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Better now. Yes, cool. That's fine. Ok. Uh Good evening everybody. Um My name is Shirley. I'm currently an ST two emergency medicine trainee in the West Midlands. And uh, tonight I'll just be presenting an overview of lower gi bleed. Um I know it's a Saturday night. We all have plans. I promise not to keep you here for too long. Um So just use this outline to um, guide our discussion tonight. Uh just uh introduction some causes of lower gi bleed, look at the clinical presentation, um, investigations and then management. Uh So lower gly is basically any blood loss from the gastrointestinal tract. Uh, they start to the ligament of trace. So if you look at this picture on the right side, um, the ligament of trace, which is also known as the suspensor ligament of the duo of the duodenum basically connects the fourth part of the duodenum to the diaphragm. So any um, blood loss distal to this point is termed lower gi um hemorrhage and any blood loss proximal to it is um, upper gi hemorrhage. Um According to the British Society of Gastroenterology, uh lower gi bleed has got an annual incidence of uh 33 to 87 per 100,000 population. Um The incidence increases with age and is more commonly seen in men than in women. Now, this is because the two most common causes of lower gi bleed, which are diverticular disease and um angiodysplasia, uh mostly seen in men. I'm not sure why. That is. Um most um lower gi hemorrhage is so limited. And because of this, it only accounts for about 3% of emergency surgical referrals. Uh moving on to etiology. So the causes of lower gi bleed, one, we have anatomical abnormalities. Now, here you have the diverticular disease um which is the most common cause of lower gi bleed, especially in the older age group. So it could be diverticulosis or diverticulitis. So, when you have the um herniation of the mucosa of the so called submucosa and the submucosa of the um colon through the muscle layer and then when they become infected, that's diverticulitis. Um the most common site for this is the colon and it accounts for about 60% of uh lower gi bleed is actually a leading cause of lower gi hemorrhage in older adults. Um Another anatomical abnormality is the maker diverticulum. This now is more commonly seen in the pediatric um age group. So it is uh a congenital malformation that results in um ileal uh diverticulum. There's this rule of twos that is associated with maker's diverticulum. Um If anyone can just volunteer and give us those. I think there are about five of them. Anyone can give us the rule of twos associated with makers of them. One anyone. All right. Um So you have the rule of two. So it occurs in 2% of population. Um usually um presents before the age of two. It is about two inches in length and is situated within 2 ft uh of the ileal valve. And it also contains two ectopic tissues which is gastric uh pancreatic uh tissue. So, the meckels diverticulum is usually um asymptomatic, but it can undergo complications of which bleeding is one of them and present as a painless uh rectal bleed in Children. Um Other cause is you called the anorectal malformations. So, here you have the hemorrhoids, uh hemorrhoids, uh is the most common cause of lower jaw bleeding. Younger. Um adults, uh you could have the external or the internal hemorrhoids and the internal hemorrhoids are mostly associated with bleeding. So, you know, for the hemorrhoids, they are usually um inner cushions that you find normally in the 37 and 11 o'clock positions. And uh due to some risk factors like um constipation, pregnancy or the pelvic masses, then you could have these, you know, protruding into the inner canal, sometimes outside the inner canal, uh get bruised and cause uh bright red bleeding per rectum. Another an erectile uh problem causing lower G IB is anal fissure. Uh This is basically a distal skin, uh split, uh distal anal skin splits that is usually associated with very painful defecation and um erectile bleeding, bright red bleeding, perrectal. You can also have rectal viruses. This is not a common cause of lower gi bleed. You mostly see these in patients with portal hypertension. It has the same pathophysiology as um esophageal viruses. Then you've got the malignant causes the colorectal cancer and anal cancer. You've got vascular malformations, uh like colonic angiodysplasia. Now, this is the second most common cause of lower gi bleed in older adults after diverticular disease. What happens here is that there is a degenerative vascular malformation um causing the blood vessels in the colon to become fragile and leaky and it's mostly in the, in the cecum and the ascending colon. That's where you find this colonic chondrodysplasia. Uh another vascular causes ischemic colitis. So what happens here is that um either due to embolic causes or thrombotic causes, you could have a reduced blood supply to the colon resulting in um ulcers or sores in the colon, which can then bleed. Uh Some of the risk factors for this could include um smoking, atrial fibrillation or other hypercoagulable uh states for radiation induced um uh lower gi bleed. What happens is that the radiation causes inflammatory changes