Management Of Lower

Gastrointestinal Bleed
Megat Mohd Azman Adzmi
Khoo Yimei
Teo Yi Yan
Muhammad Hassanuddin

Definition
Lower gastrointestinal bleeding is
blood loss from the gastrointestinal
tract of recent onset emanating from
a location distal to the ligament of
Treitz resulting in instability of vital
signs, anemia, and/or need for blood
transfusion.

Aetiology

Aetiology
Diverticular diseases(MC) in elderly
males.
Angiodysplasia
Anorectal diseases in middle aged
males.
Carcinoma/polyps
Colitis ischemic, infective, radiation
Inflammatory bowel disease (IBD)
Meckel`s diverticulum in childhood.

Aetiology
Uncommon causes
Varices (Rectal)
Intussusception
Solitary rectal ulcer
Aorto enteric fistulae
Vasculitis
NSAID induced ulcer, colitis

Small intestinal causes

Vascular ectasias
Tumors

UPPER GI SOURCE should always be excluded in all

patients with massive lower GI bleeding.

Signs and symptoms

The clinical presentation of LGIB varies with the
anatomical source of the bleeding, as follows:
Maroon stools, with LGIB from the right side of the
colon
Bright red blood per rectum with LGIB from the left
side of the colon
Melena with cecal bleeding
However, patients with upper GI bleeding and rightsided colonic bleeding may also present with bright red
blood per rectum if the bleeding is brisk and massive.

Signs and symptoms

The presentation of LGIB can also vary
depending on the etiology. A young
patient with infectious or noninfectious
(idiopathic) colitis may present with
the following:
Fever
Dehydration
Abdominal cramps
Hematochezia

Approach Consideration
The management of LGIB has 3
components, as follows:
Resuscitation and initial assessment
Localization of the bleeding site
Therapeutic intervention to stop
bleeding at the site

Resuscitation and Initial Assessment

Initial resuscitation involves establishing large-bore IV
access and administration of normal saline. Besides
ordering routine laboratory studies (eg, complete
blood cell (CBC) count, electrolyte levels, and
coagulation studies), blood should be typed and crossmatched.
The 2008 SIGN guideline states that patients in shock
should receive fluid volume replacement without delay.
Colloid or crystalloid solutions may be used to achieve
volume restoration before administering blood
products. Red cell transfusion should be considered
after loss of 30% of the circulating volume.

Resuscitation and Initial Assessment

Signs of hemodynamic compromise
include postural changes with dyspnea,
tachypnea, and tachycardia.
An orthostatic drop in systolic blood
pressure of more than 10 mm Hg or an
increase in heart rate of more than 10
beats per minute is indicative of at
least 15% of blood volume loss.

Resuscitation and Initial Assessment

Severe postural dizziness with a postural
pulse increase of at least 30 beats per
minute is a sensitive and specific indicator
of acute blood loss of more than 630 mL.
Coagulopathy, such as an international
normalized ratio (INR) of greater than 1.5,
may require correction with fresh frozen
plasma; thrombocytopenia can be
corrected with platelet transfusions.

Resuscitation and Initial Assessment

Transfer to ICU
Patients who require admission to the intensive
care unit and early involvement of both a
gastroenterologist and a surgeon include the
following:
Patients in shock
Patients with continuous active bleeding
Patients at high risk, such as patients with
serious comorbidities, those needing multiple
blood transfusions, or those with an acute
abdomen

Localization of the Bleeding Site

In about 10% of patients presenting with LGIB,
the source of bleeding is from the upper
gastrointestinal (GI) tract.
Some patients with LGIB should have a
nasogastric (NG) tube placed, and if the
aspirate or lavage does not show any blood or
coffee groundappearing material but dose
show bile, bleeding originating from the upper
GI tract is unlikely.
In case of high suspicion, obtain an
esophagogastroduodenoscopy (EGD) evaluation

Initial Approach to Hemostasis

In patients who are hemodynamically
stable with mild to moderate
bleeding or in patients who have had
a massive bleed that has
stabilized,colonoscopyshould be
performed initially. Once the bleeding
site is localized, therapeutic options
include coagulation and injection with
vasoconstrictors or sclerosing agents.

