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COLORECTAL BLEEDING: A MULTIDISCIPLINARY APPROACH

COLORECTAL BLEEDING: A MULTIDISCIPLINARY APPROACH. Colon and Rectum : Benign Sources Luigi Bucci. Colon and Rectum: Benign Sources Radiation Colitis/Proctitis. Colon and Rectum: Benign Sources Radiation Colitis/Proctitis. Difficult to describe the real incidence.

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COLORECTAL BLEEDING: A MULTIDISCIPLINARY APPROACH

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  1. COLORECTAL BLEEDING: A MULTIDISCIPLINARY APPROACH Colon and Rectum : Benign Sources Luigi Bucci

  2. Colon and Rectum: Benign SourcesRadiation Colitis/Proctitis

  3. Colon and Rectum: Benign SourcesRadiation Colitis/Proctitis

  4. Difficult to describe the real incidence • Evaluation of patients with lower gastrointestinal haemorrhage is variable and institution-specific • Age • Severity • Elective vs Urgency Admission • Institution availability of a bleeding team • As many as 5.6 to 20% remain obscure These different results are related to “conventional examinations” • Nature of bleeding influences its incidence and management as well

  5. Colon and Rectum : Benign Sources

  6. Differential Diagnosis of Colorectal Bleeding Adults

  7. Differential Diagnosis of Colorectal Bleeding Adults

  8. Colon and Rectum: Benign Sources Farrell JJ, Friedman LS - Review article: the management of lower gastrointestinal bleeding.Aliment Pharmacol Ther. 2005 Jun 1;21(11):1281-98. Review.

  9. Differential Diagnosis of Colorectal Bleeding Children and Adolescents

  10. Colon and Rectum: Benign SourcesDiverticular Disease • A mean of 17% of patients with colonic diverticulosis experience bleeding • Diverticular bleeding may range from minor to life-threatening • Altough diverticular disease affects the left colon, bleeding from right colon is more common and usually severe • As many as 80 to 85% of diverticular haemorrhages stop spontaneusly

  11. Colon and Rectum: Benign SourcesDiverticular Disease • The rate of recurrent bleeding is 9% at 1 year, 10% at 2 years, 19% at 3 years and 25% at 4 years (Longstrth GF, 1995) • The risk of re-bleeding after a second diverticular harmorrhage exceeds 50% • About 35% of patients require transfusion or invasive diagnostic/therapeutic evaluation • About 5% require emergency operation

  12. Colon and Rectum: Benign SourcesArteriovenous malformationsMoore’s classification • Related to age, angiographic findings and familiar history • Camilleri based his classification on pathological findings • Type I • Large bowel (ascending colon) • Elderly patients • - Type II • Small bowel • Young patients • - Type III • Multifocality • Association with cutis and mucosae • Children • Rendu-Osler-Weber syndrome

  13. Colon and Rectum: Benign SourcesArteriovenous malformations • Arteriovenous malformations include vascular ectasias, angiomas, and angiodysplasias • Angiodysplasias are acquired abnormalities caused by chronic intermittent partial obstruction of submucosal veins from colonic muscle wall contraction • Angiodysplasias involve most commonly the right colon • There is an association between bleeding and calcific aortic stenosis, quality platetet abnormalities and dialisis

  14. Colon and Rectum: Benign SourcesAngiodysplasias • Massive hemorrhage occur in 15% of patients • Patients with colonic angiodysplasia may present with hematochezia (0-60%), melena (0-26%), hemoccult positive stool (4-47%) or iron deficiency anemia (0-51%) • Up to 90% of patients there is a spontaneous cessation of bleeding • Re-bleeding occur in 25-85% of patients

  15. Colon and Rectum: Benign SourcesInflammatory bowel disease • Massive haemorrhage is unusual • Aestimates are 0.9-6% (Robert JR, 1991) • Bleeding stops spontaneously in about 50% of patients • About 35% of patients experience rebleeding after a spontaneous cessation • Rarely the rectum is the site of the main bleeding

  16. Colon and Rectum: Benign SourcesIschemic colitis

  17. Colon and Rectum: Benign SourcesRare causes • Solitary rectal and colonic ulcer • Rectum  Related to digitation, stress, prolapse (?) • Colon  chronic drug abuse, HIV, peptic colon ulcer, colonic stasis, local ischemia, atherosclerosis, Strongyloidasis, portal hypertension (?)

  18. Colon and Rectum: Benign SourcesPortal colopathy

  19. Colon and Rectum: Benign SourcesCoagulopathy • It is unclear whether spontaneous gastrointestinal bleeding occurs without identifiable lesions • Platelet count of ≤ 20.000/mm3 seems to be responsible for 50% of significant gastrointestinal bleeding in patients with acute leukemia • Gastrointestinal haemorrhage in patients while taking heparin or warfarin had a similar distribution as general population • Diagnostic algorythm is the same as patients with normal coagulation and include specific treatment of coagulation abnormality

  20. Colon and Rectum: Benign SourcesRare causes • Infectious colitis • Bacteria (Campylobacter, E. Coli, Myc. Tuberculosis) • Protozoa (Entoamoeba hystolitica) • Viruses (CMV) • Helmints (Scistosoma, Trichuris)

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