeding anatomical possibility
UGIB hemorrhage
small bowel
colorectal
anorectal outlet
history to ask for LGIB
occult vs overt
duration acute vs chronic
massive vs slow bleeding
obscure GIB
quantity GI symptoms anorectal symptoms hemodynamics hx of previous bleeding, previous ix, systemic symptoms, other comorbidities, drugs (NSAIDS, coagulopathies) fam hx sexual social hx
outlet bleeding character
fresh blood ON stool
small amounts
anorectal symptoms
no hemodynamic distrubances
acute LGIB causes
- angiodysplasia
- diverticular disease
- acute anal fissure
management of acute LGIB
- resuscitation and stabilize hemodynamics
- -venous access
- IV crystalloid solution for volume expansion
- type and screen for transfusion
- monitor (BP, pulse, urine output, CVP, hb, hematocrit, LRFT, coagulation)
- localization of bleeding site
- history, p/e, ix
- colonoscopy, upper endoscopy
- angiography
- radionuclide scan
- CT, small bowel contrast
- therapeutic intervention (endoscopic, angiographic, surgical)
indications for transfusion
- profuse bleeding
- persistent hemodynamic instability despite crystalloid resuscitation
- symptomatic anemia
- ami / unstable angina with low Hb
p/e for LGIB
- hemodynamic status (vitals)
- pallor
- abdominal exam
- DRE, proctoscopy
LGIB if upper endoscopy and colonoscopy showed negative findings what to do next
repeat
enteroscopy
intraoperative endoscopy
Therapeutic modalities in colonoscopy for angiodysplasia, diverticulitis
- sclerotherapy
- heat probe
hemoclips - electrocoagulation
- laser
- argon beam coagulation
what is angiography for LGIB
selective catheterization of celiac artery, SMA, IMA by seldinger technique
positive test for angiography
extravasation of contrast
complications for angiography
- contrast allergy
- renal failure
- bleeding from puncture site
therapeutic angiography
- embolization
- vasopressin injection
LGIB indications for surgery
hemodynamic instability
- transfusion requirement >=6 units
- persistent bleeding
- rebleeding within 1 week
LGIB surgery options with and without localization
with localization –> segment resection
without localization –> subtotal colectomy if bleeding is colonic origin; intraop colonoscopy or enteroscopy for localization
common causes for LGIB
colorectal
- diverticular disease
- angiodysplasia
- post polypectomy
- colorectal neoplasm
- ischemic colitis
- IBD colitis
- radiation colitis
- infective colitis
anorectal sources
- hemorrhoids
- anal fissures
- rectal ulcer
- rectal varices
- anorectal neoplasm
- IBD proctocolitis
- radiation proctocolitis
- infective proctocolitis
small bowel sources
- Meckel’s diverticulitis
- jejunoileal diverticula
- vascular lesions (angiodysplasia, hemangioma)
- small bowel neoplasms
- small bowel ulcers (NSAID)
- Crohn’s disease
- Aortoenteric fistula
- TB enteritis
massive hemorrhage UGIB
why does diverticulosis cause bleeding
ruptured vasa rectum
how to dx diverticular disease
by endoscopy/ angiography
treatment for diverticular disease or angiodysplasia
- endoscopic therapy
- surgical resection
where does diverticulum occur in asians?
right colon
what is angiodysplasia? what is it associated with?
acquired ectasia of vessels in submucosa due to degeneration
asso with vascular malformations in GI tract and aortic stenosis
bleeding characteristics between angiodysplasia and diverticular disease
angiodysplasia less severe bleeding but more rebleeding
surgical treatment for crohns disease
total colectomy +/- anastomosis
segmental small bowel resection