Initial Approach to Hemostasis

For diverticular bleeding, bipolar probe
coagulation, epinephrine injection, and
metallic clips may be used. If recurrent
bleeding is present, the affected bowel
segment can be resected.
For angiodysplasia, thermal therapy, such as
electrocoagulation or argon plasma
coagulation, is generally successful.
Angiodysplastic lesions may be missed at
colonoscopy if the lesions are small or covered
with blood clots.

Initial Approach to Hemostasis

The 2008 SIGN guideline states that
colonoscopic hemostasis is an
effective way to control hemorrhage
from active diverticular or postpolypectomy bleeding in patients
with massive LGIB.

Therapeutic intervention
Therapeutic intervention to stop
bleeding at the site includes:
Colonoscopy
Vasoconstrictive Therapy
Superselective Embolization
Endoscopic therapies
Emergent surgery

Colonoscopy
Colonoscopy is useful in radiation therapy
induced gastrointestinal (GI) bleeding and
in the treatment of colonic polyp lesions.
Endoscopic treatment of radiation-induced
bleeding includes topical application of
formalin, Nd:YAG laser therapy, and argon
plasma coagulation.
Neoplastic bleeding due to polyps requires
polypectomy.
Patients diagnosed with colonic tumors
may require surgical resection.

Vasoconstrictive Therapy
In patients in whom the bleeding site cannot be
determined based on colonoscopy and in patients
with active, brisk LGIB, angiography with or
without a preceding radionuclide scan should be
performed to locate the bleeding site as well as to
intervene therapeutically.
Initially, vasoconstrictive agents, such as
vasopressin can be used.
An experimental study of treatment of LGIB by
selective arterial infusion of vasoconstrictors,
such as epinephrine with propranolol and
vasopressin, was reported. Although epinephrine
and propranolol drastically reduced mesenteric
blood flow, they also caused a rebound increase

Vasoconstrictive Therapy
Vasopressin is a pituitary hormone that
causes severe vasoconstriction in the
splanchnic bed.
Vasoconstriction reduces the blood flow
and facilitates hemostatic plug formation
in the bleeding vessel.
Vasopressin infusions are more effective in
diverticular bleeding, which is arterial, as
opposed to angiodysplastic bleeding,
which is of the venocapillary type. The
results are less than satisfactory in
patients with severe atherosclerosis and

Vasoconstrictive Therapy
Intra-arterial vasopressin infusions begin at a rate of 0.2
U/min, with repeat angiography performed after 20
minutes.
The bleeding stops in about 91% of patients receiving
intra-arterial vasopressin but recurs in up to 50% of
patients when the infusion is stopped.
If bleeding persists, the rate of the infusion is increased
to 0.4-0.6 U/min.
Once the bleeding is controlled, the infusion is continued
in an intensive care setting for 12-48 hours and then
tapered over the next 24 hours.
In patients with rebleeding, surgery should be
considered.

Complications of
Vasoconstrictive Therapy
During vasopressin infusion, monitor patients for
recurrent hemorrhage, myocardial ischemia,
arrhythmias, hypertension, and volume overload
with hyponatremia.
Nitroglycerine paste or drip can be used to
overcome cardiac complications.
Selective mesenteric infusion induces bowel wall
contraction and spasms.
Do not administer vasopressin into systemic
circulation intravenously, because this causes
coronary vasoconstriction, diminished cardiac
output, and tachyphylaxis.
Vasopressin infusions are contraindicated in

Superselective Embolization
An alternative to vasopressin infusion is embolization with
agents such as gelatin sponge, coil springs, polyvinyl
alcohol, and oxidized cellulose.
Embolization involves superselective catheterization of
the bleeding vessel to minimize necrosis, the most feared
complication of ischemic colitis.
This therapeutic modality is useful in patients in whom
vasopressin is unsuccessful or contraindicated.
Initial experience with embolization suggested that
complications of intestinal infarction were as high as 20%.
With the advent of superselective catheterization and
embolization of the vasa recta, successful embolization
has been performed without intestinal infarction.