in the bowel and then also results in ulcers or sores that can then bleed. Uh There is also enter enter aortoenteric fistula, which is basically a connection between the abnormal connection between the aorta and the, and the gut and then you can have bleeding um presenting uh de la Foy's lesion. I'm not sure I pronounce that correctly. Um Is also another vascular malformation where you have the submucosal blood vessels um become enlarged and they just bleed without any, any abnormality. It's a rare cause of lower gi uh bleed. There are also inflammatory causes the Crohn's disease, ulcerative colitis. This can present as bloody diarrhea. You have infectious causes with these organisms. Uh E coli especially the enterohemorrhagic one enterohemorrhagic strain, uh salmonella shigella and other organisms that can give you bloody diarrhea as well. Then other causes of um lo lower gi bleed. Uh if you've got upper gi hemorrhage, which is now hemorrhage, uh originating from any point proximal to the ligament of trace if you've got bleeding from that site, but it's transiting rapidly through the intestines. It can present as a bright red bleed or um through the rectum or via the rectum. Then coagulopathies either with um any blood clotting abnormalities or anticoagulant use can also present with this uh post surgery for instance, after polypectomy or say patient has had um prostate biopsy. So they can come down with complications uh of uh gi bleed or lower gi bleed. No, in terms of presentation. So broadly speaking, lower G IB usually present either as Melina or as um bright red blood in stool or as are called lower G IB where you don't have any visible blood uh coming via the stool or via the rectum. But the patient is anemic. Well, whichever the presentation, uh basically depends on the, the severity of the bleed one and also the underlying cause of the um, of the abnormality of the uh bleed. So, for an erectile abnormalities, for hemorrhoids, um usually present with uh bright red blood or the history is that of bright red blood, either painting the surface of the stool or in the toilet bowl or uh bright red blood on the toilet paper, on wiping, it's usually painless, it's intermittent. Um and you could have also this other um factors that will like predispose you to uh hemorrhoids, like constipation, pelvic masses or anything like that. Uh on examination, you may or may not find external hemorrhoids if you do an endoscopy or proctoscopy by the bedside, which is this image uh depicted on the right side here. So with the endoscope or the Procope and the patient, either in the dorsal position or the left lateral position, lubricate the endoscope and then insert it with the intra in. And then you um we draw the introducer and then gently we draw the endoscope while looking into um looking into the rectum via the window uh in the endoscope. And then as you withdraw, if there is any internal hemorrhoid, it will just, you know, i it into your field of view as shown in this um picture here. So those are the ones that are commonly associated with bleeding, like we earlier said, and the patients here are usually hemodynamically stable. Um for anal fissure, which we said is it uh distal um split in the distal anal skin. You can see it here in the picture here. Um Usually if you have a history of severe pain on passing stool, there could be history of um constipation or chronic diarrhea and also bright red blood on wiping. When you examine the patient on pa the Botox, you will see a visible uh fissure on the Botox, usually in the posterior midline. Um and this usually doesn't let you do any other examinations. So you can do a digital rectal or a proctoscopy or endoscopy by the best side because it's usually very uh tender, very painful and the patients are usually hemodynamically stable as well. It rarely causes severe gi bleed or severe lower gi bleed. Um for diverticular disease, which we said is the most common cause of lower gi bleed in um older adults. The history is that of the middle aged patients usually in their sixties. Uh recurrent left lower abdominal pain bloating, constipation or diarrhea. They may have red, bright red uh blood or blood in stool. And uh the bleeding might be either mild or severe and is usually painless as well on examination, depending on the severity of bleeding. You can have um unstable vital signs. So their BP may be low, they may be tachy, they may be clammy, maybe reduced, uh cap refill uh on abdominal examination, abdomen exam may be normal or there might be left uh lower um left eye left foa tenderness. When you do a digital rectal examination, you may find bright red blood or blood clots on uh rectal exam. Um in chronic angiodysplasia, which is the second most common cause of lower gi bleed after diverticular disease. Again, you find this in middle aged patients, uh they give you a history of intermittent chronic bright red bleeding that is painless. And there may be these other comorbidities that are associated with dysplasia, like atic stenosis, von Willebrand disease or endstage renal disease. When you examine them, they vital signs may be unstable if this bleeding is severe, they could also show signs of anemia. They are