Makindo Medical Notes

Related Subjects: | Ulcerative Colitis | Microscopic Colitis | Irritable Bowel Syndrome | Lower GI Bleeding

💉 PR bleeding within 24 h of admission + Hb drop ≥2 g/dL and/or transfusion ≥2 units = 🚨 emergency → requires urgent diagnosis & intervention. ⚠️ Always consider an upper GI source if unstable with haematochezia.

🩺 Initial Management (Resus First!)

• 🏥 Admission: In the UK, admit under Lower GI Surgery (with gastro input). Bleeds can deteriorate fast → senior surgical oversight is key.
• 🫁 Airway & Breathing: High-flow O₂ if hypoxic. Intubate if airway protection needed (rare in LGI bleed but consider in shock/encephalopathy).
• 💉 Circulation: 2 wide-bore cannulae. Send bloods: FBC, U&E, clotting, LFT, CRP, group & save/crossmatch. Begin IV crystalloids. 🚨 Activate major haemorrhage protocol if ongoing shock.
• 🩸 Transfusion: PRBCs guided by Hb (aim >70 g/L, >80–90 if elderly/cardiac). Balanced transfusion if massive bleed. Reverse anticoagulants (vit K, PCC, idarucizumab, andexanet as appropriate).
• 📊 Monitoring: Continuous vitals, urine output, stool chart, Hb 4–6 hourly. Involve ITU if unstable.

🔧 Investigations & Interventions

• 📷 Colonoscopy (within 24 h if stable) → diagnostic + therapeutic (clips, diathermy, adrenaline).
• 🧲 CT Angiography → first-line in unstable bleeds (localises active site, guides IR embolisation).
• 💉 Interventional Radiology → embolisation highly effective if source localised.
• 🔪 Surgery → subtotal colectomy in exsanguination or refractory bleeds, but high risk in frail patients.

📖 About Lower GI Bleeding

• Bleeding distal to the ligament of Treitz.
• Commonest in elderly and anticoagulated patients.
• Mortality ~2–4% (lower than UGIB but significant in frail elderly).
• ⚠️ If source unclear → OGD or capsule endoscopy may be needed.

⚠️ Risk Factors for Severe Bleeding

• 💊 NSAIDs / anticoagulants
• ≥2 comorbidities
• Pulse >100 bpm
• SBP <115 mmHg
• Age >70 years
• Intestinal ischaemia

🧾 Causes (Mnemonic = DRAIN IT)

• 🩸 Diverticular disease – painless, brisk bleeds.
• 🍑 Rectal causes – haemorrhoids, fissures, anal cancer.
• 🧪 Adenocarcinoma (colorectal cancer).
• 🔥 Inflammatory – UC, Crohn’s, ischaemic colitis.
• 🌱 Neovascular (angiodysplasia, AVMs).
• 💉 Iatrogenic – post-polypectomy, anticoagulation.
• 🤕 Trauma (rare, e.g. foreign body).

🔎 Clinical Features

• 💉 Bright red PR bleed ± clots → distal source (diverticula, haemorrhoids).
• 🩸 Bloody diarrhoea → IBD, ischaemic colitis.
• 🤕 Pain + bleed → fissure, ischaemia.
• ⚠️ Cachexia/anaemia → malignancy.
• 🚨 Shock → severe ongoing bleed.
• 🔍 Rectal exam essential: haemorrhoids, fissure, mass, blood.
• 🔎 Hx AAA → think aortoenteric fistula.

📋 Common Causes Table

🧪 Investigations

• 🩸 Bloods: FBC, U&E, LFTs, clotting, group & save / crossmatch.
• 📷 Colonoscopy (gold standard if stable).
• Sigmoidoscopy for distal lesions.
• Proctoscopy for anorectal pathology.
• CT Angio → unstable or uncontrolled bleed.

⚕️ Management Summary

• 🚑 Resuscitate first → IV fluids, blood, correct clotting.
• 📞 Early surgical + IR involvement in severe bleeds.
• 📷 Colonoscopy within 24 h (if stable).
• 🧲 CT Angio → unstable or recurrent severe bleeds.
• 💉 IR embolisation if localised source found.
• 🔪 Surgery → refractory/uncontrolled bleeds or ≥4–5 units transfused in 24 h.
• 📌 Post-stabilisation: address underlying cause (IBD, malignancy, diverticulosis).

💡 Teaching Pearls:
– Painless massive bleed = diverticulosis / angiodysplasia.
– Painful bleed = fissure, IBD, ischaemia.
– Haematochezia + shock = may still be an upper GI bleed (do OGD).
– Always correct coagulopathy (warfarin/DOAC reversal).
– Frail elderly at greatest risk of decompensation.

📚 References

• Lower GI Bleeding: Epidemiology & Management
• ACG Guideline: Acute Lower GI Bleeding