LGIH: Lower GastroIntestinal Hemorrhage

Lower GI Bleeding: Diagnostic Criteria & Management

Notes:

• This table is intended as a quick reference guide and does not cover all possible diagnostic criteria or management options.
• Treatment should always be individualized based on the patient's specific clinical presentation, overall health, and preferences.
• LGIH Bleeding is stopped. Don't forget to do Colonoscopy for diagnosis and treatment.

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Intro

Lower gastrointestinal bleeding (LGIB) is a frequent and often challenging presentation in surgical practice. Characterized by bleeding distal to the ligament of Treitz, it encompasses a spectrum of etiologies with varying levels of acuity and severity. This guide aims to provide a comprehensive overview of LGIB, focusing on practical aspects relevant to surgical residents.

Clinical Presentation

Patients with LGIB typically present with hematochezia (bright red blood per rectum), suggestive of a lower GI source. However, melena (black, tarry stools) can also occur, especially with brisk bleeding from the right colon or small bowel. Occult bleeding, detected by fecal occult blood testing, is often asymptomatic and discovered during routine screening.

History and Physical Examination

A detailed history is crucial and should focus on:

• Bleeding Characteristics: Onset, duration, frequency, amount, and color.
• Associated Symptoms: Abdominal pain, changes in bowel habits, weight loss, fever, nausea, vomiting.
• Past Medical History: History of GI disorders, previous surgeries, medication use (especially anticoagulants and NSAIDs).
• Family History: Colorectal cancer or other hereditary GI conditions.

Physical examination should include:

• Vital Signs: Assess for hemodynamic stability (hypotension and tachycardia suggest significant blood loss).
• Abdominal Exam: Evaluate for tenderness, distension, masses, and bowel sounds.
• Rectal Exam: Inspect for hemorrhoids, fissures, masses, and assess for rectal tone.
• Digital Rectal Exam (DRE): Essential to assess for rectal masses, blood in the rectum, and sphincter tone.

Differential Diagnosis by Age Group

While LGIB can affect individuals of all ages, certain conditions are more common in specific age groups:

Young Adults (18-40 years old)

• Meckel's Diverticulum:
  • Definition: A congenital anomaly, a true diverticulum, containing all layers of the intestinal wall, most commonly located in the ileum within 2 feet of the ileocecal valve.
  • Etiology: Persistence of the omphalomesenteric duct.
  • Pathophysiology: Presence of ectopic gastric mucosa within the diverticulum leading to acid secretion and ulceration.
  • Clinical Presentation: Typically painless rectal bleeding; can range from occult blood loss to massive hemorrhage.
  • Diagnosis: Technetium-99m pertechnetate scan (Meckel's scan) has high sensitivity in detecting ectopic gastric mucosa.
  • Management: Surgical resection of the diverticulum.
• Inflammatory Bowel Disease (IBD):
  • Definition: Chronic inflammatory disorders of the gastrointestinal tract, primarily Crohn’s disease and ulcerative colitis.
  • Etiology: Multifactorial, involving genetic predisposition, immune dysregulation, and environmental triggers.
  • Pathophysiology: Chronic inflammation leads to mucosal ulceration and bleeding.
  • Clinical Presentation: Recurrent episodes of abdominal pain, diarrhea, rectal bleeding, weight loss, and fatigue. May present with acute severe hemorrhage requiring hospitalization.
  • Diagnosis: Colonoscopy with biopsy revealing characteristic inflammatory changes and architectural distortion.
  • Management: Medical management with aminosalicylates, corticosteroids, immunomodulators, and biologic agents. Surgery may be necessary for complications like strictures, fistulas, or uncontrolled bleeding.
• Polyps:
  • Definition: Benign growths arising from the mucosal lining of the colon and rectum.
  • Etiology: Primarily driven by genetic mutations, often involving the APC gene in familial adenomatous polyposis (FAP).
  • Pathophysiology: Although benign, they can bleed, especially as they enlarge. Malignant transformation is a significant concern, particularly with adenomatous polyps.
  • Clinical Presentation: Often asymptomatic, may present with rectal bleeding, changes in bowel habits, or iron deficiency anemia.
  • Diagnosis: Colonoscopy with biopsy for histopathological evaluation.
  • Management: Endoscopic removal during colonoscopy (polypectomy). Surveillance colonoscopy is recommended based on the number, size, and histology of polyps.

Adults < 60 Years

• Diverticulosis and Diverticular Hemorrhage:
  • Definition: Presence of diverticula (small, sac-like outpouchings) in the colonic wall, most commonly in the sigmoid colon.
  • Etiology: Develop due to increased intraluminal pressure and weakness in the bowel wall, often associated with a low-fiber diet.
  • Pathophysiology: Bleeding arises from erosion of a blood vessel adjacent to a diverticulum.
  • Clinical Presentation: Typically presents as painless, often massive, hematochezia.
  • Diagnosis: Colonoscopy is the preferred diagnostic tool, although it may be challenging during active bleeding. CT angiography can be helpful in localizing the bleeding site.
  • Management: Most cases resolve spontaneously. Endoscopic hemostasis with epinephrine injection or thermal therapy may be required. Surgery is reserved for persistent or recurrent bleeding.
• Neoplasms (Colorectal Cancer):
  • Definition: Malignant tumors arising from the lining of the colon or rectum.
  • Etiology: Multifactorial, involving genetic predisposition, dietary factors, and chronic inflammation.
  • Pathophysiology: Tumor growth invades surrounding tissues and blood vessels, leading to bleeding.
  • Clinical Presentation: Insidious onset, often asymptomatic in early stages. May present with rectal bleeding, changes in bowel habits (constipation or diarrhea), abdominal pain, weight loss, and fatigue.
  • Diagnosis: Colonoscopy with biopsy for histological confirmation. Staging involves imaging studies (CT scan, MRI).
  • Management: Surgical resection is the mainstay of treatment, often combined with chemotherapy and/or radiation therapy depending on the stage.