pale and all of that abdomen exam may be normal. If you do apr there may or may not be uh rectal bleeding. Um on rectal examination uh for ischemic colitis. Again, you have patients middle aged um with history of sudden onset low abdominal pain, uh right rectal bleeding. There may be history of these other risk factors that predispose one to ischemic colitis, like smoking, um atrial fibrillation, maybe other hypercoagulable states that uh may predispose them to that. On examination. The abdomen is severely tender, um presence of peritoneal size or absence of bowel signs may suggest perforation of the bowel when you do your blood gas, usually the lactate is, uh, raised on the blood gas, um, for infectious uh, colitis. So, you have a history of diarrhea, abdo pain. There may be history of travel to, um, areas with high risk of infectious diarrhea or they may have ingested, uh, maybe, uh, food that is improperly cooked. Um, come down with this di uh bloody diarrhea. On examination. You may find abdominal tenderness will present fever depending on how much uh fluid and blood and electrolytes that they have lost via the bloody diarrhea. That results just uh vital signs may be unstable as well. Uh For colorectal cancer, typically, you have a patient who is um over 40 with rectal bleeding, there may not be rectal bleeding as well because depending on the side where this uh malignancy is. So, if it's on the left side, you could have rectal bleeding. If it's on the right side, it can present with altered blood in stool. Um So they can have weight loss as well change in bowel movements. So usually they have either diarrhea or alternating with constipation. There might be decreased um caliber of their stool. They can have tennis loss, abdominal pain, anorexia. They can also have a, a positive family history of um cancer or colorectal cancer. So, on examination, you may find a palpable mass on um abdominal exam. When you do a digital rectal examination, there may or may not be uh rectal mass uh failed. Uh So in terms of workup, so this patient has come into A&E and you've taken your history, examined them. So you want to like do your investigations and or want to ascertain the severity of the bleed and also to help you uh localize the bleed. Um Also, in terms of workup, you also want to, apart from like um assessing the severity of the bleed, localizing the bleed, you also want to um find that there are any other um interventions that you should be doing for the patient. So you've got your blood test, your full blood count. You want to be looking at the HB, um comparing that with their previous normal HB, there's a significant drop, then they will need um replacement of the of blood or blood transfusion. Um You can also look at the white cell count for if you're suspecting an infectious cause of the bleed. I'm looking at the platelets as well because coagulopathies also can be implicated in lower gi bleed. Uh You and these, you want to be looking at the, the clotting profile again because of uh coagulopathy, the blood gas, you're looking at the, it can give you information about the hemoglobin, give you information about the lactate if you're suspecting an ischemic colitis, uh you also need to group and cross match blood because these patients might need transfusion depending on the severity of the bleed. Uh We've got endoscopic tests. So your colonoscopy, colonoscopy is usually the initial imaging uh procedure in all patients with uh lower gi bleed. So what it does is that or the advantage is that it can localize the source of the bleed. And uh even through the colonoscopy, you can do some therapeutic interventions. Like um if there's a bleeding vessel, you could use a, a thermal probe to coagulate the bleeding vessel. If there's a bleeding mass or a bleeding polyp, uh you could like take a biopsy or remove that and you know, cauterize the area. Um The disadvantage of this is that you need the bowel to be prepped for you to be able to visualize properly the colon. So if you're doing it as an emergency without the bowel being prepped, chances are that you might not, you know, be able to visualize the colon properly. Um Also, there's a risk of perforation with colonoscopy and if the bleeding is uh very heavy, it will also obscure your view. And so you might not be able to um see the colon properly. Another um limitation of the colonoscopy is that it is not able to visualize the small bowel. So you can only see the colon but not the small bowel. If you remember that lower gi bleed is from the, from a point distal to the ligament of chairs. And you know, from there, the fourth part of the duodenum, you've got the ilium, you have called the JM. So it can only go as far as the colon. You, you're not able to visualize the other uh small bowel to see if the bleeding is coming from there. Um Another endoscopy test is your O GD. So this is when you remember when we were talking about the causes, we've said that um sometimes your upper gi bleed with rapid uh transit time can present as lower gi bleed. So you need to do your OO GD to rule out um an upper gi um origin of the bleed. I've got your CT scan here. It's useful in diagnosis of ischemic colitis, your malignancies