Clinical Core Tutorial - PR Bleeding PDF

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Clinical Core Tutorial - PR Bleeding...

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Surgery – CTT 3 - PR Bleeding – Haematochezia Blood Supply to the GIT Branch Level of origin Coeliac

T12

Embryonic part of gut supplied Foregut

Superior mesenteric

L1

Midgut

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Inferior mesenteric

L3

Hindgut

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Coeliac artery – Branches 1. Left gastric artery o Oesophageal branches 2. Common hepatic artery o Right gastric o Gastroduodenal  Superior pancreatico-duodenal  Right gastro-epiploic artery o Eft hepatic o Cystic 3. Splenic artery o Left gastro-epiploic artery o Short gastric arteries o Pancreatic branches

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Adult gut supplied       

Oesophagus Stomach Liver Gallbladder Pancreas Spleen Proximal duodenum o To the greater duodenal papilla Part of pancreas Distal duodenum Jejunum Ileum Caecum Appendix Ascending colon Proximal transverse colon o Near left colic flexure Distal transverse colon Descending colon Sigmoid colon Rectum

SMA – Branches 1. Inferior pancreatico-duodenal artery Right side 1. Ileocolic artery (terminal branch) 2. Right colic artery a. Ascending and descending branches 3. Middle colic artery a. Right and left branches Left side 1. Jejunal branches 2. Ileal branches IMA – Branches 1. Left colic artery o Ascending and descending branches 2. 2-4 sigmoid arteries 3. Superior rectal artery (terminal branch)

PR Bleeding  The passage of fresh blood per rectum  Generally caused by bleeding from the lower gastrointestinal tract o May occur in patients with large upper GI bleeds or from small bowel lesions  Can eventually result in significant haemodynamic instability if not managed appropriately

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Acute PR bleeding is broadly divided into regions of the colon from which it comes from  Blood is typically different from each site Site Anorectal

Blood Bright red blood  On surface of stool & paper  After defecation

Rectosigmoid

Darker red blood  With clots  Surface of stool and mixed

1. Diverticular disease 2. Rectal tumours o Benign or malignant 3. IBD 4. Proctocolitis

Proximal colonic

Dark red blood  Mixed into stool  Altered blood

1. Diverticular disease 2. Colonic tumours o Benign or malignant 3. Ischaemic colitis 4. Angiodysplasia 5. NSAID – induced ulceration  Massive upper GI bleeds  Aorto-enteric fistula  Small bowel tumours o Associated with significant haemodynamic instability

Upper GI

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Melena Or dark red blood

1. 2. 3. 4.

Differentials Haemorrhoids Acute anal fissure Distal proctitis Rectal prolapse

Peri-Anal Disease Complications occurring in the rectum and anus Significantly more common in people with Crohn’s and Ulcerative colitis o Often the first signs of IBD

1. Abscess & Fistulas o Abscess – area of inflammation, where pus collects o Fistula – abnormal connection between two epithelial structures  Presence of fistulous tract across / between / adjacent to the anal sphincters  Discharge, pain, incontinence  Can lead to abscess formation 2. Anal fissure o Tear or split at the end of the anal canal

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3. Skin tags o Narrow growth that sticks out of the skin o Can be large, swollen and hard or flat, soft and painless 4. Stricture o Narrowing of a section of digestive tract o Anal stricture = spasm of sphincters o Rectal stricture = build-up of fibrous tissue  Made up of collagen and fibronectin  Repair damage caused by ulcerations, abscesses, fistulas or inflammation 5. Haemorrhoids o Disrupted and dilated anal cushions o Anal cushion – discontinuous masses of spongy vascular tissue lining the anus o Prone to displacement and rupture o The effect of gravity, increased anal tone and straining make them become both bulky and loose  Form piles o Vulnerable to trauma (stools) o Bleed readily from the capillaries in the underlying lamina propria 1st degree 2nd degree 3rd degree 4th degree

Remain in the rectum Prolapse through the anus on defecation  However spontaneously reduce As for 2nd degree  However, require digital reduction Remain persistently prolapsed

