LOWER GASTROINTESTINAL BLEEDING

RESUSCITATION

Severe bleeding needs the early involvement of a surgeon

CIRCULATION

2 x 16G IV access in each limb
Urgent Crossmatch 6 Units (Consider O -ve or Type Specific blood initially if severely unwell)
FBC, EUC
IDC (keep U/O > 40ml/hr)

EVALUATE CAUSE

CAUSE/LESION	FREQUENCY
Diverticular disease	20-40%
Angiodysplasia	10-30%
Neoplasia	~10%
Idiopathic	~ 5%
Rectal Tear

DETERMINE SEVERITY

Indications of significant bleed

Postural hypotension
Tachycardia
Hypotension

FURTHER INVESTIGATIONS

INR (in massive bleed, coagulapathy)
CXR (if suspected perforation)

IMAGING MODALITY

Ba enema
RBC scan (useful if done during or soon after bleed)
Colonoscopy (done > 48 hours after bleed)
Angiography (for preoperative evaluation of bleeding site)

Modality	Sensitivity	Information obtained	Advantages	Disadvantages
Barium Enema		Diverticular disease Intussusception (Not angiodysplasia)	Less specialised facilities	Irradiation
RBC scan	43% (stable) 86% (unstable)	Site of bleed	Non-invasive	Requires imaging suite Localisation inexact
Colonoscopy	42%	Less accurate in angiodysplasia	Intervention possible	Less useful acutely
Angiography	40% (stable) 65% (unstable)	Site of bleed	Intervention possible	Requires imaging suite Radiocontrast Risk of arterial injury

DEFINITIVE MANAGEMENT

80% of bleeding stops spontaneously and need no further acute management

If unstable the options are:

Interventional angiography
Surgery - subtotal colectomy

DISPOSAL

Discharge if:

Stable
Bleeding stopped
No bleeding for 12 hours
Identifiable non-serious lesion

Followup

Refer patients to Colorectal surgical clinic for colonoscopy
Advise patients to return if further bleeding

Admit to HDU/ICU if:

Continued bleeding
Haemodynamically unstable
Hb < 7g/dL or Hb fall of 3g/dL
Elderly/Co-morbidities/Complications
History of anticoagulant use

Admit all others to ward

PROGNOSIS

By Clinical features

Good

< 75 y.o.

No comorbidities/APTT normal

SBP > 100 in first 60 min

History of previous lower GI bleed

No further bleeding

Bad

None of above features

Rebleed

Transfusion requirements = 4 Units on arrival or 1 Unit/8 hrs or initial HB < 8

By colonoscopic findings/causative lesion

LESION	ACUTE REBLEEDING RATE	SURGICAL RATE	MORTALITY
Diverticular disease	20-55%	15-35%	5-20%
Angiodysplasia	80-90%	80-90%	10-15%