or your aortoenteric uh fistula. So this will usually delineate that um angiography is usually for patients um with negative colonoscopy, uh not suitable for endoscopy and they've got still bleeding or they've got persistent gi bleed. So, what the angiography does is that it can accurately uh localize the site of the bleed. And through that you can also uh do some therapeutic um interventions. For example, um embolization. Um The disadvantage here for the CT angiography is that uses contrast and you can have uh contrast reactions in some patients. And in those with say declining renal function, giving them contrast can also further um make the renal function to, you know, go south. Uh there's a ride scan. So I've not seen this done before. I actually don't know how this is done, but it's important for those with persistent gi bleed uh with normal colonoscopy and normal O GD. Um So this can also like localize the site of bleed. But the advantage is that it can, it can localize even the tiniest um source of bleed. Uh it's noninvasive as well. Um But the thing here is that the downside to it is that it, it has no therapeutic um benefit or you cannot do any therapeutic intervention with this. It can only just show you the site of the bleed, but you can do any other thing uh through it. Uh There are also other methods of uh visualizing the small bowel. So there's wireless capsule, endoscopy, uh cushion. These are all things that uh I saw while researching this subject. So I haven't seen any of these done before. I don't know if anyone has seen them done before. Um So you also got your stool studies. If you suspect an infectious cause of the uh bleed, you need to do your uh your stool studies for microscopy and culture to delineate any organism that may be responsible for that. Now, in terms of management, uh there are three components of the management. So one you have your initial assessment and resuscitation. So your patient comes maybe presents to the emergency medicine with lower gi bleed. You want to first take a focused history. You want to find out how long they've been bleeding for um the color of the bleed and how it is related with the stool, if it's, um, you know, painted, if it paints the stool or is mixed in with the stool, if it, there's pain associated, it, it is, the color of the blood is bright red or is it altered blood? Is there, um, presence of clots, um, in the, is the presence of clots coming out as well? Um How long they've been bleeding for? You want to find out if there are any, um symptoms that could also point you to severity of the bleed, like any dizziness, um any syncope, you know, and any other comorbidities as well. Um You want to do a thorough physical examination. Um abdominal exam, you want to be assassin if there are any masses, anything like uh you know, like signs of portal hypertension that may be pointing to probably rectal varies also uh responsible for the bleed. Uh You want to do your vital signs. Also, this will also let you know the uh give you an idea of the severity of the bleed, check the heart rate. Are they tachycardic, is their BP low? What is edemic inadequate urine is the presence of postural hypo hypotension all of these. Um We'll let you know if the bleed is severe or not. Um So you also need to resuscitate these patients. Uh You want to be put in, in a white b cannula ureter has to monitor their urine output um in crystalloid infusion probably before you get your red cells if they need to um be transfused or if they've been having uh say they've been having perfused bloody diarrhea, you also want to like replace uh fluids and replace electrolytes. Um The these patients may also need transfusion of red blood cells depending on how severe the bleed has been and how much their um HB has dropped. You generally aim to keep the HB above um 7 g per year. Also remember to involve these um other specialties early on like the general surgeons, the gastroenterologist, the itu specialist, depending on how stable or unstable the patient is. Uh the second component of management is localization of the bleeding site. So this is where your imaging procedures, uh your endoscopy procedures, all of them come in your colonoscopy, your O GD, your angiography, your CT scans. This is where it comes in for you to be able to localize the bleeding site and deal with it. Uh And then the third one, that's where they have the therapeutic interventions then come in. Basically, you want to stop the bleeding at the site so that they are not losing any more bloods. So you can do this via colonoscopy, um either like coagulating the bleeding sites um or you can do this via interventional radiology. So, embolization when you do your angiography, you can also embolize any uh bleeding uh vessels there at surgery. So in case of hemorrhoids, if it's not bleeding, they can have hemorrhoidectomy if um in F I think they've got um surgical interventions for that as well. If there's a malignancy, they could also, if it's operable, then they could have uh like removal of that to basically control the uh the bleeding and the uh whatever underlying etiology. Uh This is an algorithm. I think this was from the British Society of Gastroenterology