2. Lower Gastrointestinal Bleeding
Prof.dr/ Wafaa Hussin Mekki
Students/ from 285 to 296

3. •Introduction
•Ayman shahtot (285)

6. Upper GI bleeding:
bleeding that occurs proximal to the ligament
of Treitz.
The upper GI tract includes the esophagus,
stomach, and first part of the small intestine.

7. Lower GI bleeding :
bleeding that occurs distal to the
ligament of Treitz.
This includes the last 1/4 of the
duodenum and the entire area of the
jejunum, ileum, colon, rectum and anus.

8. Presentation:
It is usually suspected when patients complain of
hematochezia.
Although, the distinctions based upon stool color
are not absolute since melena can be seen
with LGI bleeding from the right colon (or
small intestine), and hematochezia can be
seen with massive upper GI bleeding.

9. Incidence:
- 20-33% of episodes of gastrointestinal (GI)
hemorrhage.
- annual incidence of about 20-27 cases per
100,000 population.
- The incidence rises steeply with advancing
age.
- 80% resolve spontaneously.
- 25% will re-bleed.

10. Categorization of (LGI) bleeding by
intensity:
Massive bleeding
Moderate bleeding
Occult bleeding

12. Etiology:

13. Etiology:
Diverticular disease 60%
Inflammatory bowel disease 13%
Benign anorectal diseases
11%
Neoplasia 9%
Angiodysplasia 4%
Coagulopathy 3%

15. Dirverticular diseases
Aya adel (290)
Aya abdo (293)

16. What is Diverticulosis?

17. Most common site
• Diverticula can occur throughout the colon
but are most common near the end of the left
colon referred to as the sigmoid colon.

18. Risk factors
• increasing age
• constipation
• a diet that is low in dietary fiber
• high intake of meat and red meat
• connective tissue disorders (such as Mara fan
syndrome) that may cause weakness in the
colon wall
• hereditary or genetic predisposition

19. How do diverticula form?

20. The muscular wall of the colon grows thicker with age,
although the cause of this thickening is unclear. It may reflect
the increasing pressures required by the colon to eliminate
feces. For example, a diet low in fiber can lead to small, hard
stools which are difficult to pass and which require increased
pressure to pass. The lack of fiber and small stools also may
allow segments of the colon to close off from the rest of the
colon when the colonic muscle in the segment contracts. The
pressure in these closed-off segments may become high since
the increased pressure cannot dissipate to the rest of the
colon. Over time, high pressures in the colon push the inner
intestinal lining outward (herniation) through weak areas in
the muscular walls. These pouches or sacs that develop are
called diverticula.

21. What are the symptoms of diverticular disease?
• Most patients with diverticulosis have few or no
symptoms.
• The most common symptoms of diverticular
disease include:
 abdominal cramping,
 constipation, and
 diarrhea.
These symptoms are related to difficulty in passing
stool through the left colon, which is narrowed by
diverticular disease.

22. Complications of diverticulosis
293

23. • The most common complication is diverticulitis
which is a condition in which diverticuli in the
colon rupture. Which results in infection in the
tissues that surround the colon

24. What are the complications of diverticulitis?
• Bleeding:caused by a small blood vessel in a
diverticulum that weakens and then bursts

25. Abscess, Perforation, and Peritonitis
• Diverticulitis may lead to infection, which often
clears up after a few days of treatment with
antibiotics. If the infection gets worse, an abscess
may form in the wall of the colon.
• Infected diverticula may develop perforations.
• Sometimes the perforations leak pus out of the colon
and form a large abscess in the abdominal cavity, a
condition called peritonitis.

26. Fistula
• When diverticulitis-related infection spreads outside
the colon, the colonic tissue may stick to nearby
tissues. The organs usually involved are the bladder,
small intestine, and skin.
• The most common type of fistula occurs between the
bladder and the colon.
• This type of fistula affects men more often than
women. It can result in a severe, long-lasting
infection of the urinary tract. The problem can be
corrected with surgery to remove the fistula and the
affected part of the colon.

27. Intestinal Obstruction
• Scarring caused by infection may lead to
partial or total blockage of the intestine, called
intestinal obstruction

28. How is the diagnosis of diverticular disease
made?
• Colonoscopy

30. • Barium X-rays (barium enemas) can be
performed to visualize the colon. Diverticula
are seen as barium filled pouches protruding
from the colon wall.
• ultrasound and CT scan examinations of the
abdomen and pelvis can be done to detect
collections of pus.