Superselective
Embolization
Embolization is performed using a 3
French (F) microcatheter placed
coaxially through the diagnostic 5F
catheter.
The therapeutic catheter is advanced
as far as the vasa recta over a 0.018inch guidewire so as to decrease the
risk of infarction.

Superselective
Embolization
Once the bleeding vessel is identified,
microcoils are used to occlude the bleeding
vessel and to achieve hemostasis.
Although microcoils are most commonly
used, polyvinyl alcohol and Gelfoam are also
used alone or in conjunction with microcoils.
However, if terminal mural branches of the
bleeding vessel cannot be catheterized,
abort the procedure and immediately
perform surgery.

Superselective
Embolization
Kuo et al concluded superselective
microcoil embolization for the treatment
of LGIB is safe and effective.
They reported complete clinical success
in 86% of patients with a rebleeding rate
of 14%. Minor ischemic complication rates
were noted as 4.5%, and major ischemic
complication rates were reported as 0%.

Superselective
Embolization

Rossetti at al reviewed 11 years of

experience in transarterial embolization of
acute colonic bleeding in Switzerland.
Twenty-four patients underwent colonic
embolization for diverticular, postpolypectomy, bleeding, and bleeding from
cancer, angiodysplasia, and hemorrhoids.
All bleeding stopped except hemorrhoidal
bleeding, requiring hemorrhoidal ligature.
The risk of bowel ischemia was 21%.

Superselective
Embolization
In another study by Yap et al, 95 patients underwent
embolization for acute GI hemorrhage; 80% of the
patients had upper GI hemorrhage and the rest had
lower GI hemorrhage.
Vessels embolized included gastroduodenal (39%),
pancreatoduodenal (20%), gastric (19%), superior
mesenteric (11%), inferior mesenteric (11%), and
splenic artery (4%).
Immediate hemostasis was obtained in 98% of
patients. Complications included bowel ischemia in
4% and coil migration in 3% of patients.
The overall 30-day mortality rate was 18%.

Complications of Superselective
Embolization
Rosenkrantz et al reported 3 cases of
colonic infarction.
One patient died following segmental
colectomy, and the other patients
revealed full-thickness bowel wall injury in
the resected specimen.
Intestinal ischemia and infarction have
also been reported.
To prevent this complication, perform
embolization beyond the marginal artery
as close as possible to the bleeding point

Complications of Superselective
Embolization
The relevance of surgery after embolization of
gastrointestinal and abdominal surgery was also
studied in 2014.
In a retrospective study, a total of 54 patients with
55 bleeding events were identified; only 25 patients
(45%) had LGIB.
The rebleeding rate was 24% (n=6), and 50% of
those with recurrent LGIB required surgery.
The study revealed a primary clinical embolization
success rate of 82%, the rate of early recurrent
bleeding (< 30 d) was 18%, and the rate of delayed
bleeding (>30 days) was 3.6%.
Surgery after embolization was required in 20% of
patients (n=11). The investigators concluded that

Endoscopic therapies
Advantages of upper or lower endoscopic evaluation is that
it provides access to therapy in patients with GI bleeding.
Endoscopic control of bleeding can be achieved using the
thermal modalities or sclerosing agents. Absolute alcohol,
morrhuate sodium, and sodium tetradecyl sulfate can be
used for sclerotherapy of upper and lower GI lesions.
Endoscopic epinephrine injection is commonly used
because of its low cost, easy accessibility and low risk of
complications. An additional hemostatic method such as
clips or thermoregulation is needed to prevent subsequent
bleeding.

Endoscopic therapies
Endoscopic thermal modalities such as laser
photocoagulation, electrocoagulation, heater probe can
also be used to arrest hemorrhage.
Endoscopic control of hemorrhage is suitable for GI
polyps and cancers, arteriovenous malformations,
mucosal lesions, postpolypectomy hemorrhage,
endometriosis, and colonic and rectal varices.
Postpolypectomy hemorrhage can be managed by
electrocoagulation of the polypectomy site bleeding
with either snare or hot biopsy forceps or by
epinephrine injection.

