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Related Subjects: |Ulcerative Colitis |Microscopic colitis |Irritable bowel syndrome |Lower Gastrointestinal (Rectal) Bleeding

PR bleeding of fresh blood within the first 24 h of hospitalization with a drop in the haemoglobin of at least 2 g/dL and/or a transfusion requirement of at least 2 units of packed red blood cells, urgent diagnosis and intervention are required to control the bleeding.

About

• Bleeding from the GI tract from beyond the Ligament of Treitz.
• In practice is predominantly Colorectal.
• More common in the elderly and anticoagulated
• If unsure then OGD and capsule endoscopy should also be considered
• Overall mortality rate from colonic bleeding is 2.4-3.9 %

Risks for severe bleeding

• Aspirin use
• Two or more comorbid illnesses
• Pulse greater than 100/minute
• Systolic blood pressure <115 mmHg
• Age over 70 years
• Intestinal ischaemia

Aetiology

• Diverticular disease 35%
• Inflammatory bowel disease 15%
• Colonic polyp or Colorectal cancer 15%
• Angiodysplasia 10%
• Ischaemic colitis
• Pseudomembranous colitis
• Meckel's diverticulum
• Haemorrhoids

Clinical

• Bright red blood usually. May be mixed in with the faeces (haematochezia)or melena
• Painless severe bleeding with clots is more common with diverticular haemorrhage. Haemorrhoids also bleed painlessly.
• Bloody diarrhoea often occurs with ischaemic and inflammatory colitides
• May be abdominal pain suggesting ischaemic colitis or diverticular disease
• Cachexia may suggest malignancy as a cause.
• Vascular disease my suggest mesenteric ischaemia.
• Hereditary haemorrhagic telangiectasia
• PR exam may show bleeding and haemorrhoids or a rectal mass
• Anal fissure or local ulcer: very painful
• Assess for BP drop on sitting. Poor capillary return. Hypotension. Needs resuscitation
• A history of AAA with or without surgical repair (possible aorto-enteric fistula)

Haematochezia (PR bleeding) associated with haemodynamic instability may be a large upper gastrointestinal (GI) bleeding source and thus warrants an OGD (EGD) to check the top end.

Investigations

• FBC, U&E, Coagulation if coagulopathy suspected. Group and cross match if transfusion needed
• Colonoscopy is the most comprehensive visualising the entire colon. It should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic haemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic haemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the aetiology of bleeding, access to the bleeding site, and endoscopist experience with the various haemostasis modalities. Repeat colonoscopy, with endoscopic haemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding.
• Sigmoidoscopy may be used for a distal lesion
• Proctoscopy is useful to identify haemorrhoids
• CT Angiography can help locate the bleeding point in the unstable patient which can aid embolisation or surgical management.
• Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy

ACG Clinical Guideline: Management of Patients with Acute Lower Gastrointestinal Bleeding 2016

Another Algorithm

Management

• ABC's and resuscitate with 1 L 0.9% Saline and blood as for upper GI bleed. Correct any coagulopathy. Most cases settle conservatively but if significant inform surgeons early. May benefit from an NG tube.
• Colonoscopy is the diagnostic and therapeutic modality of choice in the stable patient and should be done within 24 hrs or sooner. See above. Colonoscopy can be difficult if there is marked bleeding but increases the diagnostic yield and treatment of bleeding stigmata, as well as reduces the rebleeding rate.
• Unstable bleeding patients may need a CT Angiogram to discovered the bleeding source and if no lower GI source is seen then OGD may be needed. If a source is found then consider transcatheter embolisation.
• If there is massive or ongoing bleeding (> 4-5 units in 24 hours) then surgery should be indicated urgent discussion with the surgical team.
• Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.

References

• Lower GI Bleeding: Epidemiology and Management
• New ACG Clinical Guideline: Management of Patients with Acute Lower Gastrointestinal Bleeding Lisa L. Strate, MD, MPH, FACG and Ian M. Gralnek, MD, MSHS