Lower gastrointestinal bleeding resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]; Rim Halaby, M.D. [3]

Overview

Lower GI bleed refers to any bleeding originating from gastrointestinal tract distal to ligament of Treitz.

Acute GI bleed	Bleeding occurring for less than 3 days.
Chronic GI bleed	Slow and intermittent bleeding occurring over a duration of several days.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Severe gastrointestinal bleeding is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

• Anal fissure
• Angiodysplasia
• Colitis
• Colon cancer
• Diverticulosis
• Hemorrhoids
• Inflammatory bowel disease
• Radiation enteritis
• Rectal varices

Management

Initial Management

Shown below is an algorithm summarizing the approach to initial assessment of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy.

Characterize the symptoms: ❑ Frank blood per rectum ❑ Dark or maroon colored stools ❑ Abdominal pain ❑ Fatigue ❑ Diarrhea ❑ Constipation ❑ Fever ❑ Tenesmus ❑ Palpitations ❑ Lightheadedness Obtain the medical history: ❑ Previous GI bleed ❑ Use of NSAIDs, aspirin or anticoagulants ❑ History of radiation ❑ History of liver disease ❑ History of IBD ❑ Recent polypectomy ❑ Family history of colorectal cancer

Examine the patient: ❑ Assess the hemodynamic status ❑ Blood pressure ❑ Heart rate ❑ Pulse ❑ Severity of bleeding Severity of blood loss Signs Mild to moderate Resting tachycardia 15% blood loss Orthostatic hypotension 40% blood loss Hypotension Shock Cold clammy extremities Weak and thready pulse ❑ Perform a digital rectal examination ❑ Examine the stool for occult blood

Order tests: ❑ Blood type and cross match ❑ CBC ❑ Coagulation profile ❑ Liver function tests ❑ Electrolytes ❑ BUN ❑ Creatinine ❑ EKG (for elderly )

Initiate initial supportive measures: ❑ Establish intravenous access ❑ Initiate fluid resuscitation ❑ 500 ml of NS over 30 minutes. ❑ Administer supplemental oxygen ❑ Cardiac monitoring

Risk stratification of patients

❑ Young patient ❑ Scant bleeding ❑ No anemia ❑ Suspected anorectal bleeding

❑ Severe active bleeding ❑ Hemodynamic instability ❑ Need for > 2 units of blood transfusion ❑ Presence of other significant comorbidities

❑ Bleeding stopped ❑ Hemodynamic stability

❑ Outpatient treatment

❑ Admit to ICU

❑ Admit to hospital ward

GI: Gastrointestinal; NSAIDs: Non steroid anti-inflammatory drugs; IBD: Inflammatory bowel disease; BUN: Blood urea nitrogen; CBC: Complete blood count; EKG: Electrocardiogram; NS: Normal saline; ICU: Intensive care unit

Approach to Endoscopic Management

Shown below is an algorithm summarizing the approach to endoscopic management of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy.

❑ Assess the hemodynamic status

Massive bleeding

Moderate to severe bleeding

Intermittent scant bleeding

❑ Assess hemodynamic stability

❑ Colonoscopy ❑ Endoscopic therapy

❑ Age > 50 years ❑ Presence of anemia

❑ Age < 40 years ❑ Hemodynamically stable patient ❑ Suspected anorectal source of bleeding

❑ Colonoscopy ❑ Endoscopic therapy

❑ Colonoscopy ❑ Endoscopic therapy

❑ Colonoscopy ❑ Endoscopic therapy

❑ Perform digital rectal examination ❑ Sigmoidoscopy

❑ Emergent angiography with angiotherapy ❑ Request a surgical consult

❑ EGD to rule out upper GI bleed

Anorectal source of bleeding confirmed

Bleeding not controlled?

Lesion identified?

No

No

❑ Surgery

Yes

❑ Colonoscopy ❑ Endoscopic therapy

❑ Colonoscopy ❑ Endoscopic therapy

Yes

❑ Treat as upper GI bleed

❑ Treat accordingly

GI: Gastrointestinal; EGD: Esophagogastroduodenoscopy

Endoscopic Management

Shown below is an algorithm summarizing the endoscopic management of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy and American College of Gastroenterology.

Colonoscopic therapy ❑ Schedule the procedure within 12-48 hours ❑ Prepare the patient for endoscopy ❑ Administer 4-6 L of polyethylene glycol (PEG) at a rate of 1 L every 30 min in acute cases. ❑ Consider metoclopramide 10 mg IV.

Lesion not identified

Lesion identified

❑ Assess if bleeding is persistent

Proceed with endotherapy ❑ Thermal contact modalities ❑ Heat probe ❑ Bipolar/multipolar coagulation ❑ Epinephrine injection ❑ Metallic clips ❑ Argon plasma coagulation

Persistent bleeding

Ceased bleeding

Persistent bleeding

Ceased bleeding

❑ Proceed with EGD

❑ Proceed with arteriography (+/- consider nuclear scan first)

❑ Consider surgery

❑ No additional therapy is required

Lesion identified

Lesion not identified

❑ Treat as upper GI bleed

❑ Proceed with small bowel studies: ❑ Capsule enteroscopy ❑ Double balloon enteroscopy

GI: Gastrointestinal; EGD: Esophagogastroduodenoscopy

Do's

• Suspect bleeding from the left colon in case of frank blood per rectum versus bleeding from the right colon in case of dark or maroon colored stools.
• Perform colonoscopy in patients with positive fecal occult blood test.
• Consider plain abdominal radiographs or CT if colitis, obstruction or perforation are highly suspected.
• Proceed with upper endoscopy in patients presenting with melena.
• Transfuse blood to maintain a hemoglobin of > 7 g/dL. In high risk patients with advanced age and significant comorbidities maintain an Hb > 10 g/dL.
• Maintain an INR of < 2 with fresh frozen plasma in cases of coagulopathy. Consider platelet transfusion if platelet count is < 50,000.
• Administer vit K in patients taking warfarin. Fresh frozen plasma or prothrombin complex can also be given due to their quick onset of action.
• Request a cardiac consult for patients with mechanical cardiac valves and/or metallic coronary stents.
• Consider abdominal X-ray or CT prior to colonoscopy in cases of suspected colitis or aortoenteric fistula.
• Use band ligation to control bleeding from internal hemorrhoids and rectal varices.
• Epinephrine injections:
  • Inject 1-3 ml of 1:10,000 diluted epinephrine solution at 1 or more sites in and around the bleeding lesion.
    
  • Inject 1-3 mm away from the lesion in cases of non bleeding visible vessels.

Dont's

• Do not use sclerosants and dessicating agents in colon to achieve hemostasis.
• Due to low sensitivity and poor negative likelihood ratio, nasogastric lavage cannot rule out upper GI bleed effectively in cases of hematochezia.

References

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