Endoscopic therapies
Photocoagulation using lasers such as argon
laser or Nd:YAG laser.
Argon laser treatment is recommended for
mucosal or superficial lesions, because the
energy penetrates only 1 mm. Nd:YAG lasers
are more useful for deeper lesions, because
they penetrate 3-4 mm.
Endoscopic therapy for LGIB is a minimally
invasive.

Emergent surgery
Emergency surgery is required in about 10-25% of
patients with lower gastrointestinal bleeding (LGIB) in
whom non-operative management is unsuccessful or
unavailable.
Surgical indications:
Persistent hemodynamic instability with active
bleeding
Persistent, recurrent bleeding
Transfusion of more than 4 units packed red bloods
cells in a 24-hour period, with active or recurrent
bleeding

Segmental bowel resection and

subtotal colectomy
Segmental bowel resection following precise
localization of the bleeding point is a well-accepted
surgical practice in hemodynamically stable patients.
The procedure of choice in patients who are actively
bleeding from an unknown source.
Intraoperative esophagogastroduodenoscopy (EGD),
surgeon-guided enteroscopy, andcolonoscopymay
be helpful in diagnosing undiagnosed massive GI
bleeding.

 Patients who are hemodynamically stable should

have preoperative localization of the bleeding
whereas patients who are hemodynamically
unstable with active bleeding may undergo
emergency exploratory laparotomy with
intraoperative endoscopy.
In patients who are hemodynamically stable, once
the bleeding site is preoperatively localized, intraarterial vasopressin is used as a temporizing
measure to reduce the bleeding before patients
undergo segmental colectomy. Using this
approach the operative morbidity rate is
approximately 8.6%, the mortality rate is around
10%, and the rate of rebleed ranges from 0-14%.

 In patients undergoing emergency

laparotomy, every attempt should be made to
localize the bleeding intraoperatively, because
a segmental colectomy is preferred. If the
bleeding site is not localized, a subtotal
colectomy is performed with an inherent
morbidity rate of around 37% and a mortality
rate of about 11%-33%. In unstable patients,
a two-stage procedure is preferred: temporary
end ileostomy and delayed ileoproctostomy.
postoperative diarrhea can be a significant
problem in elderly patients who undergo
subtotal colectomy and ileoproctostomy.

Pre-operative details
Acute LGIB is a common clinical entity and
is associated with significant morbidity and
mortality (10-20%).
These factors are dependent on the patient
age (>60 y), the presence of multi-organ
system disease, transfusion requirements
(>4 units), need for operation, and recent
stress (eg, surgery, trauma, sepsis).

3 major aspects involved in managing LGIB:

Treat shock
Localization of the source of bleeding
Formulating and interventional plan
Insert a nasogastric (NG) tube in all patients. A clear bilestained aspirate generally excludes bleeding proximal to
the Treitz ligamentum. After initial resuscitation,
undertake a search for the cause of the bleeding to
precisely locate the bleeding point.
Following accurate localization by angiogram, bleeding
can be temporarily controlled with either angiographic
embolization or vasopressin infusion to stabilize the
patient in anticipation of semi-urgent segmental bowel
resection.

 Segmental bowel resection is performed in the next 24-48

hours following correction of the patient's physiologic
parameters, which include hypotension, hypothermia, acute
hemorrhagic anemia, and deficient coagulation factors.
Use selective mesenteric embolization in high-risk patients
for whom the operative management is associated with
prohibitive risk of morbidity and mortality. If mesenteric
embolization is used, these patients must be carefully
monitored for bowel ischemia and perforation. Any evidence
of ongoing bowel ischemia and/or unexplained sepsis
following mesenteric embolization requires exploratory
laparotomy to resect the affected bowel segment.
Perform subtotal colectomy with ileoproctostomy in patients
with multiple episodes of non-localized LGIB or bilateral
sources of colonic hemorrhage.

