Lower GI bleeding accounts for 24% of GI bleeding and usually presents with melena or hematochezia. It is typically less severe than upper GI bleeding, with a mortality rate of 2-3.6%. Common causes in patients under 50 include inflammatory bowel disease and anorectal diseases like hemorrhoids, while those over 50 often experience bleeding from diverticulosis, angiodysplasias, or neoplasms. Diagnostic evaluations include rectal exam, endoscopy, technetium scan, angiography, and colonoscopy. Initial management focuses on ABCs, IV fluids, and identifying the source and severity of bleeding.

1. LOWER G.I.T BLEED

2. G.I.BLEEDING DEFINITIONS
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Acute versus chronic
Upper (proximal to ligament of treitz)
Lower(distal to ligament of treitz)
Overt-clinical signs/symptoms present
Occult-not clinically evident(FOBT + or iron
def anemia)
Obscure-routine evaluation

3. INTRODUCTION



Bleeding arising below the Ligament Of Treitz
Either from the small intestine or from the
colon
Majority of the cases arise from colon
specially the ANORECTAL region

4. HEMATOCHEZIA


Related term
meaning
FRESH
BRIGHT RED BLOOD PER RECTUM

5. LOWER GI BLEED
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Accounts for 24% of all GI bleeding
Presentation can be malena(19%)or
hematochezia(81%)
Usually less severe than upper GI bleeding
Mortality of 2-3.6%

6. TYPES
(Depending upon patients age)
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PATIENTS BELOW
50years OF AGE
Inflammatory bowel
diseases
Infectious colitis due to
Shigella,E.coli
Anorectal diseases like
Hemorrhoids, Anal
fissures

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PATIENTS ABOVE
50years OF AGE
Diverticulosis
Angiodysplasias
Neoplasms
Ischemic colitis

7. TYPES BASED ON BLEEDING

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BLEEDING WITH
PAIN
Anal fissures
Ischemic colitis
Inflammatory bowel
diseases
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
PAINLESS
BLEEDING
Internal hemorrhoids
Diverticulosis
Angiodysplasias

8. EPIDEMIOLOGY


Mortality is usually due to co-morbid
conditions(like organ
failure,AMI,aspiration,sepsis)
Bleeding stops spontaneously>80% of the
time.

9. SYMPTOMOLOGY AND
EVALUATION
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DIVERTICULOSIS
Presents as MAROON or BRIGHT RED
hematochezia
Bleeding stops spontaneously
Common in patients over 50 years of age

10. ANGIODYSPLASIA

Patient presents with painless bleeding

Common after 70 years of age

11. NEOPLASMS
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Both benign polyps and carcinoma can cause
bleeding
Usually chronic occult bleeding
May cause mild intermittent hematochezia

12. INFLAMATORY BOWEL
DISEASE
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Most commonly ulcerative colitis presents
with diarrhea with occult blood or recurrent
hematochezia,abdominal pain,tenesmus and
urgency

13. ANORECTAL DISEASE
Hemorrhoids present as painless bleeding mixed
with stool or dipping into toilet bowl
Painless small bleeding can occur in case of
small fissure

14. ISCHEMIC COLITIS
Seen in elderly especially those who have
atherosclerosis presenting as bloody diarrhea
with mild abdominal pain

15. DIAGNOSTIC PROTOCOLS
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1.Rectal examination
2.Anoscopy and sigmoidoscopy
3.Nasogastric intubation
4.Technetium scan
5.Angiography
6.Colonoscopy

16. 
RECTAL
EXAM,SIGMOIDOSCOPY AND
ANOSCOPY
Digital examination anoscopy and
sigmoidoscopy to look for anorectal
diseases,inflammatory bowel disease or
infectious colitis.

17. TECHNETIUM-99mRBC scan


Performed in active bleeding to detect source
of bleeding
Can also be performed for intermittent
bleeding

18. ANGIOGRAPHY
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In active bleeding it is the investigation of choice
Selective angiography indicated for massive ongoing
lower G.I bleeding or with recurrent bleeding and
negative colonoscopy.
Can detect rates of 0.5ml/min
Can be used as therapy-coil
embolization,alcohols,vasoconstrictors.
70-100%effective if positive
Low rebleeding rate-12%

19. COLONOSCOPY
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Performed if bleeding stops or occurs at slow
rate
Allows identification of angiodysplasia,tissue
biopsy and therapeutic intervention with
electrocautery heater probe or laser therapy of
active bleeding
Not helpful during massive bleeding

20. ASSESMENT
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Includes history and examination
Age
Attention to vitals, volume status, oxygen
saturation, urine output
Evidence of liver disease
Risk factors, use of
NSAIDs,anticoagulation,co-morbidities,

21. LABORATORY ASSESMENT
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Complete blood count
Blood type and cross-match
Coagulation factors PT,APTT
Chemistry panel
BUN/Cr ratio
Bilirubin,albumin,INR to asses for hepatic
synthetic dysfunctions

22. INITIAL MANAGEMENT
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ABC management
Oxygen
I/v access
FLUIDS
ETT

23. MANAGEMENT
If the patient has massive ongoing bleeding with
homodynamic instability, urgent angiography
is indicated
If colonoscopy does not reveal a source, but
bleeding continues-tagged RBC scan should
be done to localize bleeding
If colonoscopy doesn't reveal a source,but
bleeding stops, observe patient.

24. SURGERY
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Done on patients who have failed
medical,colonoscopic,angiographic
intervention
Ongoing bleeding>4U of PRBC per 24h
Effort should be made to localize the source
prior to surgery.

25. SURGICAL PROCEDURES
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Targeted subtotal colectomy
Blind subtotal colectomy(high mortality)
Blind segmental colectomy(high mortality and
54%re-bleeding rate-not preferred)

26. OCCULT LOWER GI BLEED
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Loss of small blood that can not be seen
Detected in 2 settings
FOBT +
Iron def anemia

27. CONCLUSION
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Always remember to treat the patient
Resuscitate-ABC
Correct coagulopathy
Patient die from co-morbidities
Gi bleeding requires a multidisciplinary
approach-critical care,medicine,G.I radiology
and surgery.

28. THANK YOU