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Lower GI Bleeding

Lower GI Bleeding

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Lower GI Bleeding

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  1. Lower GI Bleeding

  2. Presentation • Iron deficiency anaemia • PR bleeding • Acute colonic bleeding

  3. Bleeding with defecation • History • How much? • Mixed in with the stool? Colour? • Pain on defecation? • Pattern of bleeding – remissions, exacerbations? • Constipation (anal fisure) or diraahoeaUlcerative colitis) • Associated symptoms – tenesmus, signs of malignancy • Examination • Anal inspection – external hemorrhoids (internal via straining), anal fissure • PR Exam – ulcerative lesion (carcinoma – especially with blood on gloved finger), spasm of Int sphincter may make Ex impossible (anal fissure) • Proctoscopy – 1st and 2nd degree haemorrhoids (non palpable), lower rectal carcinoma, anal fissure

  4. DDx • Haemorrhoids • Carcinoma of rectum/sigmoid colon • Anal fissure • Adenomatous polyp • IBD (with diarrhoea)

  5. Haemorrhoids • Internal Haemorrhoids: prolapse of the anal mucosa (anal cushions) containing the internal rectal venous plexus. Prolapse often lead to strangulation and ulceration • External Haemorrhoids: thrombosis of external rectal venous plexus. Caused by anything that impedes venous return, pregnancy, constipation and extended toilet sitting and straining • Pattern of bleeding: bleeding at the end of defecation, bright red, seen on toilet paper • Clinically painless – prolapse may lead to moderate discomfort • Portal Hypertension

  6. Rectal/sigmoid carcinoma • Bleeding of recent onset, colour depends on location, mixed with bowel motion, persists without remission • Recent history of increasing tenesmus(feeling of incomplete evacuation)

  7. Anal Fissure • Tear in the skin of the lower anal canal – distal to the dentate line • Leads to spasm of the internal sphincter – impedes healing • Usually caused by constipation – leads to severe pain, leads to further constipation, exacerbating the condition

  8. Adenomatous Polyp • Bleeding without change in bowel habit • Intermittent • Colour depends on location • Large benign tumours may cause tenesmus and mucus in bowel motions (diarrhoea)

  9. Iron Deficiency Anaemia • No clinical evidence pointing towards bleeding • Must do a full system review and examination due to many causes of iron deficiency anaemia • DDx: carcinoma of the caecum, Crohn’s disease (more often normocytic anaemia of chronic disease). Other Upper GI problems.

  10. Acute Haemorrhage • Massive Lower GI bleeding is very RARE • Is ACUTE but reasonably benign compared to acute UPPER GI bleeding • Perforated peptic ulcer may lead to passage of bright red blood per rectum – VERY SEVERE AND LEADING TO SHOCK • Usually spontaneously resolves • DDx: Diverticular disease, angiodysplasia, ischaemic colitis, IBD, polyp/carcinoma (rare), Meckel’s diverticulum

  11. Angiodysplasia • Vascular malformation of the colon – usually caecum and ascending colon – multiple lesions • GI bleeding (hematochezia/melena) and anaemia • Bleeding – risk increased with a coagulation disorder • Patients usually over 60

  12. Ischaemic Colitis • Sudden onset crampy left lower quadrant pain followed by hematochezia within 24 hours • Sudden and transient reduction of blood flow – usually splenic flexure and left colon - limited collateral supply • Usually mucosal (not transmural) therefore complications of stricture of gangrenous colitis are rare • Often misdiagnosed as IBD or infectious colitis