2. • as any bleed that occurs distal to the ligament
of Treitz and superior to the anus
• 20-33% of episodes of gastrointestinal (GI)
hemorrhage
– 85% from colon
– 10% from UGI
– 5% from SB
• The mortality rate for LGIB is between 2–4%
3.
4. • marginal artery of Drummond -
Connects the inferior mesenteric
artery (IMA) with the superior
mesenteric artery (SMA)
• The Arc of Riolan (Riolan's arcade,
Haller's anastomosis or'meandering
mesenteric artery) -connect the
proximal middle colic artery with a
branch of the left colic artery. This
artery is found low in the mesentery,
near the root. It is a poor
anastomosis.
12. History
• Presenting complaint(s)
• History of presenting illness
• Systemic review
• Past medical and surgical history
• Medication history (iatrogenic factors)
• Family history
• Social history
13. Information about bleeding
• Volume and frequency (amount)of bleeding
• Colour of blood?
• Relationship of bleeding to defecation?
[before, during (mixed into faeces or coating surface?) or after]
• Associatiated symptoms eg, Painful
defecation?, abdominal pain?
18. Colour- indicate the site
• occult, microscopic bleeding
• Black tarry -melena - usually indicates blood
that has been in the GI tract for at least 8
hours. likely to come UGI
• Maroon color suggests rt. Sided lesion
• Bright red stool- called hematochezia- sign of
a fast moving active GI bleed
19. Relationship of bleeding to
defecation?
• minor blood on toilet paper
• streaks of bright red blood
• Blood mixed stools
• Slash in pan
• Mixed with mucus
20. Associated symptoms
• Bloody diarrhoea:
– acute inflammation of the colon; amoebic
colitis; ulcerative colitis; ischaemic colitis;
rectal and colonic carcinoma; shigellosis
21. •Abdominal pain?
–Carcinoma of the colon; ischaemic colitis (in
elderly(; ulcerative colitis; amoebic colitis
•No abdominal pain?
–Painless bleeding from colonic diverticula,
colonic angiodysplastic lesion; malignant lesion
arising in the rectal ampulla
28. • past medical history
– constipation or diarrhea- (hemorrhoids, colitis),
– the presence of diverticulosis (diverticular
bleeding),
– receipt of radiation therapy (radiation enteritis),
– recent polypectomy (postpolypectomy bleeding),
and
– vascular disease/hypotension (ischemic colitis).
– anticoagulant
– A family history of colon cancer - colorectal
neoplasm
32. Colour- indicate the site
• occult, microscopic bleeding
• Black tarry -melena - usually indicates blood
that has been in the GI tract for at least 8
hours. likely to come UGI
• Maroon color suggests rt. Sided lesion
• Bright red stool- called hematochezia- sign of
a fast moving active GI bleed
33. LOCALIZATION
• past medical history
– constipation or diarrhea- (hemorrhoids, colitis),
– the presence of diverticulosis (diverticular
bleeding),
– receipt of radiation therapy (radiation enteritis),
– recent polypectomy (postpolypectomy bleeding),
and
– vascular disease/hypotension (ischemic colitis).
– anticoagulant
– A family history of colon cancer - colorectal
neoplasm
37. COLONOSCOPY
• Identifies lesion in 75 % or more
• Can provide endoscopic therapyand disadvantages of common diagnostic procedures used in the evaluation of lower
gastrointestinal bleeding
Advantages Disadvantages
• Therapeutic possibilities • Bowel preparation required
• Diagnostic for all sources of
bleeding
• Can be difficult to orchestrate without on-
call endoscopy facilities or staff
• Needed to confirm diagnosis in
most patients regardless of initial
testing
• Invasive
• Efficient/cost-effective
• No bowel preparation needed • Requires active bleeding at the time of the
exam
• Therapeutic possibilities • Less sensitive to venous bleeding
38. MESENTERIC ANGIOGRAM
• Selective embolization initially controls
hemorrhage in up to 100% of patients, but
rebleeding rates are 15% to 40%
and disadvantages of common diagnostic procedures used in the evaluation of lower
gastrointestinal bleeding
Advantages Disadvantages
• Therapeutic possibilities • Bowel preparation required
• Diagnostic for all sources of
bleeding
• Can be difficult to orchestrate without on-
call endoscopy facilities or staff
• Needed to confirm diagnosis in
most patients regardless of initial
testing
• Invasive
• Efficient/cost-effective
y • No bowel preparation needed • Requires active bleeding at the time of the
exam
• Therapeutic possibilities • Less sensitive to venous bleeding
• May be superior for patients with
severe bleeding
• Diagnosis must be confirmed with
endoscopy/surgery
• Serious complications are possible
e • Noninvasive • Variable accuracy (false positives)
• Sensitive to low rates of bleeding • Not therapeutic
• No bowel preparation • May delay therapeutic intervention
39. RADIONUCLIDE SCAN
•May be superior for patients with
severe bleeding
•Diagnosis must be confirmed with
endoscopy/surgery
• Seriouscomplications are possible
e •Noninvasive • Variable accuracy(false positives)
• Sensitive to lowratesof bleeding •Nottherapeutic
•No bowel preparation •May delaytherapeutic intervention
•Easilyrepeated if bleeding recurs •Diagnosis must be confirmed with
endoscopy/surgery
py
•Diagnostic andtherapeutic • Visualizesonlythe left colon
40. Treatment
Lower GI bleed
Small volume Large volume
Investigate cause
Manage cause
Resuscitate
Bleeding
stops
Bleeding
persists
? Surgical
intervention
41. SURGERY
• two settings: massive or recurrent bleeding.
• Try to localize
– Localisation- segmental rather
– Not localise- blind subtotal colectomy.
