Lower GI bleed
Epidemiology
Incr morbidity rate if: haemodynamic instability, rpted haematochezia, gross blood on PR, initial Hct <35%,
syncope, non-tender abdo, aspirin use, >2 co-morbid conditions
Distal to ligament of Trietz
Pathophysiology
Causes
60% diverticular disease (R=L; acute, painless; can be heavy; 90% resolve spontaneously)
Assessment
Investigations
Mng
In paeds
Mortality 5-10%; 20% of all GI bleeds; significant haemorrhage with haemodynamic compromise
uncommon; stops spontaenously in 80%
10-20% no cause found
12% angiodysplasia (more in elderly; often recurrent; usually R; rarely severe; assoc with AS)
2% Ca / polyp
Others: ischaemic colitis, infection, IBD, aorto-enteric fistula
If <20yrs: Peutz Jegher syndrome, HSP, Meckel’s diverticulus
Sx: blood mixed with stool = likely higher; pink frothy blood in pan or on paper = haemorrhoids; tarry black stool =
upper GI; bright red and not severely shocked = lower GI; haematemesis = upper GI; bright red on surface of stool
or toilet paper = fissure
OE: look for signs of chronic liver disease
Bloods: incr Ur:Cr and incr K suggests upper GI; decr Hb and normal MCV = acute; decr Hb and MCV = chronic;
incr plt = acute; macrocytosis = hepatic disease; G+S if mod, XM if severe
Erect CXR: if AP or findings in chest
CT: 79-100% sens
IVF
As OP if:
bleeding not haemodynamically signficant and ceased
Colonoscopy if: bleeding haemodynamically significant
but ceased
if rectal bleeding >50yrs, need colonscopy as OP
Angiography if: bleeding haemodynamically signficiant
and ongoing
requires >0.5ml/min; 10% serious complication rate
OT if: torrential bleeding or failed scope
?ischaemic colitis; laparotomy has incr mortality and morbidity
Technetium-labelled RBC: good at detecting intermittent bleeding; requires >0.1ml/min
<2/12: swallowed maternal blood, infectious colitis, intussusception, volvuls, AVM, haemorrhagic disease of
newborn, Hirschsprung disease
milk allergy (onset 12-24hrs after introduction of new formula or chronic diarrhoea, poor weight gain and
AP; IgE mediated)
meckel diverticulum (remnant of omphalomesenteric duct in distal ileum, 2% incidence, lined with ectopic
gastric mucosa, painless PR bleeding; may result in signficant bleeding)
2/12 – 2yr: milk allergy, intussusception, volvulus, meckel diverticulum
anal fissure, gastro, HUS, HSP (may be severe), polyps, IBD
>2yr: intussusception, volvulus, meckel diverticulum, anal fissure, gastro, HUS, HSP, polyps, IBD
haemorrhoids, colitis, angiodysplasia, celiac disease, PUD
Notes from: Dunn, Cameron, TinTin