GUIDE

DR. K.C. CHOUDHARY

DR. S.S. RATHORE
PRESENTED BY
DR. NEERAJ BHATEJA

ABNORMAL
INTRAMURAL BLEEDING
EMANATING FROM A SITE
DISTAL TO THE LIG. OF
TREITZ

INCIDENCE & MAGNITUDE OF PROBLEM

ANNUAL INCIDENCE IS
ESTIMATED UPTO 100 EPISODES
PER 1 LAKH PERSONS
MOST PTS. DO NOT REQUIRE
ADMISSION
PTS. WITH SYMPTOMATIC G.I.
BLEED COMPRISE 1-2% OF ALL
ACUTE MEDICAL & SURGICAL
HOSP. ADMISSIONS.

PRESENTATIONS

ACUTE LGIB
MELENA
HEMATOCHEZIA

INTERMITTENT

OCCULT G.I. BLEEDING

ACUTE LGIB BLEED OF <3

DAYS THAT RESULTS IN
HEMODYNAMIC COMPROMISE
ANEMIA
NEED FOR BLD. TRANSFUSION

IN 75% CASES BLEEDING STOPS SPONTANEOUSLY

INTERMITTENT HEMATOCHEZIA
(OR LESS COMMONLY MELENA) IS

CHRONIC LGIB LASTING FOR >3

DAYS
OCCULT GI BLEEDING :1. FECAL OCCULT BLD TESTING +Ve
2. Fe DEF. ANEMIA
3. NO OBVIOUS EVIDENCE OF GI
BLEED

ETIOLOGY (ADULTS)
WESTERN
DATA *

INDIAN
STUDIES +

DIVERTICULAR DIS.

60%

15%

COLITIS
(UC, CD, ISCHAEMIC
INFECTIOUS,
RADIATION)

13%

20%

ANORECTAL CAUSES

11%

35%

NEOPLASIA

9%

15%

COAGULOPATHY

4%

3%

AVM

3%

12%

* VERNAV & COLLEAGUES SURVEY OF 4410 PTS.

+ BOMBAY HOSPITAL & RESEARCH CENTRE

ETIOLOGY
(PAEDIATRIC & ADOLESCENT AGE GP.)

INTUSSUSCEPTION
POLYPS & POLYPOSIS SYNDROMES

JEVVENILE POLYPS & POLYPOSIS

PEUTZ JEGHARS SYNDROME
FAP

IBD CD, UC
MECKELS DIVERTICULUM

EVALUATION OF LGIB

RAPID ASSESSEMENT OF HEMODYNAMIC

STATUS & RESUSCITATION
MILD HEMORRHAGIC SHOCK

15 - 20% BLOOD LOSS

MODERATE

20 - 40% VOL. LOSS

PROFOUND

- > 40% VOL. LOSS

IV ACCESS
BLD. SAMPLE HEMATOCRIT, COAG. PROFILE
- TYPING & CROSS MATCHING
ISOTONIC CRYTALLOIDS & COLLOIDS
O2 SUPPLEMENTATION

MONITORING & ADDITIONAL

LAB. STUDIES

SERIAL VITALS
MENTAL STATUS
HEMATOCRIT
DETERMINATIONS
URINE OUTPUT
CONTINUOUS EKG
PULSE OXIMETRY

CBC
PLATELETS
PT,PTT
Na+, K+, UREA
CREATININE
LFT

HISTORY AND EXAMINATION

CURRENT EPISODE &

PRESENTATION
PRIOR EPISODES OF GI BLEEDING
MED. H/O PEPTIC ULCER DIS.

LIVER DIS.
CIRRHOSIS
COAGULOPATHY
IBD

MEDICATIONS NSAIDS, WARFARN

DRE & PROCTOSIGMOIDOSCOPY

ASSOCIATED SYMPTOMS

ABD. PAIN ISCHEMIA, IBD,

ANEURYSM
PAINLESS MASSIVE BLEED
DIVERTICULA, ANGIODYPLASIA,
HEMORRHOIDS
BLDY. DIARRHEA IBD, INFECTION
BLEEDING WITH RECTAL PAIN
FISSURES, HEMORRHOIDS OR
RECTAL ULCERS.

ASSOCIATED SYMPTOMS

BLOOD ON THE TOILET PAPER OR

DRIPPING INTO THE TOILET WATER
PERIANAL LESION
BLOOD COATING ON OUTSIDE OF
STOOL ANAL CANAL
BLD. STREAKING OR MIXED WITH
STOOL PLOYP OR MALIGNANCY IN
DESC. COLON
MAROON COLOURED STOOLS
SMALL BOWEL & PROXIMMAL COLON.

UGI BLEED v/s LGIB

UGI SOURCE

LGI SOURCE

HEMATEMESIS

ASSURED

RULED OUT

MELENA

PROBABLE

POSSIBLE

HEMATOCHEZIA

UNLIKELY

HIGHLY
PROBABLE

BLD. STREAKED
STOOL

RULED OUT

ASSURED

OCCULT

POSSIBLE

POSSIBLE

FURTHER EVALUATION
NASOGATRIC
ASPIRATION

BILE + NT,
NO BLD.

