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]

Definition

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

Initial Assessment

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 and an article by Louis M. et al.

Characterize the symptoms ❑ Frank blood per rectum (bleeding from left colon) ❑ Dark or maroon colored stools (bleeding from right colon) ❑ Abdominal pain ❑ Fatigue ❑ Diarrhea ❑ Constipation ❑ Fever ❑ Tenesmus ❑ Palpitations ❑ Lightheadedness Obtain past 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 hemodynamic status ❑ Digital rectal examination ❑ Stool examination for occult blood

Hematochezia PLUS hemodynamic instability

Nasogastric lavage (to rule out upper GI bleed)

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

Blood in NG lavage fluid

Copious amount of bile with no trace of blood

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

❑ Proceed with EGD after initial assessment

❑ Proceed with colonoscopy after initial assesment

Risk stratification of patients

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

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

❑ Bleeding stopped ❑ Patient is hemodynamically stable

Outpatient treatment

Admit to ICU

Admit to hospital ward

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 and an article by Louis M. et al.

Assess hemodynamic status

Unstable patient

Stable patient

Massive bleeding

Moderate to severe bleeding

Intermittent scant bleeding

❑ Assess if endoscopy can be done according to hemodynamic status

❑ Age > 50 years ❑ Anemic patient

❑ Age < 40 years ❑ Healthy stable patient ❑ Anorectal source of bleeding highly suspected

No (highly unstable patient)

Yes

❑ Colonoscopy

❑ Perform digital rectal examination ❑ Sigmoidoscopy

❑ Emergent angiography with angiotherapy ❑ Request a surgical consult

❑ EGD to rule out upper GI bleed

❑ Anorectal source of bleeding not confirmed?

❑ Anorectal source of bleeding confirmed?

Bleeding not controlled?

Lesion identified?

No

Colonoscopy

Treat accordingly

Surgery

Yes

Colonoscopy

Treat as upper GI bleed

Colonoscopic therapy ❑ Recommended within 12-48 hours ❑ Prep colon for endoscopy ❑ Administer 4-6 L of polyethylene glycol (PEG) at a rate of 1 L every 30 min

Lesion identified

Lesion not identified

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

❑ Consider EGD ❑ Small bowel studies

Lesion identified?

No

Yes

Angiography

Treat accordingly

• 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.

Do's

• Perform colonoscopy in patients with positive fecal occult blood test.

  • Air contrast barium enema, virtual colonoscopy or CT colonography can be used in cases of incomplete colonoscopy.

• Proceed with upper endoscopy in patients presenting with melena.
• Transfuse blood to maintain a hemoglobin of > 7 g/dL. In 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 clotting derangements. Consider platelet transfusion if platelet count is < 50,000.
• 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.

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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