Intra-operative details
Surgical intervention is required in only a small percentage of
patients with LGIB. The surgical option depends on whether the
bleeding source has been accurately identified preoperatively; if
so, it is then possible to perform segmental intestinal resection.
If the bleeding source is unknown, an upper gastrointestinal
endoscopy should be performed before any surgical exploration.
The abdominal cavity is explored through a midline vertical
incision. The assistance of a gastroenterologist or another
surgical endoscopist or surgeon is required for intraoperative
endoscopic evaluation. The colonoscope is introduced, and the
surgeon assists its passage. On-table colonic lavage and
colonoscopy may identify the colonic source of bleeding.
Surgeon-guided intraoperative small bowel enteroscopy is also
performed when no colonic source of bleeding is identified.

 Colonoscopic manipulation of the small bowel may

cause iatrogenic mucosal tears and hematomas,
which may be mistakenly identified as a source of
bleeding.
Another intraoperative strategy is to clamp
segments of the bowel with non-crushing intestinal
clamps to identify the segment that fills with blood.
If the bleeding point cannot be diagnosed through
intraoperative pan-intestinal endoscopy and
examination, and if evidence points to a colonic
bleeding, perform a subtotal colectomy with end
ileostomy.

Post-operative details
Hypotension and shock are the eventual
consequences of blood loss, but this
depends on the rate of bleeding and the
patient's response.
Clinical development of shock may
precipitate myocardial infarction,
cerebrovascular accident, and renal or
hepatic failure. Azotemia occurs in patients
with gastrointestinal blood loss.

COMPLICATION OF LOWER
GASTROINTESTINAL BLEED
Anemia
Shock
Kidney failure
Complications of blood transfusions
Complications related to massive blood
transfusions (greater than one blood volume
in 24 hour) are hypothermia, hypocalcemia,
hyperkalemia, dilutional thrombocytopenia,
and coagulation factor deficiencies.

Complication of surgery
The most common early postoperative
complications are
intra-abdominal or anastomotic bleeding,
mechanical small bowel obstruction (SBO),
intra-abdominal sepsis,
localized or generalized peritonitis,
wound infection and/or dehiscence,
Clostridium difficilecolitis
deep venous thrombosis (DVT),
pulmonary embolus (PE).

TRANSFUSION FREE MANAGEMENT

The management of lower GI bleeding (LGIB) can be
challenging in patients who refuse transfusions of blood or
blood products. However, transfusion-free management of GI
bleeding may be effective with an acceptable mortality rate.
Studied has been done in Englewood Hospital in which they
experience in managing patients with gastrointestinal
bleeding who do not accept blood-derived products most of
them survived
These results suggest that transfusion-free management of
gastrointestinal hemorrhage can be effective with mortality
comparable with the general population accepting medically
indicated transfusion.
Management of these patients is challenging and requires a
dedicated multidisciplinary team approach knowledgeable in
techniques of blood conservation.

 Surviving patients were treated with epoetin alfa

(Procrit) stimulate erythropoesis - once daily for
5 days, IV iron dextran(plasa vol expender)
infusion once daily for 10 days, IV folic acid daily,
vitamin C twice daily, as well as IM vitamin B12
injection once. These patients also received betablockers (to reduce the cardiac workload) and
supplemental oxygen (100%) with intubation (to
improve the oxygen delivery as much as possible
without blood transfusions).
The overall mortality rate was 10%.

LONG TERM MONITORING

Postoperative office visits every 2 weeks are essential to ensure
proper wound healing.
Upon discharge, a general diet abundant in fruits and vegetables
is recommended.
Patients are instructed to drink 6-8 glasses of fluid per day.
Psyllium seed preparationsa(dietary fibre) should also be started.
Increased levels of physical activity may prevent the progression
of diverticular disease
Aspirin and NSAID use is associated with increased risk of
diverticular bleeding.
The need for a follow-upcolonoscopy is determined by a
recurrence of symptoms.
Angiodysplasia is more likely to rebleed if untreated and may
require follow-up intervention to localize and treat recurrent
bleeding.
Colonoscopic electrocoagulation is generally successful in such
situations.