BILE -NT
BLD -NT

BLOOD OR
COFFEE GROUND
MATERIAL

UGI RULED OUT

CONSIDER LGIB
COLONOSCOPY

ELICIT GAG
REFLEX

UGI
BLEEDING
UGIE

-VE FOR BLD

CONSIDER (LGIB)

+VE FOR BLD.

(UGI SOURCE)

SPECIFIC DIAGNOSTIC MANEUVRES

DRE & PROCTOSIGMOIDOSCOPY

COLONOSCOPY

DONE AFTER HEMODYNAMIC STABILITY

AFTER RAPID ORAL PURGE
OVERALL DIAGNOSTIC ACCURACY FOR
BLEEDING SITE 90%
BIOPSY CAN BE PERFORMED
ENDOSCOPIC HOMEOSTASIS 70%

INJ. THERAPY
THERMAL (MONO/BIPOLAR
COAGULATION HEATER PROB.)
LASER
METALLIC CLIPS, RUBBER BAND
LIGATION.
APC (ARGON PLASMA COAGULATION)

INJ. THERAPY ADRENALIN,

POLIDOCANOL, ETHANOLAMINE,
SOD TETRADECYL SULFATE,
CYANOACRYLATE, ALCOHOL,
AUTOLOGUS CLOT
ARGON PLASMA COAGULATION
1. NON CONTACT THERMAL TECHNIQUE
2. CURRENT PASSES VIA IONIZED ARGON
PLASMA EMITTED BY A PROBE.

DISADVANTAGES OF COLONOSCOPY

REQUIRES PREP.
FAILURE DURING MASSIVE ACTIVE
BLEEDING
INTERMITTENT BLEEDING LIMITS
DIGNOSTIC YIELD
ORAL LAVAGE FLUID OVERLOAD
EXCESS PURGE DEHYDRATION,
ELECTROLYTE IMBALANCE,
HYPOVOLEMIA, PERFORATION
NOT ABLE TO DETECT LESIONS LIMITED
WITHIN THE NAIL

NUCLEAR SCINTIGRAPHY

TECHMITIUN SULFUR COLLOID

TECHNITIUM 99M LABELED (99m Tc)
RBC SCAN
NON INVASIVE, VERY SENSITIVE (0.1mL/min.)
EFFECTIVE SCREENING TEST PRIOR TO
ANGIOGRAPHY
DISADVANTAGES
SULFUR COLLOID SCANS MAY NOT DETECT
INTERMITTENT BLEEDING COS OF RAPID
CLEARANCE
SIGNIFICANT HEPATIC & SPLENIC UPTAKE
OBSCURES UPPER ABDOMEN
LABELING REQUIRES TIME

ENTEROSCOPY
PUSH ENTEROSCOPY.
SONDE ENTEROSCOPY.
INTRA OPERATIVE ENTEROSCOPY.
RETROGRADE CANULATION OF IC
VALVE.

WIRELESS CAPSULE ENDOSCOPY

A SIGNIFICANT ADVANCE

VIRTUAL COLONOSCOPY

USES HELICAL OR SPIRAL CT SCANNERS

OR MRI TO OBTAIN IMAGES OF COLON TO
DETECT PRECANCEROUS LESIONS LIKE
ADENOMATOUS POLYPS
NON INVASIVE TEST
SENSITIVITY OF 90-92% FOR DETECTION
OF 1 cm. COLONIC POLYPS
NEEDS REFINEMENT

EUS (ENDOSCOPIC ULTRASOUND

SMALL US PROBE ATTACHED TO THE

ENDOSCOPE THAT ALLOWS
SIMULTANEOUS US & VISUAL IMAGE
OF INTESTINAL TRACE
ALLOWS TO LOOK BEYOND THE
SURFACE OF MUCOSA. (TO SEE DEEPER
LAYERS & STRUCTURES THAT
SURROUND THE GUT).
STAGING OF TUMORS OF THE GUT ESP
ESOPHAGUS & RECTAL CANCER.

OTHERS TESTS

DOUBLE CONTRAST BARIUM ENEMA

ENTEROCLYSIS BARUIM + AIR
INFUSED DIRECTLY INTO DUODENUM
VIA A TUBE (FLOUROSCOPIC STUDY)
PROVOCATIVE TESTS
ARTERIOGRAPY
+
HEPARIN (OR THROMBOLYTICS)

TREATMENT MODALITIES

MEDICAL THERAPY
VASOCONSTRICTORS VASPRESSIN,
EPINEPHRINE WITH PROPRANOLOL
HORMONAL THERAPY ESTROGENS FOR
ANGIODYSPLASIAS
OCTREOTIDE DECREASES THE NEED
FOR TRANSFUSION
AMINOCAPROIC ACID DECREASES
FREQ. OF BLEEDING EPISODES
DANAZOL DECREASED TRANSFUSION
REQUIREMENTS

SUPER SELECTIVE EMBOLIZATION

PERCUTANEOUS TRANS CATHETER

EMBOLIZATION AT THE LEVEL OF TERMINAL
ARCADES, VASA RECTA, OR EVEN MURAL
TRUNKS
USE OF MICROCOILS, GELFOAM, PVA,
AUTOLOGUS CLOT, ETHANOLAMINE OR
OXIDIZED CELLULOSE.
RELATIVELY RISKY IN COLONIC AREA.
INTESTINAL ISCHEMIA & INFARCTION
REPORTED.