31. General Gross Description

33. General Micro Description

34. • Inflammatory bowel disease. 287
• Enas shams (287)

35. Is a form of inflammatory bowel disease,
characterized by inflammation with ulcer
formation in the lining of colon.

36. Site of involvment
Whole
colon
Sigmoid&
descending
colon
rectum
Inflammation of the distal
terminal ileum may occur

37. pathology
macroscopic
Diffuse inflammation
limited to mucosa
-Extensive ulceration
-Mucosa appear as
inflammatory polyps

38. pathology
microscopic
Crypt abscesses
(the characteristic)
Progress to
ulceration

39. Clinical picture
Bleeding per rectum.
- Diarrhea (bloody diarrhea) with mucous.
- Tenesmus, when the disease is confined to the
rectum.
-Abdominal discomfort.
- Remissions & exacerbations.

40. EXTRA INTESTINAL MANIFESTATIONS

41. ISCHEMIC COLITIS
a medical condition in which inflammation and
injury of the large intestine result from
inadequate blood supply.

42. causes

43. • Mucosal &submucosal hge
mild • Mild necrosis
• edema
• Chronic ulceration
severe • pseudopolyps
• Crypt abscesses
• Transmural infarction
Most severe • perforation

45. Site of ischemia
Common site
affection
Transverse
colon
Splenic
flexure

46. Clinical picture
( depend on severity of ischemia)
1-abdominal pain
2-rectal bleeding
3-diarrhea
4-fever.

47. Hemorrhoids
Enal Mahmoud Fahmy(288)

48. Incidence and Epidemiology:
• Hemorrhoids affect >1 million in western
civilization per year.
• The prevalence is less in the underdeveloped
countries and not selective for age or sex.
• Common among pregnant women.

49. Predisposing factors:
• Constipation.
• Sitting for long periods of time.
• Obesity.
• Heavy Lifting.

50. Anatomy and Pathophysiology:

51. Anatomy and Pathophysiology:
•

52. Clinical Presentation :
• Patients commonly present to a physician for two
main reasons:
• Bleeding.
• Protrusion.
• Pain.
• Anal Itching.

53. Diagnosis:
• Mainly during the physical examination
by:
I. Inspection of the perianal region,
with careful digital examination.
II. Anoscopy
III. Staging.

54. Staging :
•

56. Angiodyplasia
Neoplasm
Aya shawky (289)

57. Angiodyplasia
• It is a tourtious dilatations of submucosal and
mucosal blood vessels are seen most often in
the cecum or right colon

58. Incidence:
Age • >70
Sex equal
Bleeding from angiodysplasia is usually self-
Mortality/Morbidity limited, but it can be chronic, recurrent, or
even acute and life threatening.
Site:
77% of angiodysplasias are located in the cecum and ascending colon,
15% are located in the jejunum and ileum, and the remainder is
distributed throughout the alimentary tract.

59. Pathophysiology of angiodysplasia
most prominent theory
• Repeated episodes of colonic distention
associated with transient increase in pressure
and size
• This results in multiple episodes of incresing
wall tension with obstruction of submucosal
outflow

60. Neoplasm
• Neoplastic bleeding can be from a polyp or
carcinoma.
• Colon cancer is the predominant cause of
neoplastic bleeding and is responsible for around
10% of rectal bleeding in patients older than 50
years.
• The bleeding is usually low-grade and recurrent,
occurring as a result of mucosal ulceration or
erosion. Though neoplastic bleeding can present
as bright red blood per rectum, it is unusual for it
to cause massive colonic bleeding.

61. Lower Gastrointestinal Bleeding in
Children and Adolescents
Intussusception
Polyps and polyposis syndromes
Juvenile polyps and polyposis
Peutz-Jeghers syndrome
Familial adenomatous polyposis (FAP)

62. Colorectal polyp
hyperplastic
neoplastic (adenomatous & malignant),
hamartomatous
inflammatory.

63. Histopathology of colorectal polyps
Micrograph of a sessile
serrated adenoma. H&E Micrograph of a
stain. tubular adenoma
Micrograph of a villous adenoma.

64. Colorectal cancer

65. Coagulopathy
Ayman Fawzy Salmona 286

66. Coagulopathy
• (also called clotting disorder and bleeding disorder)
is a condition in which the blood’s ability to
clot is impaired. This condition can cause
prolonged or excessive bleeding, which may
occur spontaneously or following an injury or
medical procedures.

