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LOWER GI BLEED MR G. BOINTAS SCF IN EMERGENCY GENERAL SURGERY KINGSTON HOSPITAL 05.03.2024 INTRODUCTION • LOWER GI BLEEDING HAS ESTIMATED INCIDENCE OF 33-87/100,000 AND ACCOUNTS FOR 3% OF EMERGENCY SURGICAL REFERRALS • LOWER GI BLEEDING USUALLY CAUSES LESS HAEMODYNAMIC INSTABILITY THAN UPPER GI HAEMORRHAGE • HOWEVER, IT CAN PRESENT AS A WIDE SPECTRUM FROM TRIVIAL BRIGHT RED BLOOD PER RECTUM TO MASSIVE HAEMORRHAGE WITH SHOCK. AS SUCH, THE BLEEDING CAN BE CATASTROPHIC AND SHOULD BE CONSIDERED AS A POTENTIAL SURGICAL EMERGENCY, WITH MORTALITY RATES REPORTEDLY AS HIGH AS 21% IN THOSE WITH MASSIVE GI HAEMORRHAGE • HOWEVER, IN THE MAJORITY OF CASES BLEEDING STOPS DURING INITIAL RESUSCITATION, ALLOWING TIME FOR FURTHER INVESTIGATIONS TO ELICIT THE EXACT SOURCE AND CAUSE OF BLEEDING, WITH AN OVERALL MORTALITY RATE OF AROUND 2-4% DEFINITION • LOWER GASTROINTESTINAL BLEEDING (LGIB): BLEEDING DISTAL TO THE LIGAMENT OF TREITZ, I.E. SOME OF THE SMALL BOWEL, THE COLON AND THE RECTUM. ACCOUNTS FOR 20–30% OF ALL GASTROINTESTINAL HAEMORRHAGES • ACUTE LOWER GI BLEEDING IS OF RECENT ONSET AND MAY BE SEVERE, RESULTING IN HAEMODYNAMIC INSTABILITY AND DECREASING HAEMOGLOBIN LEVELS. THE DIAGNOSIS IS OFTEN DIFFICULT TO MAKE AND MAY REQUIRE MULTIPLE INVESTIGATIONS TO IDENTIFY THE SOURCE OF BLEEDING.CLASSIFICATION PRESENTATION * DEPENDING ON THE SOURCE OF THE BLEEDING AND HOW LONG THE BLOOD REMAINS IN THE DIGESTIVE TRACT, CLINICAL SYMPTOMS MAY INCLUDE : • HAEMATOCHEZIA = FRESH BLOOD IN STOOL …WITHOUT THE PRESENCE OF BLOOD IN GASTRIC ASPIRATE • MELAENA = BLACK , TARRY STOOL • FRANK BLOOD PRESENTATION ** UGI BLEED CAN ALSO PRESENT WITH BRIGHT RED BLEEDING PER RECTUM ** (BRISK BLEEDING/HAEMODYNAMIC INSTABILITY) EG. OESOPHAGEAL VARICES OR PUD ** MELAENA MAY BE CAUSED BY UPPER AS WELL AS LOWER GI BLOOD LOSS! BLEEDING OF THE MOUTH AND THROAT (NOCTURNAL NOSEBLEEDS, TUMOURS) SHOULD ALSO BE CONSIDERED AS A POSSIBLE CAUSE !ANATOMICAL CONSIDERATIONS AETIOLOGY A) EROSIVE OR INFLAMMATORY : DIVERTICULAR DISEASE (17-40 %), INFLAMMATORY BOWEL DISEASE (IBD) = CROHN’S DISEASE / ULCERATIVE COLITIS, INFECTIVE COLITIS B) VASCULAR : HAEMORRHOIDS, ANGIODYSPLASIA , ISCHAEMIC COLITIS, RECTAL VARICES , AORTOENTERIC FISTULA (AFTER PREVIOUS AAA REPAIR),DIEULAFOY’S LESION C) TUMOURS : COLORECTAL CANCER, ANAL CANCER D) TRAUMATIC/IATROGENIC : FOLLOWING INTERVENTIONS EG. POLYPECTOMY/BIOPSY/POSTOP ANASTOMOTIC BLEEDING E) FURTHER : MECKEL’S DIVERTICULUM, COAGULOPATHY, ANAL FISSURE , RADIATION PROCTITIS, DIVERSION PROCTITIS OVERVIEW-ACUTE LOWER GI BLEED ØHISTORY ØEXAMINATION ØINITIAL INVESTIGATIONS ØINITIAL MANAGEMENT ØFURTHER MANAGEMENT HISTORY • USUALLY SUDDEN ONSET , PAINLESS PR BLEEDING • IF PR BLEEDING & ABDO PAIN & DIARRHOEA àISCHAEMIC COLITIS, INFECTIVE COLITIS OR IBD • IF WEIGHT LOSS, TENESMUS, RECENT CHANGE OF BOWEL HABIT àCOLORECTAL CA • POSSIBLE HX OF FATIGUE, ANAEMIA, COLLAPSE • ?? PREVIOUS HX OF : IBD, PELVIC RADIOTHERAPY, AAA REPAIR, ANTICOAGULANTS, COAGULOPATHY, STOMAS, PUD, NSAID, STEROIDS, ETOH ABUSE ?? EXAMINATION • PR EXAMINATION (DRE +/- PROCTOSCOPY) MUST BE PERFORMED IN ALL THOSE SUSPECTED OF GI HAEMORRHAGE, NOT ONLY TO ASSESS THE STOOL COLOUR/PRESENCE OF BLOOD BUT ALSO TO LOOK FOR ANORECTAL LESIONS EG LOW RECTAL OR ANAL CANCER / HAEMORRHOIDS • DEPENDING ON SEVERITY, PATIENT MAY LOOK CLAMMY AND PALE, OCCASIONALLY CONFUSED • ? TACHYCARDIC , HYPOTENSIVE , TACHYPNOEIC PT MAY SUGGEST SIGNIFICANT BLOOD LOSS/ SHOCK • IF ABDOMINAL TENDERNESS à ISCHAEMIC COLITIS OR INFLAMMATORY CAUSE • CHECK FOR SCARS, STOMAS ( ?AORTO-ENTERIC FISTULA OR DIVERSION PROCTITIS) RISK ASSESSMENT • DESPITE THE FACT THAT THERE IS NO WELL-VALIDATED RISK CLASSIFICATION SYSTEM FOR PR BLEEDING , ANY PATIENT WITH HAEMODYNAMIC INSTABILITY IS HIGH RISK FOR SEVERE BLEEDING • OAKLAND SCORE (TO ASSESS NEED FOR ADMISSION TO HOSPITAL) JAMA NETW OPEN. 2020 JUL; 3(7): E209630 OAKLAND SCORE • THE OAKLAND SCORE CAN BE USED TO HELP STRATIFY PATIENTS PRESENTING WITH A LOWER GI BLEED TO DETERMINE IF OUTPATIENT MANAGEMENT IS FEASIBLE. • FACTORS USED TO DETERMINE THE OAKLAND SCORE ARE : AGE, SEX, PREVIOUS ADMISSIONS FOR LOWER GI BLEEDING, PR FINDINGS, HEART RATE, SYSTOLIC BLOOD PRESSURE, AND HAEMOGLOBIN CONCENTRATION. HTTPS://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC7341175 SIGN GUIDELINES (HTTP://WWW .SIGN.AC.UK/ASSETS/SIGN105.PDF) INITIAL INVESTIGATIONS *** INITIAL ASSESSMENT AND RESUSCITATION SHOULD COINCIDE. ESPECIALLY IN SHOCKED PATIENTS!!! RESUS SHOULD NOT BE DELAYED WHILE AWAITING THE RESULTS OF THE INVESTIGATIONS * GROUP & SAVE : IN ALL PATIENTS WITH LOWER GI BLEEDING. CROSS-MATCH 2-4 UNITS OF PACKED RBCS IF SEVERE BLEEDING OR LOW HB * THE MAJORITY OF PATIENTS WITH LOWER GI HAEMORRHAGE WILL STOP BLEEDING DURING INITIAL RESUSCITATION ALLOWING INVESTIGATION OF THE SOURCE OF BLEEDING TO PROCEED AS AN IN-PATIENT. INITIAL MANAGEMENT • EARLY GOALS : vFLUID RESUSCITATION (AT LEAST 2 LARGE-BORE PERIPHERAL IV CANNULAE , CRYSTALLOIDS OR COLLOIDS, POSSIBLE TRANSFUSION, HIGH