External haemorrhoid  Origin below the dentate line  External rectal plexus Internal haemorrhoid  Origin above the dentate line  Internal rectal plexus Mixed haemorrhoid  Origin above and below the dentate line  Both rectal plexuses Dentate line (pectinate line) = divides the upper 2/3rds and lower 1/3 of the anal canal  Location of anal valves  Anything above the line is painless Treatment 4

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Medical

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Non-operative

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Surgery

1st degree  Increase fluid and fibre  Topical analgesia  Stool softener (bulk forming) nd 2 and 3rd degree / failed 1st degree  Rubber band ligation  Scleroscants – produce fibrotic reaction  Infra-red coagulation  Excisional haemorrhoidectomy o Excision of piles ± ligation of vascular pedicles  Stapled haemorrhoidectomy o For prolapsed haemorrhoids o In cases with large internal component

Diverticular Disease 

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Diverticulum o Outpouching of the gut wall o Usually at the site of entry of perforating arteries Diverticulosis o Diverticula are present Diverticular disease o Diverticula are symptomatic Diverticulitis o Inflammation of a diverticulum

Can be acquired or congenital and may occur elsewhere  Most important are colonic acquired diverticula Pathology  Mostly in the sigmoid colon  95% of complications are this site  Possible to have right sided and single massive diverticula 1. 2. 3. 4.

High intraluminal pressure (lack of fibre) Force mucosa to herniate through the muscle layers of the gut At weak points Adjacent to penetrating vessels

Diagnosis  Most are asymptomatic  Common incidental finding on colonoscopy o Risk of perforation  CT abdomen o Best to confirm acute diverticulitis 5

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o Identify extend of disease & complications Abdominal x-ray o Identify obstruction o Identify free air = perforation Diverticular disease Altered bowel habit Left sided colic Nausea Flatulence Relieved by defecation

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Diverticulitis Altered bowel habit Left sided colic Nausea Flatulence Relieved by defecation + Pyrexia Increased WCC Raised CRP/ESR Tender colon ± localized or general peritonism

Treatment  Diverticular disease o High fibre diets do not help symptoms o Anti-spasmodics e.g. mebeverine  Diverticulitis o Mild attacks = bowel rest  fluid only ± antibiotics o On admission = analgesia, NMB, IV fluid and antibiotics Complications 1. Perforation o Ileus o Peritonitis o ± shock 2. Haemorrhage o Sudden and painless o Rectal bleeding 3. Fistulae o Enterocolic o Colovaginal / Colovesical 4. Abscess 5. Post infective strictures o Sigmoid colon

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Angiodysplasia Formation of arteriovenous malformations between previously healthy blood vessels Most common = caecum & ascending colon Prevalence = 1-2% 2nd most common cause of rectal bleeding >60

Pathophysiology Acquired 1. Reduced submucosal venous drainage in the colon 2. Due to chronic and intermittent contraction of the colon 3. Resulting in tortuous and dilated veins 4. Loss of pre-capillary sphincter competency 5. Formation of small arterio-venous communications 6. Characterized by a small tuft of dilated vessels

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Congenital 1. Hereditary haemorrhagic telangiectasia o Spider veins o Widened venules o Thread like pattern on skin 2. Heyde’s syndrome o GI bleeding from angiodysplasia in the presence of aortic stenosis

Proctitis Inflammation of the lining of the rectum

Aetiology 1. STIs 2. IDB 3. Bacterial infections – salmonella / shigella / C. difficile (post-antibiotics) 4. Post radiation – ovarian / anal / rectal / prostate cancer Symptoms 1. Tenesmus o Frequent urge to have a bowel movement o Caused by inflammation and irritation of the rectal lining 2. Pain 3. PR bleeding 4. Mucous / discharge 5. Loose stools 6. Watery diarrhoea

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Meckel’s Diverticulum Congenital defect – outpouching o True diverticulum – all layers of the GI tract are present in its walls Distal ileum o 75% occur within 60cm of the ileo-caecal valve Due to fibrous degeneration of the omphalomesenteric (vitelline) duct o The duct connects the yolk sac to the midgut through the umbilical cord o Typically obliterated in the 5-8th week of gestation Symptoms usually occur in 1st year of life

