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Bleeding from lower GI tract

Overview
  • Definition: Haemorrhage originating distal to the ligament of Treitz, usually presenting as fresh blood per rectum or melaena.
Common Causes
  • Diverticular Disease: Most common in Western countries.
  • Angiodysplasia: Abnormal blood vessels in the colon.
  • Colorectal Cancer: Especially if advanced.
  • Inflammatory Bowel Disease (e.g., Ulcerative Colitis, Crohn’s).
  • Anorectal sources: Haemorrhoids, fissures.
  • Ischaemic colitis.
  • Meckel’s diverticulum (though often considered upper GI).
Diagnostic Approach
  • History & Examination: To assess severity and potential sources.
  • Lab tests: Full blood count, coagulation profile, renal function.
  • Colonoscopy: First-line, allows for direct visualisation and potential therapeutic intervention.
  • CT Angiography: Useful if rapid bleeding (>0.5 mL/min).
  • Tagged Red Blood Cell Scan: For slower bleeds.
  • Flexible sigmoidoscopy: In patients unfit for full colonoscopy.
Surgical Approach
  • Resuscitation First: IV fluids, blood transfusion, cross-match blood.
  • For ongoing or recurrent bleeding not amenable to endoscopic control:
    • Segmental colectomy if source identified.
    • Total/subtotal colectomy if source not identified or multiple sites.
  • Preoperative Localisation: CT angiography or tagged RBC scan may help localise bleed.
  • Laparoscopic vs Open: Approach decided based on patient stability, surgeon expertise, and suspected pathology.
Post-operative Management
  • Monitor vital signs and haemoglobin levels.
  • Ensure adequate pain relief.
  • Early mobilisation to prevent thromboembolic events.
  • Consider prophylactic antibiotics if large bowel surgery performed.
Key Points
  • Resuscitation is the first step in management of significant lower GI bleed.
  • Colonoscopy remains the mainstay of both diagnosis and therapeutic intervention.
  • Surgery is reserved for those with ongoing or recurrent bleeding not controlled by endoscopic means or if a resectable pathology is identified (e.g., cancer).

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