This document discusses lower gastrointestinal (GI) bleeding, including its causes, presentation, evaluation, and management. Some key points: - The most common causes of major LGI bleed are diverticulosis, colonic neoplasms, and angiodysplasias. Colonoscopy is the investigation of choice. - Occult LGI bleeding is first evaluated with fecal occult blood testing (FOBT). CT angiography can help localize bleeding if it persists or patients are unstable. - Evaluation involves history, physical exam including rectal exam, blood tests, stool tests, endoscopy, imaging studies like colonoscopy, angiography or nuclear scans depending on findings. - Treatment depends on

1. LOWER GI BLEED- CAUSES AND
MANAGEMENT
DR MUBASHIR BASHIR
DR DIVYA PRASAD
(Moderator)

2. MCQ’s
• 1) Most common cause of major LGI bleed
• Hemmorhoids
• Fissure in ano
• Colonic growth
• Diverticulosis

3. • 2) Investigation of choice in LGI bleeding
• CT angiography
• Colonoscopy
• Proctoscopy
• Barium study

4. • 3) A patient has occult LGI bleeding first
investigation will be
• FOBT
• CT angiography
• Colonoscopy
• Barium study

5. • 4) Most common cause of mild LGI bleed
• Hemmorhoids
• Fissure in ano
• Colonic growth
• Polyp

6. • 5) Painless LGI bleed in children is mostly due to
• Intusussception
• Fissure in ano
• Meckels diverticulum
• Polyp

7. LOWER GASTROINTESTINAL
HAEMORRHAGE refers to haemorrhage in the
GI tract distal to the Ligament of Treitz
PRESENTATION:
 HEMATOCHEZIA: (range from bright red
blood to old clots)
 MELAENA black tarry foul smelling stools(if
bleeding is slower or from a more proximal
source)
 Occult LGI Bleed

8. Incidence
• Lower GI bleed constitutes approx.20-33% of
episodes of GI haemorrhage
• Incidence rises with age
• 80% resolve spontaneously
• 25% will re-bleed

9. CAUSES
COLONIC BLEEDING(95%) SMALL BOWEL BLEEDING
DIVERTICULAR DISEASE (30-40%) ANGIODYSPLASIAS
ISCHEMIA (5-10%) EROSIONS,ULCERS(e.g ,NSAIDS)
ANORECTAL DISEASE
5-15%
CROHN’S DISEASE
NEOPLASIA (5-10%) RADIATION
INFECTIOUS COLITIS
3-8%
MECKEL’S DIVERTICULUM
POSTPOLYPECTOMY
3-7%
NEOPLASIA
IBD (3-4%) AORTOENTERIC FISTULA
ANGIODYSPLASIAS 3%
RADIATION COLITIS,PROCTITIS 1-3%

11. CATEGORIZATION of LGI bleeding by
intensity
Massive
• Bleeding >1.5L/day, hemodynamically instable
• Presents as large volume of bright red blood PR
Moderate
• Presents as haematochezia or malaena
• Hemodynamically stable
Occult
• ≤10 ml of blood loss/day
• Detected by routine stool tests

12. GENERAL APPROACH FOR
ACUTE GI BLEED
HISTORY AND EXAM
Identify risk factors
Previous surgery
Medications
INITIAL
ASSESSMENT &
RESUSCITATION
INITIATE
THERAPY
Pharmacologic
Endoscopic
Angiographic
Surgical
LOCALIZE BLEEDING
NGT aspirate
Endoscopy ,others

13. HISTORY
1. AGE :
Elderly pt. carcinoma
Young pt.  Ulcer ds., Esophageal Varices
2. HOPI:
→ Duration of bleeding
 Colour of blood
 Quantity
• Abdominal pain /tenderness
• Associated anal pain+/-defaecation
• Altered bowel habit: stool frequency & consistency
• Diarrhoea/constipation/both
• Tenesmus
• Anorexia and weight loss
3. Past History:
p/h/o bleeding PR, peptic ulcer disease
 Blood with
mucus colitis, ca
 Fresh blood as
splashes in pan
haemorrhoids
 Maroon coloured
stool MD
 Red currant jelly
Intussception
 Bright red blood
polpys
 Blood streak on
stool Anal fissure

14. • 4. Drug history- aspirin, warfarin, iron
supplements
• 5. Family history- Crohn’s, UC, bowel CA, polyps,
FAP
• 6. Personal- alcohol intake, smoker

15. EXAMINATION
• INSPECTION:
 Breathlesness, jaundice, cachexia
 Signs of anaemia-pallor,koilonychia
Mouth ulcers,angular stomatitis in IDA
• PALPATION:
 Abdominal tenderness(LIF-Div., RIF-
crohn’s/caecal CA)
 Abdominal mass
 hepatomegaly – liver mets

