األية البقرة األية 32سورة البقرة 32سورة

By

Dr. Hassan Tantawy

Prof. of General SurgeryFaculty of Medicine

Ain Shams University

Location Causes

A- Small Intestine - Meckel’s diverticulum : Peptic ulceration – & Inversion causing intussusception.- Crohn’s disease. - T.B. - Tumors : Benign & malignant.

B- Colon - Diverticulosis , diverticulitis.- Colitis : bacillary, amoebic, bilharzial, ulcerative.- Tumors : - Benign : adenoma, familial polyposis. - Malignant : carcinoma.

C- Anorectal - Piles, fissure, fistula, proctitis, rectal prolapse.- Tumors : - Benign : adenoma, villous adenoma. - Malignant : Carcinoma.

D- Upper GIT - Varices, peptic ulceration.- Tumors of stomach.

Most common sources are diverticulosis , vascular ectasias and ischaemic colitis .

Common Uncommon Diverticula Vascular ectasias Ischemia Cancer Hemorrhoids

Inflammatory bowel diseases

Infectious colitis Radiation colitis Rectal ulcers

D.D. of Lower GI Bleeding in the Elderely :

- Nearly 50% of pts. over >60 Y. have radiologic evidence of diverticula - 20% have bleeding at one time of their lifetime , 25% have massive bleeding. - Hemorrhage accounts for 25% of complications reporetd e’ diverticula and is more e’ diverticulosis than diverticulitis.

Pathogenesis : - Vasa recta , the intramural branches of marginal a. penetrate colonic wall perpendicularly. When diverticulum is there , it crosses over the serosal surface of its dome very close to lumen seperated by a few muscle strands.- Bleeding intracolonic ( not intraperitoneal) occurs e’ progressive weak of arterial wall leading to eccentric rupture and massive bleeding.

Pattern of Bleeding : - Bleeding is arterial ,tends to be sudden and severe and usually stop spontaneously. - 25% will have 2nd bleed and 50% of latter will have further bleeding. - Mild persistant bleeding must be attributed to Ca.,polyps or vascular ectasias rather than diverticulosis.

- Known as angiodysplasia or arteriovenous malformations.- Mostly Rt. Sided in cecum ,ascending colon of 25% of pts.above 60Y.- Lesions are degenerative not congenital or neoplastic, usually <5mm in diameter .

Pattern of Bleeding :- Tends to be mild, 15% massive , stops spontaneously ,but mostly recurs within days.- 10-15% may have intermittent hemo-occult +ve stool and iron def. anemia, 25% have melena and reminder have hematochezia.- Varies from melena to marron stool to bright red blood. This reflects bleeding from capillaries, venules to AV communications.- Common and early feature is dilated often huge submucosal veins.- Exact etiology is” repeated partial intermittent low-grade obstruction of submucosal veins where they pierce the colonic muscle layer”.- Many years of cecal distension and contraction raise intravenous pressure dilated tortuous veins. So, cecum is a common site.

Conditions associated with vascular ectasias : - Heart diseases , aortic stenosis . - Chronic renal failure. - Cirrhosis. - History of gut irridiation. - Collagen vascular diseases.

Aortic stenosis is found in 50% 0f pts.and is responsible for high

risk of bleeding. May be due to low perfusion pressure causing ischemic necrosis of the single endothelial covering layer that separate the vessel from the colonic lumen.

- Almost seen in elderly . C/P : Typically, pt. will have sudden abd. cramps in LIF e’ tensmus,

followed within a day by bloody diarrhea.- Bleeding may precede any GIT symptoms of mesenteric ischemia.

O/E : May be mild tenderness in LIF.- Commonly affects splenic flexture , descending and sigmoid colon.- Recovery may be complete, or segmental colitis and subsequent stricture may develops- Rarely, severe and leads to gangrene and perforation .- Plain x-ray shows “thumb printing” ( colonic submucosal edema and bleeding) .- Bleeding usually stops spontaneously.

Age : - Children : Rectal polyp , rectal prolapse , intussusception. - Adults : Piles , fissure , fistula . - Aged : Ca. of rectum & colon.