Symptoms  GI bleeding – seen in stool o Due to ulcer in the small intestine that secretes stomach acid  Abdominal pain / cramping  Umbilical region tenderness  Bowel obstruction o Bloating / constipation / diarrhoea / vomiting  Diverticulitis o Meckel’s diverticulitis

Ischaemic colitis  Inflammation of the colon secondary to vascular insufficiency and ischaemia  Elderly individuals o Atherosclerotic disease o Low flow states  Young individuals (rare) o Vasculitis o Hypercoagulable states (venous thrombosis) Presentation  Abdominal pain  Bloody stools Severe cases with necrosis & perforation = peritonitis Pathology  Diminished or absent blood flow = bowel wall ischaemia and secondary inflammation  Bacterial contamination = superimposed pseudomembranous inflammation  Necrosis = ulcerations or perforations  Acute event = fibrosis may lead to strictures of the bowel lumen

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Aorto-Enteric Fistula  Pathological communications between the aorta (or aorto-iliac tree) and the GI tract o Uncommon cause of severe GI bleeding  Primary  associated with complicated AAA  Secondary  associated with graft repair Presentation 1. Initially, minor GI haemorrhage 2. Later, life-threatening GI haemorrhage 3. Primary aorto-enteric fistula  recurrent septicaemia with enteric pathogens Pathology 

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Primary When large abdominal aortic aneurysms closely abuts bowel loops o Usually 3rd/4th part of duodenum o Due to low standing pressure the  aneurysm slowly erodes the bowel wall

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Secondary Complications of aortic reconstructive surgery o ± placement of aortic stent graft

PR bleeding - Acute Management Plan 1. ABC o Resuscitation if necessary 2. History and examination o Full GI history & exam 3. Blood tests Bedside 1 FOB 2

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Lactate

ECG

Haematology 1 FBC

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U&E

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LFTs

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GI bleeding Benign / malignant tumours Evaluation of sepsis Meningitis Signs of hypoxia – SOB / rapid breathing / paleness / muscle weakness Shock / Heart attack / severe congestive heart failure If hypotensive

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Anaemia – haemorrhage / bleeding Infection Coagulation disorder Renal function Before CT contrast is administered Alanine aminotransferase (ALT) – an enzyme mainly found in the liver  hepatitis Aspartate aminotransferase (AST) – an enzyme found in the liver and a few other places o Heart and other muscles Total bilirubin – total bilirubin pigment in the blood Conjugated bilirubin - bilirubin made only in the liver o Often requested with total bilirubin in infants with jaundice Alkaline phosphatase (ALP) – an enzyme related to the bile ducts o Often increased when they are blocked, either inside or outside the liver Albumin – Tells how well the liver is making this protein Total protein - measures albumin and all other proteins in blood o ncluding antibodies made to help fight off infections

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Clotting Amylase

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CRP Group & hold

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Radiology 1 Abdominal x-ray 2 Erect x-ray

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Await Hb result before cross matching unless unstable and bleeding

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CT mesenteric angiogram

Special Tests 1 Colonoscopy 2 OGD

Reduced coagulation factors Pancreatitis Blocked pancreatic duct

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If signs of perforation o Sepsis o Peritonitis  CT (contrast) guided x-ray of the mesenteric blood vessels 1. Identify site of GI bleeding o Possible to embolise vessel during procedure o Mesenteric embolization 2. Identify abnormalities of blood vessels o Narrowing / blockages

Oesophago-gastro-duoden-oscopy o Gastroscopy / endoscopy o Examines as far as duodenum

4. Fluid management o Insert two cannulas (>18G) into the antecubital fossae o Insert urinary catheter  If suspicion of haemodynamic compromise o Crystalloid as replacement and maintenance intravenous infusion (IVI) o Blood transfusion  Only if significant blood loss 5. Antibiotics o Required if evidence of sepsis / perforation o Tazobactam / piperacillin (4.5g/8h IV) 6. Clotting o With hold o ± reverse anti-coagulation & antiplatelet agents 7. Surgery o Indicated if unremitting, massive bleeding that is not controlled by other means

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