16. PR Examination:
• Haemorrhoids, prolapse, fissures or fistula
• Palpable mass per rectum
• Stool colour/consistency
• Blood on examining finger

17. INVESTIGATIONS
Blood tests-
• CBC
• Electrolytes
• BUN/S.Creatinine
• Coagulation profile
• LFT
• Blood group & cross match
• Iron profile
Stool examination-
• Ova/cyst/worms
• Occult blood-Fecal OBT
• Barium enema
• Proctoscopy for piles
• Sigmoidoscopy – for
rectosigmoid diseases
• Colonoscopy for
colitis,carcinomas,polyps
• Small bowel
enema(enteroclysis)
Normal faecal blood
loss-1.2ml/day
Loss >10ml/day
significant

18. Endoscopy
• Gastroduodenoscopy
• Proctosigmoidoscopy
• Colonoscopy- test of choice
• Capsule Endoscopy

19. Colonoscopy
• Therapeutic uses are
1. Electro-cauterization of bleeding points
2. Polypectomy
• Diagnostic uses are
1. Imaging
2. Biopsy of thelesion

20. Ulcerative colitis CAcolon with bleeding
Crohn's disease Diverticulosis

23. Angiography
• Identifies when bleeding rate is 0.5 ml/min
• Useful in active bleed

25. Nuclear scintigraphy
• Identifies 0.1 ml/min of bleed;
• Tc sulphur colloid scan is very sensitive
• Tc labelled RBC recirculates & so effective for
one day with better localisation
• ADVANTAGES: High sensitivity even with active
continued bleed.
• DISADVANTAGES: Therapy not possible

26. OBSCURE GI
BLEED
• It is intermittent GI bleed for which no source has
been found endoscopically/radiologically.
• It is 5% common.
• Either d/t missed common cause or angiodysplasia.
• If it is angiodysplasia , angiography, nuclear
scintigraphy, capsule endoscopy;then angiographic
embolisation or resection of the part of the bowel is
done.
• Enteroscopy, upper & lower GI scopies are needed
in other conditions.

27. Other methods:
• CT angiography , MR angiography
• Aortography for aortoenteric fistula

28. DIAGNOSTIC
INTERVENTIONS
• RESUSCITATE
• DRE,PROCTOSCOPY, SIGMOIDOSCOPY
• NGT ASPIRATE & UGI ENDOSCOPY(to r/o
UGI cause)
• COLONOSCOPY
• RADIONUCLEOTIDE SCANNING
• MESENTERIC ANGIOGRAPHY
• EMERGENCY OPERATIVE INTERVENTIONS

29. ACUTE LOWER
GI BLEEDING
ASSESS FOR
ANORECTAL BLEED
DRE &
PROCTO/ANOSCOP
Y
YES
INITIATE
APPROPRIATE
THERAPY
RULE OUT UPPER GI
BLEEDING
NGT ASPIRATE / EGD +VE
NO
UGI BLEED
MANAGEMENT

30. NGT ASPIRATE/EGD
NEGATIVE
MINOR BLEEDING
(INTERMITTENT)
MAJOR BLEEDING
(PERSISTENT)
UNSTABLE
STABLE
COLONOSCOPY
LESION
VISUALISED
NOT
VISUALISED
INITIATE
THERAPY
Small bowel series
ENTEROSCOPY
CAPSULE
ENDOSCOPY
REPEAT
COLONOSCOPY
if bleeding

31. STABLE
SMALL BOWEL
INVESTIGATION
UNSTABLE
MAJOR
BLEEDING
TAGGED
RBC SCAN
EMBOLIZATION +/-
SEGEMENTAL
RESECTION
ANGIOGRAPHY

32. OPERATING
ROOM
COLON OR SMALL BOWEL
identified as source
SOURCE
UNCERTAIN
LOCALIZED
BLEEDING:serial
clamping or
intraoperative
enteroscopy f/b
resection of
affected segment
UNSTABLE
SUBTOTAL COLECTOMY
with ILEORECTAL
ANASTOMOSIS or SMALL
BOWEL RESECTION

33. TREATMENT
• Endoscopic fulguration or therapeutic
embolisation or right hemicolectomy 
Angiodysplasia
• Endoscopic polypectomy  Polyps
• Mesacol enema/drugs/total proctocolectomy
with ileo-anal anastomosis  UC
• Surgical resection  Colonic carcinoma
• Massive resection of SI  Mesenteric ischemia
• Sigmoid colectomy  Sigmoid diverticula

34. THANK YOU