Adults > 60 Years

• Angiodysplasia:
  • Definition: Degenerative vascular lesions characterized by dilated, thin-walled vessels in the GI tract, most commonly found in the cecum and ascending colon.
  • Etiology: Strongly associated with aging, possibly related to chronic, low-grade intermittent obstruction of submucosal veins.
  • Pathophysiology: These fragile vessels are prone to bleeding.
  • Clinical Presentation: Typically presents as intermittent, painless hematochezia.
  • Diagnosis: Colonoscopy is the preferred diagnostic modality. Capsule endoscopy may be considered for suspected small bowel angiodysplasia.
  • Management: Most cases resolve spontaneously. Endoscopic treatment with argon plasma coagulation or heater probe therapy can be effective. Surgery is rarely needed.
• Diverticular Disease: As previously described, diverticulosis and diverticular hemorrhage are more common in older adults.
• Neoplasms: The incidence of colorectal cancer increases with age, making it a crucial consideration in older adults with LGIB.

Conditions Not Age-Specific

• Hemorrhoids:
  • Definition: Dilated veins in the anal canal.
  • Etiology: Increased pressure in the rectal veins, often associated with straining during bowel movements, pregnancy, or chronic constipation.
  • Pathophysiology: Engorged hemorrhoids are prone to bleeding, particularly during defecation.
  • Clinical Presentation: Bright red rectal bleeding, typically painless, often noted on toilet tissue or in the toilet bowl. May also cause anal itching, discomfort, or prolapse.
  • Diagnosis: Clinical examination and anoscopy.
  • Management: Conservative management with high-fiber diet, increased fluid intake, and topical medications. Procedures like rubber band ligation, sclerotherapy, or hemorrhoidectomy may be necessary for persistent or symptomatic hemorrhoids.
• Anal Fissure:
  • Definition: A tear or ulceration in the lining of the anal canal.
  • Etiology: Most commonly caused by passage of hard stools or trauma.
  • Pathophysiology: Linear tear in the anal canal leads to pain and bleeding.
  • Clinical Presentation: Sharp, tearing pain during defecation, often accompanied by bright red rectal bleeding.
  • Diagnosis: Visual inspection of the anal verge is usually sufficient.
  • Management: Conservative management with stool softeners, sitz baths, and topical medications (e.g., nitroglycerin ointment, calcium channel blockers). Surgery is rarely needed.
• Anal Fistula:
  • Definition: An abnormal connection between the anal canal and the perianal skin.
  • Etiology: Often develops as a complication of an anorectal abscess.
  • Pathophysiology: Persistent infection and inflammation lead to fistula formation.
  • Clinical Presentation: Perianal pain, swelling, drainage of pus or blood.
  • Diagnosis: Clinical examination and often confirmed with imaging studies like fistulography or MRI.
  • Management: Surgical intervention is generally required, involving fistulotomy or seton placement.

Initial Management of LGIB

Initial management of patients with LGIB follows the principles of ABCs (Airway, Breathing, Circulation):

• Resuscitation and Stabilization:
  • Assess and ensure airway patency, breathing, and circulation.
  • Establish large-bore intravenous access (at least two).
  • Initiate aggressive fluid resuscitation with crystalloids (e.g., normal saline) to restore intravascular volume. Blood transfusion with packed red blood cells may be necessary for significant blood loss or hemodynamic instability.
  • Monitor vital signs, urine output, and hematocrit closely.
• Identify and Control Bleeding Source:
  • Once the patient is stable, efforts should be directed toward identifying and controlling the source of bleeding.
  • History, physical examination, and laboratory tests help narrow down the differential diagnosis.
  • Endoscopy (colonoscopy) is often the initial diagnostic and therapeutic procedure of choice for most causes of LGIB.
  • Angiography with embolization may be considered for active bleeding that cannot be controlled endoscopically or for patients who are not candidates for surgery.
• Definitive Management:
  • Definitive management depends on the underlying cause of LGIB and may involve:
  • Endoscopic hemostasis (e.g., clipping, injection, thermal therapy)
  • Surgical intervention (e.g., resection of bleeding diverticulum, tumor removal)
  • Medical management (e.g., medications for IBD, treatment of underlying medical conditions)

Complications of LGIB

Complications of LGIB can include:

• Hypovolemic Shock
• Anemia
• Need for blood transfusion
• Infection
• Bowel ischemia
• Death

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Prognosis

The prognosis for patients with LGIB depends on several factors, including the underlying cause, the severity of bleeding, and the patient's overall health status. Most cases of LGIB resolve with conservative or minimally invasive management. However, certain conditions, like massive diverticular bleeding or advanced malignancy, can be associated with significant morbidity and mortality.

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Conclusion

LGIB is a common reason for admission to surgical services, and its management requires a systematic approach. Prompt resuscitation and identification of the bleeding source are crucial. A thorough understanding of the common etiologies, diagnostic modalities, and management options is essential for surgical residents to provide optimal care for patients with LGIB.