Download Lower GI bleeding

Lower Gastrointestinal Bleeding
Epidemiology
Mortality 5-10%; 20% of all GI bleeds; significant haemorrhage with haemodynamic compromise
uncommon; stops spontaenously in 80%
 morbidity rate if: haemodynamic instability, repeated haematochezia, gross blood on PR, initial Hct <
<35%, syncope, non-tender abdominal, aspirin use, >2 co-morbid conditions
Pathophysiology
Distal to ligament of Trietz
Aetiology
60% diverticular disease (R=L; acute, painless; can be heavy; 90% resolve spontaneously)
10-20% no cause found
12% angiodysplasia (more in elderly; often recurrent; usually R; rarely severe; associated with AS)
2% Cancer / polyp
Others: ischaemic colitis, infection, IBD, aorto-enteric fistula
If <20yrs: Peutz Jegher syndrome, HSP, Meckel’s diverticulus
Assessment
Symptoms: blood mixed with stool = likely higher; pink frothy blood in pan or on paper = haemorrhoids;
tarry black stool = upper GI; bright red and not severely shocked = lower GI; haematemesis = upper GI;
bright red on surface of stool or toilet paper = fissure
Examination: look for signs of chronic liver disease
Investigations
Bloods:  Ur:Cr and  K suggests upper GI;  Hb and normal MCV = acute;  Hb and MCV = chronic; 
platelets = acute; macrocytosis = hepatic disease; group and save if moderate, XM if severe
Erect CXR: if abdominal pain or findings in chest
CT: 79-100% sensitivity
Management
Paediatrics
IV fluids
As outpatient if:
Colonoscopy if:
Angiography if:
bleeding not haemodynamically signficant and ceased
bleeding haemodynamically significant
but ceased
bleeding haemodynamically signficiant
and ongoing
requires >0.5ml/min; 10% serious complication rate
OT if:
torrential bleeding or failed scope
?ischaemic colitis; laparotomy has increased mortality and morbidity
Technetium-labelled RBC: good at detecting intermittent bleeding; requires >0.1ml/min
<2/12: swallowed maternal blood, infectious colitis, intussusception, volvuls, AV malformation,
haemorrhagic disease of newborn, Hirschsprung disease; milk allergy (onset 12-24 hours after
introduction of new formula or chronic diarrhoea, poor weight gain and abdominal pain; IgE mediated);
meckel diverticulum (remnant of omphalomesenteric duct in distal ileum, 2% incidence, lined with
ectopic gastric mucosa, painless PR bleeding; may result in signficant bleeding)
2/12 – 2yr: milk allergy, intussusception, volvulus, meckel diverticulum; anal fissure, gastro, HUS, HSP
(may be severe), polyps, IBD
>2yr: intussusception, volvulus, meckel diverticulum, anal fissure, gastro, HUS, HSP, polyps, IBD
haemorrhoids, colitis, angiodysplasia, celiac disease, PUD