History : 1- What is the amount ? 2- Relation to defecation :It is independent in prolapsed piles ,fistula and polyps. 3- Color of bleeding : - Bright red : piles , fissure ,polyps. - Dark red : Ca. of rectum & colon – Dysentery. - Black : upper GI bleeding. 4- Is it mixed e’ mucus or offensive discharge ? - Intussusception : blood + mucus, no fecal matter ( Red current jelly ) - Dysentry : blood + mucus + fecal matter. - Carcinoma : blood + mucus + Foul pus ( Spurious diarrhea ) 5- Associated symptom : a- Tensmus : colitis. b- Anal pain : fissure. c- Change of bowel action : Constipation : piles, rectal polyp or prolapse. Diarrhea : colitis , carcinoma.

d- prolapsed lesion : piles , rectal polyp , prolapsed rectum. e- distension , borborygmi ,fever, vomiting.

Examination : 1- Abdominal : swelling in intussusception , carcinoma. 2- Rectal Examination : a- Inspection : piles, fissure, fistula, rectal polyp or prolapse. b- Palpation : - Anus : piles , fissure , fistula , Ca. - Rectum : polyp , malignant ulcer , tumors. N.B :- Occasionally, physician may find rectal mass, bleeding piles or distal lesion obviating further workup. - Patient may have double lesions e.g. piles with Ca. rectum or colon. 3- Stool Examination & Rectal Biopsy : amoeba , bilharzial ova , bacilli. 4- Sigmoidoscopy & Colonoscopy : - Rectal polyp. - Angiodysplasia. - Strictures. - Inflammation : Bacillary , amoebic , bilharzial , ulcerative colitis. - Tumors : - Benign : adenoma , villous adenoma , familial polyposis. - Malignant : Ca. of colon & rectum.

6- Barium meal follow through ( Ba. Progress Meal) : For diagnosis of : Meckel’s diverticulum , Crohn’s disease , ileocecal T.B.7- Angiography : Diagnostic : Angiodysplasia , ischemia. Therapeutic : Embolization of bleeding vessels.8- Laparotomy : needed in selective emergency cases.N.B :

If bleeding stops rapidly ,or continues slowly, colonoscopy is of choice : - Allowing direct visualization of bleeding site. - Possible electrocoagulation of ectasias, snaring of bleeding polyp.

Barium study should be avoided in acute cases. If bleeding is severe, upper GI endoscopy is done unless NGT shows bilious

aspirate ( Upper GI bleeding is 3rd most common cause of brisk rectal hge ).

5- Barium Enema : - Simple enema : shows gross lesions as diverticulosis, polyps ,ulcerative colitis, tumors . - Contrast enema : for diagnosis of early plaque-like Ca.

Assuming normal EGD , Technetium 99m- labelled RBCs scan is used to localize bleeding site. - If scan is +ve and colonoscopy is impossible or not available or both are –ve inspite of persistant hematochezia angiography should be done looking to sup. mesenteric then inf. mesenteric and celiac trunks.

Feature Possible cause of bleeding

- Diverticulosis - Aortic stenosis - Changed bowel habits - Abd. Pain followed by bloody diarrhea - Diarrhea e’ mucus & little blood - Rectal pain - Bright red blood ,streaks on stool

- Diverticula - Vascular ectasias - Ca. colon , inflam. bowel diseases - Ischemia - Inflammatory bowel disease - Fissure , thrombosed piles - Piles

About 5% of cases ,exact source cannot be detected. It cccurs in all ages , but is of importance in elderly.

Special studies to uncover the bleeding site include : 1- Intraoperative selective visceral angiography. 2- Intraoperative panendoscopy to evaluate upper GIT and small intestine.

Causes : - Vascular anomalies of stomach, SI, colon. - Meckel’s diverticulum. - Small intestinal smooth muscle tumors, rarely malignant. - Small intestinal diverticula, ulcers. - In elderly, 60% have colonic angiodysplasia.

