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Lower gastrointestinal haemorrhage

  • Accounts for 20% cases of acute gastrointestinal haemorrhage
  • Most patients are elderly
  • Most cases settle spontaneously without the need for emergency surgery
  • Following investigation often a cause is nor found

Causes

  • Diverticular disease
  • Angiodysplasia
  • Inflammatory bowel disease
  • Ischaemic colitis
  • Infective colitis
  • Colorectal carcinoma

Endoscopic appearance of severe acute colitis

Angiodysplasia

  • Acquired malformation of intestinal blood vessels
  • 80% lesions occur in the right side of the colon
  • Often associated with cardiac valvular disease
  • Dilated vessels or 'cherry red' areas may be seen at colonoscopy
  • Early filling of vessels seen at angiography
  • Bleeding may be visible during capillary phase of angiogram
  • Angiodysplasia is an incidental finding during 5% of colonoscopies
  • Seen in up to 25% of asymptomatic patients over the age of 75 years

Investigation 

  • Most patients are stable and can be investigated once bleeding has stopped
  • In the actively bleeding patient consider:
    • Colonoscopy - can be difficult
    • Selective mesenteric angiography
    • May show angiodysplastic lesions even once bleeding has ceased

Mesenteric angiogram showing bleeding from an angiodysplastic lesion in the region of the hepatic flexure

  • Radionuclide scanning
  • Uses technetium-99m labeled red blood cells

Rate of bleeding for detection

Investigation Rate of bleeding (ml/min)
Radiolabel red cell scan 0.1
Mesenteric angiography 1.0
Non-selective aortic angiography 6.0
Colonoscopy Any
Intraoperative endoscopy Any

Management

  • Acute bleeding tends to be self limiting
  • Consider selective mesenteric embolisation if life threatening haemorrhage
  • If bleeding persists perform endoscopy to exclude upper GI cause
  • Proceed to laparotomy and consider on-table lavage an panendoscopy
  • If right-sided angiodysplasia perform a right hemicolectomy
  • If bleeding diverticular disease perform a sigmoid colectomy
  • If source of colonic bleeding unclear perform a subtotal colectomy and end-ileostomy

Bibliography

Billingham R P.  The conundrum of lower gastrointestinal bleeding.  Surg Clin North Am 1997;  77:  241-252.

Ghosh S. Watts D, Kinnear M.  Management of gastrointestinal haemorrhage.  Postgrad Med J 2002;  78:  4-14.

Vernava A M,  Moore B A,  Longo W E,  Johnson F E.  Lower gastrointestinal bleeding.  Dis Colon Rectum 1997;  40:  846-858.

 

 
 

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