6. Upper GI bleeding:
bleeding that occurs proximal to the ligament
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.
It is usually suspected when patients complain of
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.
- 20-33% of episodes of gastrointestinal (GI)
- annual incidence of about 20-27 cases per
- The incidence rises steeply with advancing
- 80% resolve spontaneously.
- 25% will re-bleed.
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
• 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
• hereditary or genetic predisposition
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
21. What are the symptoms of diverticular disease?
• Most patients with diverticulosis have few or no
• The most common symptoms of diverticular
These symptoms are related to difficulty in passing
stool through the left colon, which is narrowed by
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.
• 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.
28. How is the diagnosis of diverticular disease
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.
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.
• It is a tourtious dilatations of submucosal and
mucosal blood vessels are seen most often in
the cecum or right colon
Age • >70
Bleeding from angiodysplasia is usually self-
Mortality/Morbidity limited, but it can be chronic, recurrent, or
even acute and life threatening.
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
• This results in multiple episodes of incresing
wall tension with obstruction of submucosal
• Neoplastic bleeding can be from a polyp or
• Colon cancer is the predominant cause of
neoplastic bleeding and is responsible for around
10% of rectal bleeding in patients older than 50
• 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
Polyps and polyposis syndromes
Juvenile polyps and polyposis
Familial adenomatous polyposis (FAP)
• (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
• is an unusual susceptibility to bleeding, that is,
an increased bleeding diathesis, due to an
abnormality in coagulation.
Wiskott-Aldrich syndrome, where they
may resemble a few bruises
Petechiae (red spots)
Vitamin K deficiency
Purpura and ecchymoses
Vitamin K deficiency
Wiskott-Aldrich syndrome, especially
Blood in stool
Bleeding gingiva (gums) Acute leukemia
Prolonged nose bleeds Wiskott-Aldrich syndrome
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
even destruction of the joint and development Von Willebrand disease
Retinal bleeding Acute leukemia
Transfusion transmitted infection, from blood
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
• (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
• 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
• Despite improvement in diagnostic imaging &
procedures, 10-20% of pts with Lower GIT
bleeding have no demonstrable bleeding
• Therefore, this complex problem requires
76. A- Initial Evaluation
-aspirin, vascular disease, past bleeding
episodes, liver cirrhosis, IBD, coagulopathy.
-duration, frequency, stool colour.
Digital rectal examination
Physical examination to assess the severity of
-HR , BP, postural changes.
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
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
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
Disadvantages of colonoscopy
- Must be performed by skilled endoscopists.
- Technical problems
91. 2-Push enteroscopy:
• May be recommended as the initial test because of
• Performed with a pediatric colonoscope and once
the bleeding site is visualized, it can be treated or
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.
• 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
98. Barium Enema
Justified only for elective evaluation of unexplained
Barium enema examination is not used in the acute
hemorrhage phase, because it makes subsequent
diagnostic evaluations, including angiography and
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
102. • Resuscitation and initial assessment.
• Localization of the bleeding site.
• Therapeutic intervention to stop bleeding at
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
• The patient's blood loss and hemodynamic status
should be evaluated, and in cases of severe bleeding,
the patient may require invasive hemodynamic
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
• 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
106. 3) Therapeutic intervention to stop bleeding at the site.
• Colonoscopy is useful in radiation
therapy–induced gastrointestinal (GI)
bleeding and in the treatment of colonic
• 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
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
• 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-
• 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.
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
• 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
• 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.
• Emergent surgery is required in patients with (LGIB)
if non operative management is unsuccessful.
Indications of Surgery :
• Persistent hemodynamic instability with active
• 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
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
• If the it is not localized, a subtotal colectomy with
ileoproctostomy is performed.
• The most common early postoperative complications
are intra-abdominal bleeding, mechanical bowel
obstruction, intra-abdominal sepsis, localized or
generalized peritonitis, wound infection and/or
• Intra-abdominal sepsis following colorectal surgery is
a life-threatening complication and requires
• Systemic conditions (eg, severe blood loss and shock,
poor bowel preparation, diabetes, malnutrition,
hypoalbuminemia) may adversely affect anastomotic
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