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: Defined as bleeding occurring for less than 3 days.
- Chronic GI bleed: Defined as 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. Any severe GI bleed can be life threatening and should be managed appropriately irrespective of the cause.
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 [[Lower GI bleed]].
Characterize the symptoms ❑ Frank blood per rectum (bleeding from left colon) Obtain past medical history: ❑ 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 | 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 ❑ Intravenous access | ❑ 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
| 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
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| Lesion identified | Lesion not identified | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Endotherapy ❑ Thermal contact modalities
❑ Epinephrine injection | ❑ 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.