N.B : 1- Any pt. above 45Y. with occult bleeding , should be investigated with upper GI endoscopy mesenteric angiography. If no diagnosis exploratory laparotomy with intraoperative angiography and enteroscopy . 2- The ‘’ Wait and See” approach sometimes applied to an elderly pt. in hope of avoiding surgery , often means that these fragile pts.( unstable with multiple transfusions ,acquired coagulopathy and other complications) go to OR. too late 3- It is better to use endoscopic or angiographic therapeutic techniques to arrest bleeding , but these should be applied early and, if they fail, surgery should follow Although risk of surgery is high, that of persistant bleeding is usually worse.

Symptom Suspected Diagnosis Action to Diagnose

Spoting on underwear,soreness,itching,perianal skin inflammation

Eczema, thread worms,Scabies, psoriasis, VD

PR & PV- Proctoscopy ifRectal dischargeDerma referal

Bleeding e’ local swelling Piles, prolapse, perianalhematoma, anal skin tag,Crohn’s disease

PR, proctosigmoidoscopyBiopsy, pile injection(I&D)If NAD Ba.enema, EUAor colonoscopy

Bleeding, pain ,spasm with defecation

Fistula,fissure ,inflammed pile, polyp or Ca.

Same as above

Bleeding after defecationBright red dripping orSpurting on paper

Anal pathology especiallypiles

Same as above

Symptom Suspected Diagnosis Action to Diagnose

Blood streaks on stool,painless bleeding not related to defecation

Polyp, rectal ulcer, proctitisor carcinoma

PR,sigmoidoscopy,biopsyIf NAD Ba.Enema,EUAcolonoscopy +laparotomyand transfusion

-Bleeding with diarrhea and mucus-Abdominal colic

Inflammatory bowel diseasedysentry, enteritis, villousadenoma

Stool culture , PRsigmoidoscopy, biopsyIf NAD Ba.enema, EUAcolonoscopy +laparotomyand transfusion

-Fresh or dark blood-Intermittent abd. Colic-Tenesmus or changed bowel habits

Ischemic colitis, diverticula(esp. heavy fresh bleeding)Colitis, polyp, carcinoma

PR,sigmoidoscopy,biopsyIf NADBa.enema ,EUA,colonoscopy +laparotomyand transfusion

Symptom Suspected diagnosis Action to diagnose

Bleeding after pelvic operation for malignancy

Irradiation proctocolitisActive malignancy

PR, proctoscopy, sigmoidoscopy, biopsyReferal to specialist

Massive rectal hge.,shock, collapse

Diverticular disease ,Angiodysplasia.

Admission to hospital forBa. enema, colonoscopyEUA , laparotomy and transfusion

Bleeding after chemotherapyHepatic or renal failure

Thrombocytopenia , hypo-prothrombinemia , ureamiccolitis

Refer to hematologist or approperiate specialist

Diarrhea, weight loss ,skin rash

AIDS Referal to specialist atdesignated unit

Lower GI Bleeding RBC radionuclide

scan

Angiography

Urgent Segmental colectomy

Elective colectomy

History & ExamPrevious bleedDiverticulosisAnticoagulantsChemotherapyIrradiation

LaboratoryHCTClotting studiesBlood typing &Cross matching

NGTAspiration

No blood

Blood

Proctoscopy ,Sigmoidoscopy

Upper GIendoscopy

Anorectal disease

No anorectal disease

Negative

Colonoscopy

Positive

No lesion

Observe

Lesion

Emergency abdominal colectomy

Bleeding site not identified

Persistant bleeding

Bleeding site identified

Infusion

Bleedingcontinue

Bleeding stop

Bleeding per rectum may result from any GI lesions- Commonly : diverticular disease, angiodysplasia and ischemic colitis.- Coagulation disorders, chemotherapy, irradiation colitis are now increasing.

Bleeding from Upper GIT is evaluated by NGT aspiration. If blood is recovered Upper GIT endoscopy.

Bright blood e’ defecation indicates anorectal disease such as piles, fissure orrectal carcinoma . Proctoscopy and sigmoidoscopy are helpful for diagnosis.

Persistant not brisk hge. e’ no anorectal lesions is evaluated by radionuclide99m Technitium labelled RBCs. This is sensitive to detect bleeding of 0.5ml/min- If –ve or bleeding stopped or very low bleeding rate colonoscopy is done.