67. Hypocoagulability
• is an unusual susceptibility to bleeding, that is,
an increased bleeding diathesis, due to an
abnormality in coagulation.

68. Causes
• Acquired
• Autoimmune
• Genetic

69. Symptoms
Symptom Disorders
 Wiskott-Aldrich syndrome, where they
may resemble a few bruises
Petechiae (red spots) 

Acute leukemia
Chronic leukemia
 Vitamin K deficiency
 Acute leukemia
Purpura and ecchymoses 

Chronic leukemia
Vitamin K deficiency
 Wiskott-Aldrich syndrome, especially
Blood in stool 
in infancy
Acute leukemia
 Wiskott-Aldrich syndrome
Bleeding gingiva (gums)  Acute leukemia
 Chronic leukemia
Prolonged nose bleeds  Wiskott-Aldrich syndrome

70. Complications
Complication Disorders
Soft tissue bleeding, e.g. deep-muscle bleeding,  Hemophilia
leading to swelling, numbness or pain of a limb.  Von Willebrand disease
Joint damage, potentially with severe pain and
 Hemophilia
even destruction of the joint and development  Von Willebrand disease
of arthritis
Retinal bleeding  Acute leukemia
Transfusion transmitted infection, from blood
 Hemophilia
transfusions that are given as treatment.
Adverse reactions to clotting factor treatment.  Hemophilia
Anemia  Von Willebrand disease
 Von Willebrand disease Acute
Exsanguination (bleeding to death) leukemia
 Vitamin K deficiency
Cerebral hemorrhage  Wiskott-Aldrich syndrome

71. Other causes of LGIB

72. Infection
• (HIV) is an infrequent cause of LGIB.
• HIV-related opportunistic infections and
associated etiologies, including:
1. (CMV) colitis,
2. idiopathic colon ulcers,
3. Kaposi sarcoma, and lymphoma

73. Drug-induced
• Mainly by NSAID and aspirin use, and it is
more common in the elderly.
• The 2008 Scottish Intercollegiate Guidelines
Network (SIGN) guideline on the
management of acute upper and lower
gastrointestinal bleeding warns that oral
anticoagulants or corticosteroids should be
used with caution in patients at risk of GIB,
especially in those who take NSAIDs or aspirin

74. Diagnosis
Aya Atef El-Sawy
291

75. DIAGNOSIS
• Despite improvement in diagnostic imaging &
procedures, 10-20% of pts with Lower GIT
bleeding have no demonstrable bleeding
source.
• Therefore, this complex problem requires
systematic evaluation.

76. A- Initial Evaluation
Patient's history:
-aspirin, vascular disease, past bleeding
episodes, liver cirrhosis, IBD, coagulopathy.
-duration, frequency, stool colour.
Digital rectal examination
Physical examination to assess the severity of
bleeding:
-HR , BP, postural changes.

77. B- Laboratory Tests
CBC
ESR/ CRP
Coagulation profile
Liver function tests
Renal function tests

78. C- Endoscopy

79. C- Endoscopy
1- Colonoscopy:
Mainstay for evaluation.
Candidates : hemodynamically stable pts.
Hemodynamically unstable pts must undergo
volume resuscitation 1st

80. Current recommendations advise thorough cleansing of
the colon in acute LGIB to improve diagnostic yield &
safety of the procedure.
For optimal purge, the pt. takes 3-6 L of a polyethylene
glycol-based solution.
While in pts with severe bleeding, urgent colonoscopy
must sometimes be carried out without purge.

81. In cases of suspected perforation or obstruction,
plain abdominal radiography should be
performed before colonoscopy to rule out
these complications.

82. Advantages of colonoscopy
-Localize the bleeding lesion in 50-70% of pts
-Identify pts who are at high risk of rebleeding
-Definitive treatment, such as thermoregulation, epinephrine
injection
Disadvantages of colonoscopy
- Must be performed by skilled endoscopists.
- Technical problems
- Perforation

83. ULCERATIVE COLITIS

84. CROHN’S DISEASE

85. DIVERTICULOSIS

86. ANGIODYSPLASIA

87. COLORECTAL TUMOUR

88. 2- Esophagogastroduodenoscopy:
It is performed if NG tube aspirate is positive for blood.
About 10% of pts presenting with LGIB have bleeding
originating from the upper GIT.

