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. Sever 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 [[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 ❑ Establish an intravenous access
❑ Administer supplemental oxygen | ❑ 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.