COLORECTAL BLEEDING: A MULTIDISCIPLINARY

APPROACH

Colon and Rectum : Benign SourcesColon and Rectum : Benign Sources

Luigi Bucci

Colon and Rectum: Benign SourcesRadiation Colitis/Proctitis

Colon and Rectum: Benign SourcesRadiation Colitis/Proctitis

Difficult to describe the real incidenceDifficult to describe the real incidence

• Evaluation of patients with lower gastrointestinal haemorrhage is variable and institution-specific

– Age

– Severity

– Elective vs Urgency Admission

– Institution availability of a bleeding team

• As many as 5.6 to 20% remain obscure

These different results are related to “conventional examinations”

• Nature of bleeding influences its incidence and management as well

Colon and Rectum : Benign Sources

1 Minor bleeding

2 Chronic Intermittent bleeding

3 Severe bleeding episodes with

haemodynamic stability in

between episodes

4 Continual active bleeding

Differential Diagnosis of Colorectal Bleeding

Diverticular disease

Inflammatory Bowel Disease

Infectious colitis

Neoplasms

Coagulopathy

Arteriovenous malformations

Radiation proctitis/enteritis

Adults

Differential Diagnosis of Colorectal Bleeding

Adults

< 60 years > 60 years

Diverticulosis Vascular ectasias

Malignancy Diverticulosis

Polyps Malignancy

Inflammatory Bowel Disease

Inflammatory Bowel Disease

Colon and Rectum: Benign Sources

Farrell JJ, Friedman LS - Review article: the management of lower gastrointestinal bleeding.Aliment Pharmacol Ther. 2005 Jun 1;21(11):1281-98. Review.

Differential Diagnosis of Colorectal Bleeding

Intussusception

Polyps and Polyposis Syndromes

Inflammatory Bowel Disease

Meckel diverticulum

Children and Adolescents

Colon and Rectum: Benign SourcesDiverticular Disease

- A mean of 17% of patients with colonic diverticulosis experience bleeding

- Diverticular bleeding may range from minor to life-threatening

- Altough diverticular disease affects the left colon, bleeding from right colon is more common and usually severe

- As many as 80 to 85% of diverticular haemorrhages stop spontaneusly

Colon and Rectum: Benign SourcesDiverticular Disease

The rate of recurrent bleeding is 9% at 1 year, 10% at 2 years, 19% at 3 years and 25% at 4 years (Longstrth GF, 1995)

-The risk of re-bleeding after a second diverticular harmorrhage exceeds 50%

- About 35% of patients require transfusion or invasive diagnostic/therapeutic evaluation

- About 5% require emergency operation

Colon and Rectum: Benign SourcesArteriovenous malformations

Moore’s classification

- Type I Large bowel (ascending colon) Elderly patients

- Type II Small bowel Young patients

- Type III Multifocality Association with cutis and mucosae Children Rendu-Osler-Weber syndrome

• Related to age, angiographic findings and familiar history

• Camilleri based his classification on pathological findings

Colon and Rectum: Benign SourcesArteriovenous malformations

- Arteriovenous malformations include vascular ectasias, angiomas, and angiodysplasias

- Angiodysplasias are acquired abnormalities caused by chronic intermittent partial obstruction of submucosal veins from colonic muscle wall contraction

- Angiodysplasias involve most commonly the right colon

- There is an association between bleeding and calcific aortic stenosis, quality platetet abnormalities and dialisis

Colon and Rectum: Benign Sources

Angiodysplasias

- Massive hemorrhage occur in 15% of patients

- Patients with colonic angiodysplasia may present with hematochezia (0-60%), melena (0-26%), hemoccult positive stool (4-47%) or iron deficiency anemia (0-51%)

- Up to 90% of patients there is a spontaneous cessation of bleeding

- Re-bleeding occur in 25-85% of patients

Colon and Rectum: Benign SourcesInflammatory bowel disease

- Massive haemorrhage is unusual

- Aestimates are 0.9-6% (Robert JR, 1991)

- Bleeding stops spontaneously in about 50% of patients

- About 35% of patients experience rebleeding after a spontaneous cessation

- Rarely the rectum is the site of the main bleeding

Colon and Rectum: Benign SourcesIschemic colitis

Colon and Rectum: Benign SourcesRare causes

Solitary rectal and colonic ulcer

- Rectum Related to digitation, stress, prolapse (?)

- Colon chronic drug abuse, HIV, peptic colon ulcer, colonic stasis, local ischemia, atherosclerosis, Strongyloidasis, portal hypertension (?)

Colon and Rectum: Benign Sources Portal colopathy

Colon and Rectum: Benign SourcesCoagulopathy

• It is unclear whether spontaneous gastrointestinal bleeding occurs without identifiable lesions

• Platelet count of ≤ 20.000/mm3 seems to be responsible for 50% of significant gastrointestinal bleeding in patients with acute leukemia

• Gastrointestinal haemorrhage in patients while taking heparin or warfarin had a similar distribution as general population

• Diagnostic algorythm is the same as patients with normal coagulation and include specific treatment of coagulation abnormality

Colon and Rectum: Benign SourcesRare causes

Infectious colitisInfectious colitis

- Bacteria (Campylobacter, E. Coli, Myc. Tuberculosis)

- Protozoa (Entoamoeba hystolitica)

- Viruses (CMV)

- Helmints (Scistosoma, Trichuris)