89. Aya Abd El-Nasser
291

90. Small Bowel Visualization
1- wireless capsule endoscopy (WCE):
increasingly being used as the test of choice for
small bowel bleeding.

91. 2-Push enteroscopy:
• May be recommended as the initial test because of
its
therapeutic capability.
• Performed with a pediatric colonoscope and once
the bleeding site is visualized, it can be treated or
tattooed.

92. Radionuclide Scanning/Nuclear Scintigraphy
Its role remains controversial.
Radionuclide scans include the technetium-99( 99 Tc) sulfur colloid
scan and the99m Tc pertechnetate–labeled autologous red blood
Cell scan (TRBC scan), as well as indium-111 ( 111 In)
labeled RBC scintigraphy.

93. • Nuclear scintigraphy is a sensitive diagnostic tool (86%)
and can detect hemorrhage at rates as low as 0.1
mL/min, as opposed to angiography, which detects
bleeding at rates of 1-1.5 mL/min. This technique is
more sensitive than angiography, but it suffers from a
low specificity compared with endoscopy or
angiography due to its limited resolution.
• Radionuclide scans frequently are performed before
angiography, because the scans detect bleeding at a slower
rate than what can be detected with angiography, thereby
potentially eliminating the need for an invasive procedure.

94. Advantages:
Noninvasive.
High sensitivity.
Disadvantages:
High false localization rate (3% to 59% ) ,
this often is due to the overlapping segments of bowel
and the migration of tagged RBCs in the large bowel.
Another disadvantage of radionuclide scans is that the
scans must be performed during active bleeding.

95. Angiography
• Performed after colonoscopy has failed to identify a
bleeding site ,can detect bleeding at a rate of more
than 0.5 mL/min.
• In a patient with active GI bleeding, the radiologist
first cannulates the superior mesenteric artery,
because most of the hemodynamically significant
bleeding originates in the right colon. The
extravasation of contrast material indicates a
positive study finding. If the findings from the study
are negative, the inferior mesenteric artery is
cannulated, followed by the celiac artery.

96. Once the bleeding point is identified,
angiography offers potential treatment options,
such as selective vasopressin drip and embolization.

97. The advantages of angiography include:
1- Accurate localization of the bleeding;
2- Therapeutic utility that includes the use of vasopressin
infusion or embolization;
3-Does not require preparation of the bowel.
The disadvantages of angiography include:
1- It has a sensitivity of approximately 30-47%;
2- It can only be performed during active bleeding;
3- It has a complication rate of about 9%. Such
complications include thrombosis, embolization, and
renal failure.

98. Barium Enema
Justified only for elective evaluation of unexplained
LGIB.
Barium enema examination is not used in the acute
hemorrhage phase, because it makes subsequent
diagnostic evaluations, including angiography and
colonoscopy impossible.

99. Abdominal Radiography /CT
• Plain abdominal radiography and/or CT might be carried
out, depending on the clinical presentation and
suspected etiology (such as ischemic or inflammatory
colitis, or in cases where bowel obstruction or
perforation are suspected).

100. Histologic Findings
Most colonic diverticula are false pulsion diverticula and
composed only of mucosa and submucosa herniated
through the colonic wall musculature.
Colonic angiodysplasias are vascular ectasias commonly
located on the right side of the colon. Microscopically,
vascular ectasia consists of dilated thin-walled venules
and capillaries localized in the submucosa of the colonic
wall.

101. Management
Aya Mohamed Khater
294

102. • Resuscitation and initial assessment.
• Localization of the bleeding site.
• Therapeutic intervention to stop bleeding at
the site.

103. 1) Resuscitation and Initial Assessment:
• IV access and administration of normal saline.
• Rapid assessment of vital signs, including heart rate,
blood pressure, pulse pressure, and urine output.
• Routine laboratory studies (CBC, electrolyte levels,
and coagulation studies), blood should be typed and
cross-matched.
• The patient's blood loss and hemodynamic status
should be evaluated, and in cases of severe bleeding,
the patient may require invasive hemodynamic
monitoring .

104. • 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.

105. 2) Localization of the Bleeding Site
• In patients who are hemo-dynamically stable with mild to
moderate bleeding or in patients who have had a massive bleed
that has stabilized, colonoscopy should be performed initially.
Once the bleeding site is localized, therapeutic options include
coagulation and injection with vasoconstrictors or sclerosing
agents.
• In cases of 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.
• In cases of angiodysplasia, thermal therapy, such as electro-
coagulation or argon plasma coagulation, is generally
successful.