FLOW O2) vMONITORING OF THE PATIENT (URIN. CATHETER AIMING FOR HOURLY UO >0.5 ML/KG/HR, FBC X 2 DAILY, STOOL CHART , HDU/ICU SUPPORT IF CO-MORBIDITIES) vCORRECTION OF ABNORMAL CLOTTING (STOP WARFARIN & ANTI-PLATELETS, NO LMWH, IF INR> 1.5 CONSIDER FFPS & VIT K IV, IF ABNORMAL PT/APTT CONSIDER D/W ON-CALL HAEMATOLOGIST) • KEEP NBM • URGENT REFERRAL TO SENIOR SURGEON AND CRITICAL CARE IF INSTABILITY PERSISTS FURTHER MANAGEMENT • IN THE MAJORITY OF PATIENTS BLEEDING STOPS SPONTANEOUSLY. ONCE HB NORMAL AND STABLE AND BOWELS OPENED WITHOUT SIGNS OF BLOOD à DISCHARGE HOME WITH AN URGENT OUTPATIENT COLONOSCOPY • IF PROFUSELY BLEEDING HAEMORRHOIDS à TX ON THE SAME ADMISSION EG HAEMORRHOIDECTOMY OR BANDING • IF ONGOING HEAVY PR BLEEDING REQUIRING REPEAT TRANSFUSIONS à - CONTACT GASTROENTEROLOGIST : OGD TO EXCLUDE UPPER GI SOURCE/ COLONOSCOPY - CONTACT IR : CT MESENTERIC ANGIOGRAM / ANGIOGRAPHY - CONTACT COLORECTAL SURGEON : SURGERY (PARTIAL OR TOTAL COLECTOMY) - CONTACT VASCULAR SURGEON IF AORTO-ENTERIC FISTULA COLONOSCOPY • OFTEN UNABLE TO IDENTIFY THE SITE OF BLEEDING, AS VISION OBSCURED • HOWEVER, IT ALLOWS CERTAIN TREATMENTS TO BE CARRIED OUT AT THE SAME TIME : EG. DIATHERMY OF ANGIODYSPLASIA, INJ. WITH ADRENALINE OF BLEEDING DIVERTICULAE, REMOVAL OF POLYPS ANGIOGRAPHY IF COLONOSCOPY FAILS TO IDENTIFY THE BLEEDING SITE… • ANGIOGRAPHY IS THOUGHT TO BE PREFERABLE IN THOSE WITH MASSIVE HAEMORRHAGE BUT THE RATE OF SUCCESS AT IDENTIFYING THE SOURCE OF BLEEDING VARIES CONSIDERABLY FROM 40-85% DEPENDING ON THE SOURCE OF BLEEDING . • THE SOURCE OF BLEEDING IS IDENTIFIED BY VISUALISING EXTRAVASATION OF CONTRAST MATERIAL INTO THE LUMEN OF THE BOWEL (HOWEVER, AT LEAST 0.5ML/MIN BLEEDING IS REQUIRED TO SHOW EXTRAVASATION) AND THIS THEN ALLOWS THERAPEUTIC SELECTIVE EMBOLIZATION, OR VASOPRESSIN INFUSION. SURGICAL MANAGEMENT INDICATIONS : … • HAEMODYNAMIC INSTABILITY PERSISTS DESPITE AGGRESSIVE RESUSCITATION • MORE THAN 6U OF BLOOD HAS NEEDED TO BE TRANSFUSED • SEVERE BLEEDING RECURS • CONSERVATIVE THERAPIES/MESENTERIC ANGIOGRAPHY – EMBOLISATION HAVE FAILED • ACCURATE PRE-OPERATIVE LOCALISATION OF THE BLEEDING SITE, WHEN POSSIBLE, IS ESSENTIAL TO ALLOW SEGMENTAL RESECTION TO BE SUCCESSFUL OR HIGH RATES OF RE- BLEEDING ARE LIKELY. • ONLY 10% OF PATIENTS WITH LOWER GI BLEEDS WILL REQUIRE SURGERY ROLE OF TXA • EFFECTS OF A HIGH-DOSE 24-H INFUSION OF TRANEXAMIC ACID ON DEATH AND THROMBOEMBOLIC EVENTS IN PATIENTS WITH ACUTE GASTROINTESTINAL BLEEDING (HALT-IT): AN INTERNATIONAL RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL ( LANCET. 