- If +ve RBC scan ,selective angiography for sup. &inf. Mesenteric arteries.- Extravasation of contrast into lumen localizes bleeding site in 60 -80%- Vasopressin inj. of 0.2 units/min is infused intraarterially. Bleeding stops

in 50% of cases then elective segmental colectomy or observation.- Colonoscopy is done if not profuse bleeding in pts. not requiring urgent op.- If lesion is found urgent segmental colectomy.

Failure of infusion angiography to control bleeding emergency segmentalColectomy.

Lower GI bleeding that requires > 3000ml bl./24 hrs. must be treated byemergency operation . When site is not identified preop- or intraoperatively total colectomy with ileorectal anastomosis or temporary ileostomy is done .

Diverticular Bleeding :- If bleeding not stop spontaneously angiographic injection of absorbable gelatin or vasopressin into the involved arteriole leading to thrombosis.- For continued bleeding segmental colectomy . Risk of surgery depends on age and co-morbid factors .- If angiogram shows both Rt. sided ectasias and Lf. sided diverticula but no active bleeding treatment is directed to ectasias not the diverticula .

Vascular Ectasias :- Once diagnosed endoscopically , colonoscopic coagulation is ttt. of choice by either mono- /bipolar electrode , heater probe or laser. Rebleeding is not uncommon .- Rt. hemicolectomy is reserved for fit pt. with documented ectasias and in whom colonoscopic therapy is unsuccessful or unavailable .

Mesenteric Ischemia :- Ttt. options include mesenteric infusion of vasodilators , revascularization by embolectomy, thrombectomy or bypass and resection of ischemic bowel .

Describe the treatment of a pt. with lower GI- bleeding ?- ABC ( airway, breathing , circulation )- Venous access : 2 large canulas in forearms .- Blood typing and cross matching .- Foley’s catheter to monitor urine output ( 30-60 ml/min ).

What is the next step ?- Nasogastric aspiration . If bilious the source is distal to ligament of Treitz .- N.B . Pt. may have duodenal bleeding with competent pylorus .

After good history and exam. What is 1st step to localize bleeding site ?- Proctoscopy , sigmoidoscopy to rule out anorectal disease .

Name 4 options available to localize lower GI bleeding ? - Tagged RBC scan. - Angiography. - Sulfur colloid scan. - Colonoscopy.

- Tagged RBC scan: needs 30-60min delay till red cells are labelled. Detects as slow as 0.5ml/min . Study takes at least 2 hrs. to complete .Because tagged cells stay in circulation ,it helps in diagnosis of intermittent bleeding .

What is role of angiography ? 1- Detects rate of 0.5-1ml/min .Diverticular bleeding is seen as an extravasation of contrast , while ectasias appear as vascular tuft or early filling vein . 2- Therapeutic : a- Infusion of pittressin into bleeding vessel . b- Embolization of bleeding vessel in poor operative risk pt. ( Complications 15% as strictures or perforations ) .

Role of Pittressin : Temporary till resuscitation , change emergency operation into urgent and it is the only ttt. In diverticular bleeding . In rebleed, either surgery or embolization .

What is the difference between sulfur colloid scan and RBC scan ? - Sulfur colloid scan: quick, detects as minimal as 0.1ml/min .Test is complete within 20 min. Rapidly cleared by liver, spleen, so not valid if bleeding site in splenic or hepatic flexure.

What are indications of surgery ?1- If pt. has received 6 units of blood (2/3 of his bl. volume)/24 hrs. with no resolution of bleeding .2- Any pt. rebleeding after pittressin injection or embolization .

What is the role of blind subtotal colectomy in massive bleeding?- If the site cannot be detected . 16% mortality. More tolerated in young .- Older pts. suffer from severe diarrhea ,urgency and incontinence .- N.B: Blind segmental colectomy has more mortality (39%) and rebleeding(54%)

What is the most common cause of bleeding in pediatrics & elderly? Pediatrics : Meckel’s diverticulum . Elderly : Diverticula - vascular ectasias – ischemic colitis .

What percentage of patients resolving spontaneously ? 75% in vascular ectasias , and 40% in diverticular bleeding .