for um assessment of lower gi bleeds. So you have, your patient comes in, you do your clinical examination, including your digital rectal exam, you assess the severity of the bleed with appropriate blood tests, uh vital signs, the heart rate, BP and all of that, you calculate the shock index. So the shock index is uh your heart rate uh divided by the systolic BP. It's a marker of um hemodynamic uh instability. So if the shock index is less than one, then it's a stable gi bleed. So it's not severe. If it's more than one, then um it's an unstable uh lower gi bleed and you need to um at very fast. And the rest of them, which I'm not going to read out is just what you do depending on what the shock index is and depending on if they are still bleeding or not. OK. So I wanted to put up a, a case uh like a case of stuff here so that we could like answer the questions, but I decided against it because I didn't want to waste anybody's time to that. Ok. So basically, in summary, uh we've saying that lower gi bleed is uh any bleed distal uh to the ligament of trees. But that doesn't mean that we shouldn't exclude upper gi bleed because upper gi bleed with rapid transit time can present as a lower gi hemorrhage. We've also seen that the most common cause of lower gi um hemorrhage in the older adults is diverticular disease and angiodysplasia. While in the younger um age group, it's usually from hemorrhoids or other and erectile a like uh an al fia. Um We've seen the components of management, the importance of taking a full history examination, assessing the severity of the bleed because that will inform how quick you intervene and what else you do the other specialties to in involve, um you need to localize the bleeding um site using appropriate um investigations and then you need to then, um stop the bleed at the site. Um, but sometimes I think it's better to say here that sometimes even with all of these, you know, investigations and all, sometimes you still cannot find the source of the bleed in these people. So I think in these people as an emergency medicine um practitioner, so you assess, you send them for the investigations to um localize the bleeding site and then refer them to the appropriate um specialty. It could be the surgeons or the gastroenterologist to um manage it from there. So, thank you, everyone. For listening. I think that's the end of our presentation. Any questions? Hello? Can you still hear me? Someone asks, how do you manage? Uh Is this, how do you manage treatment if comorbid af with patient on anticoagulant drugs? Um I think for patients with um a on anticoagulant drugs who are bleeding, you need to stop the anticoagulant medications. Sometimes you need to um reverse the anticoagulant, for instance, if they are on Warfarin uh or other anticoagulants, then you need to reverse it. So this is where you also have to involve other specialists like the hematologist to give you advice on how best to manage them. Because if they are taking the anticoagulants for an underlying medical condition, of course, stopping, it means that that medical condition isn't being taken care of. So you need to involve the appropriate specialist if II would involve the hematologist and let them know this patient is bleeding, he's on anticoagulant, he's on Warfarin or whatever for af or any other thing. And what do you advise us to do and just take the specialist advice in hyper coagulant cancer patients? I'm not sure. I understand what you mean. How would you modify management plans? Should a patient have ulcerative colitis? And how would systemic steroids and immunosuppression affect infections or bleeding risk from thin skin? So how would you modi modify management plan? Should the patient have ulcerative colitis? So, if a patient with ulcerative colitis comes with bloody diarrhea. They have, I think what you do is so there are um severity of the ulcerative colitis, mild, moderate severe, depending on what it is. They can have IV steroids to control their symptoms, isn't it? And if the blood loss through the bloody diarrhea is so much that they require replacements, then you do need to transfuse them with what they've lost. And these patients, of course, they need to be managed on joint care of the surgeons and the gastroenterologist. And uh how would systemic steroids and immunosuppression affect infections? Plus bleeding risks from thinned skin? I'm not sure about that. Is there anyone that can help us with that? Any other questions, suggestions, comments. Um I'm so sorry for joining. Uh I, I'm having a bit of um network issues and um I think she has answered um all the questions on the chat box. Um I just wanna say um a very big thank you to Doctor Shirley Gabriel for today's presentation. Um II listened and um I la lot to some parts um regardless of the network and I'm sure that we all um L one or two other things. Thank you very much for this. Um Thank you. Um If I could just ask if I could just ask, I drop the link in the chat box if you could just like it's basically a three question uh questionnaire just for feedback and areas for improvement. If you tell me areas I did well as well. So if you just then, um, she sent a link to the chat box, um.