2020 JUN 20; 395(10241): 1927–1936) ’’TRANEXAMIC ACID DID NOT REDUCE DEATH FROM GASTROINTESTINAL BLEEDING BUT WAS ASSOCIATED WITH AN INCREASED RISK OF VENOUS THROMBOEMBOLIC EVENTS AND SEIZURES. THE PROPORTION OF PATIENTS WITH REBLEEDING WAS SIMILAR IN THE TRANEXAMIC ACID AND PLACEBO GROUPS ‘’ KEY POINTS • ANY PATIENT WITH RECTAL BLEEDING REQUIRES A FLEXIBLE SIGMOIDOSCOPY OR COLONOSCOPY • A PATIENT WITH A LARGE FRESH RECTAL BLEED WHO IS HAEMODYNAMICALLY UNSTABLE HAS AN UPPER GI BLEED UNTIL PROVEN OTHERWISE • ACUTE BLEEDS MAY NOT INITIALLY SHOW AN ANAEMIA IN THE FULL BLOOD COUNT • PATIENTS WHO ARE HAEMODYNAMICALLY UNSTABLE NEED AN EMERGENCY OGD AND COLONOSCOPY TAKE HOME MESSAGES (1) • BSG MANAGEMENT ALGORITHM / SHOCK INDEX • DIVERTICULAR DISEASE ACCOUNTS FOR 40% OF SIGNIFICANT LOWER GI BLEEDS • IN MOST CASES OF LOWER GI HAEMORRHAGE THE BLEEDING WILL STOP SPONTANEOUSLY ALLOWING FURTHER INVESTIGATIONS TO BE CARRIED OUT AS AN IN-PATIENT • ALTHOUGH THE MORTALITY OF ACUTE LOWER GI BLEEDS IS LOW (ABOUT 2-4%), BLEEDING CAN BE CATASTROPHIC WITH MORTALITY AS HIGH AS 20% IN THE CASE OF MASSIVE HAEMORRHAGE • THERE IS NO COMMONLY USED RISK SCORING SYSTEM IN PATIENTS WITH LOWER GI HAEMORRHAGE BUT PATIENTS WITH HAEMODYNAMIC INSTABILITY (PARTICULARLY AFTER INITIAL RESUSCITATION) ARE AT HIGH RISK OF POOR OUTCOME (GRADE 2B, RECOMMENDATION D) (1,14) TAKE HOME MESSAGES (2) • SOME LOW-RISK PATIENTS WITH MINOR BLEEDS SECONDARY TO BENIGN ANORECTAL DISEASE MAY BE DISCHARGED AFTER ED ASSESSMENT (GRADE 4, RECOMMENDATION D) • PROMPT FLUID RESUSCITATION, EARLY SURGICAL REVIEW AND INVOLVEMENT OF CRITICAL CARE IS THE KEY TO THE MANAGEMENT OF UNSTABLE GI BLEEDS IN THE ED (GRADE 4, RECOMMENDATION D) • NONE OF THE VARIOUS TREATMENT OPTIONS NECESSARILY PREVENT REBLEEDING (GRADE 3, RECOMMENDATION D) • COLONOSCOPY PERFORMED IN AN EMERGENCY (WITHIN 24 HOURS OF ADMISSION) IS SAFE AND EFFECTIVE (GRADE 2B, RECOMMENDATION D) • SURGICAL INTERVENTION IS REQUIRED WHEN HAEMODYNAMIC INSTABILITY PERSISTS DESPITE AGGRESSIVE RESUSCITATION OR BLEEDING CONTINUES/RECURS (GRADE 3, RECOMMENDATION D)KEY POINTS (2) REFERENCES • OXFORD HANDBOOK OF EMERGENCIES IN CLINICAL SURGERY • OXFORD HANDBOOK OF CLINICAL SURGERY • SIGN GUIDELINES 2008 (HTTP://WWW.SIGN.AC.UK/ASSETS/SIGN105.PDF ) • HTTPS://WWW.RCEMLEARNING.CO.UK/REFERENCES/LOWER-GASTROINTESTINAL- HAEMORRHAGE • OAKLAND K, ET AL. GUT 2019;0:1–14. DOI:10.1136/GUTJNL-2018-317807 (BSG GUIDELINES-AVAILABLE ONLINE) THANK YOU FOR YOUR ATTENTION