Lower Gastrointestinal Tract Bleeding or LGI or Lower GI Bleeding is one of the most common serious presenting complaint by patients in emergency or OPD, to differentiate and treat according through the protocol is the art a doctor should learn. We will discuss the topic in detail along with the protocol or approach followed for same.

Definition

Lower GI (LGI) bleeding is the loss of blood from the GI tract distal to the ligament of Treitz in the form of bright red or maroon rectal bleeding called Hematocheia.

Significance

Lower GIT bleeding being a common problem not just in the multifaceted Surgical Specialities,but as well in “Emergency Medicine”,should be considered potentially life threatening until proven otherwise and accorded utmost significance.

Epidemiology

Common,seen in an incidence of 36 per 1 Lakh people – Elderly Female are most vulnerable.

Causes/Etiology

The causes in order of frequency are as follows:

  • Anal lesions such as Hemorrhoids, Fissure
  • Rectal Trauma
  • Colitis/Proctitis
  • Colonic Polyps
  • Carcinoma Colon
  • Angiodysplasia
  • Diverticular Disease
  • Intussusception
  • Solitary Ulcer
  • Blood dsycrasia
  • Vasculitis
  • Connective Tissue Disorders
  • Neurofibroma
  • Amyloidosis
  • Anti-coagulation

Lower Gi Bleeding Protocol / Approach

The following image reads out loud the Protocol of Lower GI Bleeding:

Lower GI Bleeding Protocol
Source: Harrison Medicine

History

General

History elicited includes past GI bleeding and a history of pain, trauma, ingestion or insertion of foreign bodies, and recent colonoscopies.

Specific Indications

Weight loss and changes in bowel habits may suggest Malignancy.

History of an aortic graft may suggest the possibility of an aortoenteric fistula.

Medications, such as salicylates, nonsteroidal anti-inflammatory drugs, and warfarin, increase the risk of LGI bleeding.Patients on Beta Blockers or poorly controlled hypertension might present with subtle signs of pathognomic symptoms.

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Consumption of iron or bismuth can simulate melena, and certain foods, such as beets,can simulate hematochezia. However, stool guaiac testing in those cases will be negative.

Examination

General Examination

May appear Emaciated with signs of Pallor and Weakness, Altered Mental Status.

Systemic Examination

Gastrointestinal Tract

Tenderness, Masses, Ascites or Organomegaly. Lack of Abdominal tenderness might indicate Vascular causes such as diverticulosis or angiodysplasias, while its presence associated with Inflammatory Bowel Disorders. Digital Rectal Examination might detect gross bleeding and sources viz -a- viz laceration, masses, hemorrhoids, fissures or trauma.

Cardiovascular System

Hypotension, tachycardia, angina, syncope.

Skin Appearance

Signs of petechiae and purpura might provide clues on an underlying Coagulopathy or liver disease. Cool, pale skin with increased capillary refill may signal Shock.

Lab Testing

Order laboratory tests which include CBC, coagulation studies, and typed and cross-matched blood. An ABG is always helpful.

In acute, brisk bleeding, the initial hematocrit level would not reflect the actual amount of blood loss.

Coagulation profile, including prothrombin time, partial thromboplastin time, and platelet count, is vital in patients taking anticoagulants or those with underlying liver disease.

Routine tests such as blood urea nitrogen, creatinine, electrolytes, glucose, and liver function studies.

Bleeding from a source in the upper GI tract may elevate blood urea nitrogen levels through digestion and absorption of hemoglobin.

Silent ischemia can occur secondary to the decreased oxygen delivery accompanying significant GI bleeding and an Electrocardiogram is a must,in suspected population.

Radiology

Diagnostic Procedure of Choice – Angiography,Scintigraphy or Endoscopy.

Scintigraphy appears more sensitive than angiography and can localize the site of bleeding at as low a rate as 0.1 mL/min. It also has potential value over angiography if bleeding occurs intermittently but requires a minimum of 3 mL of blood to pool.

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Technetium Labelled Red Cell Scans – detects Obscure Hemorrhage.

Radiographs like Chest Xray and Xray Abdomen are of limited value,unless indicated.

Recent Trends – Multidetector CT Angiography – 100% Specificity & Sensitivity.

Management

Resuscitate unstable or actively bleeding patients.

Administer oxygen and institute cardiac monitoring.

Place two large-bore IV lines and replace volume with crystalloids. Correct coagulopathy.

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