Mahmoud Ramadan M.D.

General Laparoscopic Surgeon

Bleeding per rectum

Rectal bleeding

Lower GI bleeding

Life threatening.

3-6 units of blood.

Hb < 10.

Dilated sub mucosal veins

Thin mucosa

Acquired (degenerative
changes of aging).
In > 50% of people > 60
years.

Mechanism of bleeding in Angiodysplasia:

Repeated segmental contractions and distension of the colon.

Chronic partial intermittent obstruction of sub mucosal veins.
Dilatation & tortuosity of the sub mucosal veins, then venules
then capillaries.
Loss of competency of precapillary sphincters.
A-V communication.
Low perfusion leading to ischemic necrosis of the epithelium.

Colonoscopy: red mucosal patch.

Pathology: Tortuous dilated capillaries in the lamina propria.

Site: Rt. 70%, Lt. 22%.

Angiography:

In 50% of people > 60 years.

20% bleed during life time, massive in 5%.

Mostly located in the sigmoid.

Bleeding is more from the right side.

Bleeding from rupture of the vasa recta at the dome of the

diverticulum (repeated arterial injury).

On the right side have wider neck: more exposure of the artery to
injury.

Cancer: occurs in 10-20 % of cases & in 2-10% of polyps.

Ischemic colitis

IBD: In 0- 4% of UC accounting to 10% of urgent colectomies.

Small intestinal causes.

Resuscitation.

Rule out blood dyscrasia.

Diagnose the site & cause.

Rule out upper GI cause, NG tube, endoscopy.

Rule out anorectal cause, proctoscopy.

85% stop spontaneously.

Tc-99 scintigraphy.

Angiography.

Colonoscopy.

Ba- enema.

I V injection of radio labeled Tc-99.

Can detect bleeding over the coming 12 hours.

Rate 0.1 ml per minute.

Sensitivity 97%, specificity 85%, predictive value 94-97%.

Inferior & superior mesenteric

Invasive, localizes the site, may suggest the cause.

Rate 0.5-1 ml per minute.

Therapeutic role (embolization, vasopressin).

The gold standard test., may be negative in 20-25%.

Abnormalities:
Extravasation
Early vein filling
Tuft.

Can be done urgently with a low out come? 60%.

Therapeutic role ( haemostatic techniques).

Can be done intraoperatively.

Low out come.

The presence of a lesion does not mean that it is the cause of
bleeding.

If conservative Rx. Fails.

Segmental resection (+,-) anastomosis if the site is identified.

If unknown site:
subtotal colectomy (rule out small intestinal cause, upper GI
cause, rectal cause).

Color

Gauge

Rate

Orange

14

320 ml/min

Gray

16

180 ml/min

White

17

125 ml/min

Green

18

80 ml/min

Pink

20

54 ml/min

Blue

22

31 ml/min

Yellow

24

23 ml/min

Crystalloids . X3 Loses

N/S 0.9% 154 meq NaCl

R/L

G/W or D/W 5%

Na: 130

Cl: 109

K: 4

Bicarbonate (Lactate): 28

Ca: 3
137

Colloids (Plasma Expanders) X1 Loses

Starch

His

FFP

H. Albumin

137

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Fit Patient ASA I, II, III

Duration less than 1 hour ( Trial < 3 hours)
Living Close to hospital
With companion
Pain Control (Good Anesthesia and Analgesia)

Thank You