106. 3) Therapeutic intervention to stop bleeding at the site.
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.

107. Vasoconstrictive Therapy :
• In patients in whom the bleeding site cannot be determined
based on colonoscopy and in patients with active 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,
epinephrine, propranolol can be used.
• Vasoconstriction reduces the blood flow and facilitates plug
formation in the bleeding vessel.
• Although epinephrine and propranolol reduced mesenteric
blood flow, they also caused a rebound increase in blood flow
and recurrent bleeding.

108. • Vasopressin causes severe vasoconstriction in the splanchnic
bed. Vasopressin infusions are more effective in diverticular
bleeding, which is arterial, as opposed to angiodysplastic
bleeding, which is of the venocapillary type.
• 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.
• 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.

109. Aya Mahmoud
296

110. Superselective Embolization:
• This therapeutic modality is useful in patients in whom
vasopressin is unsuccessful or contraindicated.
• Embolization involves superselective catheterization of the
bleeding vessel to minimize necrosis.
• Embolization with agents such as gelatin sponge, coil springs,
polyvinyl alcohol, and oxidized cellulose.
• It is performed using a 3 French (F) microcatheter placed
coaxially through the diagnostic 5F catheter.
• Once the bleeding vessel is identified, microcoils are used to
occlude the bleeding vessel.
• Although microcoils are most commonly used, polyvinyl
alcohol and Gelfoam are also used alone or in conjunction
with microcoils.

112. Complications:
• Colonic infarction, bowel wall injury, Intestinal
ischemia and infarction.
• To prevent this complication, perform
embolization as close as possible to the
bleeding point in the terminal arteries.

113. Endoscopic Therapies:
• Endoscopic control of hemorrhage is suitable for GI
polyps and cancers, arteriovenous malformations,
mucosal lesions, postpolypectomy hemorrhage,
endometriosis, colonic and rectal varices.
• It can be achieved using thermal modalities or
sclerosing agents.
• Absolute alcohol, morrhuate sodium, and sodium
tetradecyl sulfate can be used for sclerotherapy of
lower GI lesions.
• Endoscopic epinephrine injection is used commonly
because of its low cost, easy accessibility, and low
risk of complications.

114. • Endoscopic thermal modalities (eg, laser
photocoagulation, electrocoagulation) can also be
used to arrest hemorrhage.
• Postpolypectomy hemorrhage can be managed by
electrocoagulation of the polypectomy site bleeding.
• endoscopic coagulation of angiodysplasias is
becoming a treatment of choice using either heated
probe or lasers, such as Nd:YAG and argon.
• Argon laser treatment is recommended for mucosal
or superficial lesions, Nd:YAG lasers are more useful
for deeper lesions.

118. Surgery
• Emergent surgery is required in patients with (LGIB)
if non operative management is unsuccessful.
Indications of Surgery :
• Persistent hemodynamic instability with active
bleeding.
• Persistent, recurrent bleeding.
• Transfusion of more than 4 units packed red bloods
cells in a 24-hour, with active or recurrent bleeding.
• No contraindications exist with regard to surgery in
hemodynamically unstable patients with active
bleeding.

119. 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.
• Subtotal colectomy is the procedure of choice in patients who
are actively bleeding from an unknown source.
• Patients who are hemodynamically stable should have
preoperative localization of the bleeding; once it is localized,
intra-arterial vasopressin is used as a temporizing measure to
reduce the bleeding before patients undergo segmental
colectomy.
• If the it is not localized, a subtotal colectomy with
ileoproctostomy is performed.

120. Complications
• The most common early postoperative complications
are intra-abdominal bleeding, mechanical bowel
obstruction, intra-abdominal sepsis, localized or
generalized peritonitis, wound infection and/or
dehiscence.
• Intra-abdominal sepsis following colorectal surgery is
a life-threatening complication and requires
aggressive resuscitation.
• Systemic conditions (eg, severe blood loss and shock,
poor bowel preparation, diabetes, malnutrition,
hypoalbuminemia) may adversely affect anastomotic
healing.

121. • Changes in anatomy and physiology of the large
bowel, high bacterial content, improper operative
technique, and ischemia can cause anastomotic leak
associated with abscess and intra-abdominal sepsis.
• Delayed complications usually occur more than 1
week after surgery, the most common of which are
anastomotic stricture, incisional hernia, and
incontinence.