COLONOSCOPIC HEMOSTASIS

THERMAL CONTACT PROBES

LASER (Nd : YAG)
ARGON PLASMA COAGULATION
METALLIC CLIPS
RUBBER BAND LIGATION
SNARES

SURGICAL THERAPY

ABOUT 10% OF PTS. WITH SIGINIFICANT LGIB

REQUIRE EMERGENCY OR ELECTIVE
LAPAROTOMY.

INDICATIONS

LIFE THREATENING HEMORRHAGE FROM A

WELL DEFINED SITE.
BLEEDING SOURCE NOT LOCALIZED EVEN
AFTER EXTENSIVE DIAGNOSTIC WORK UP
OBSCURE
FAILURE OF ENDOSCOPIC COAGULATION OF
VASCULAR ECTASIAS DESPITE SEVERAL
ATTEMPTS

INDICATIONS

Rx OF CHOICE FOR PTS WITH SMALL

BOWEL TUMORS, MECKELS
DIVERTICULUM OR AORTO ENTERIC
FISTULA.
RISK OF BLEEDING EXCEEDS THE RISK
OF LAPAROTOMY ESP <50 YRS.
GREATER CHANCE OF SMALL BOWEL
TUMOR & MECKELS DIVERTICULUM.
PTS WHO REQUIRE > 5 TRANFUSIONS
OVER 24 HRS.

SURGICAL OPTIONS
PREOPERATIVE
LOCALIZATION
OF BLEED

SEGMENTAL
BOWEL
RESECTION

BLEEDING NOT LOCALIZED

PREOPERATIVELY
INTRA OP
EGD
SURGEON GUIDED ENTEROSCOPY
COLONOSCOPY

BLEEDING PT
LOCALIZED

SEGMENTAL
COLECTOMY

UNDERPRIVIELEGED
CENTER,
MASSIVE BLEEDING

NOT LOCALIZED

BLIND SUBTOTAL
COLECTOMY WITH
ILEORECTAL
ANASTOMOSIS

OBSCURE GI BLEEDING

INTERMITTENT GI BLEED, FOR WHICH NO

SOURCE HAS BEEN IDENTIFIED, DESPITE
RIGOROUS ENDOSCOPIC & RADIOLOGIC
INVESTIGATION.
LESIONS EASILY OVERLOOKED
- VASCULAR ECTASIAS
- DEULAFOYS LESION
- AORTOENTERIC FISTULA
- HEMOBILIA
- HEMOSUCCUS PANCREATICUS

MANAGEMENT OF OBSCURE LGIB

REPEAT ENDOSCOPY &
SCINTIGRAPHY
ENTEROSCOPY/ ENTEROCLYSIS
WIRELESS CAPSULE ENDOSCOPY
INTRA-OP ENTREOSCOPY,
RETROGRADE CANULATION OF IC
VALVE
EXP. LAP. WITH TRANSILLUMINATION
OF THE BOWEL

RARE CAUSES OF LGIB

CHRONIC RADATION ENTERITIS /

PROCTITIS
PORTAL COLOPATHY
SOLITARY RECTAL ULCER SYNDROME
DEULOFOY LESION OF COLON OR
SMALL BOWEL
VASCULITIDES

MEDICAL CONDITIONS
CAUSING LGIB
CRF
DIC
THROMBOCYTOPENIAS
HEMOPHILIA A & B
ANTICOAGULANTS

PREDICTORS OF MORTALITY
AGE >60 YEARS
MULTIORGAN SYSTEM DIS.
TRANSFUSION REQ. IN
EXCESS OF 5 UNITS
NEED FOR OPERATION
RECENT STRESS

CONCLUSION
THE MANAGEMENT OF PTS.
WITH LGIB PRESENTS A
DIAGNOSTIC & THERAPEUTIC
CHALLENGE.
PRECISE LOCALIZATION OF
THE BLEEDING IS ESSENTIAL
FOR Rx OF LGIB.

CONCLUSION
DESPITE THE IMPROVEMENTS IN
DIAGNOSTIC IMAGING &
PROCEDURES, UPTO 10-20% % PTS.
WITH LGIB HAVE NO DEMONSTRABLE
BLEEDING SOURCE.
NEWLY EMERGING NON INVASIVE
DIAGNOSTIC TECHNIQUES SOME OF
WHICH HAVE THE ADDED
THERAPEUTIC POTENTIAL HOLD THE
PROMISE OF REDUCING MORBIDITY &
MORTALITY IN THESE PTS.