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LOWER GASTROINTESTINAL
BLEEDING IN THE ELDERLY
Attapol Manatsathit, M.D.
Outline
Incidence
Definition
Causes
Management
Prognosis
Conclusion
Lower GI bleeding (LGIB)
Account for 15-20% of GI bleeding
Much less frequent than UGIB
Increase with age acquired lesion in the colon
15% of UGIB may present with haematochezia
Unidentified source of bleeding in approximately 5 % of
patients.
Am J Gastroenterol. 1997 Mar;92(3):419-24.
Langenbecks Arch Surg. 2001 Feb;386(1):8-16.
Incidence
Causes Incidence (%)
Diverticulosis 30-60
Angiodysplasia 4-15
Haemorrhoids 4-12
Ischaemic colitis 4-11
Other colitis 3-15
Tumour and malignancy 2-11
Post-polypectomy 2-7
Solitary rectal ulcer syndrome 0-6
Dieulafoy’s lesion Rare
Rectal varices Rare
ต ำรำเลือดออกในทำงเดินอำหำร, 2553.
Clin Gastroenterol Hepatol. 2004 Jun;2(6):485-90.
Lower GI bleeding (LGIB)
> 200 fold increase in the incidence f of LGIB from 3rd to
9th decade of life
64% of patients: > 70 years of age
Men and women equally affected
Elderly people with LGIB incur longer hospital stays and
greater health care costs.
Am J Gastroenterol. 1997 Mar;92(3):419-24.
Dis Colon Rectum. 1975 Jan-Feb;18(1):37-41.
Can J Gastroenterol. 2002 Oct;16(10):677-82.
Dig Dis Sci. 2005 May;50(5):898-904.
MORTALITY
Can J Gastroenterol. 2002 Oct;16(10):677-82.
Definition
Upper GI bleeding (UGIB)
มีต ำแหน่งเลือดออกตั้งแต่หลอดอำหำร กระเพำะอำหำร จนถึงล ำไส้เล็กส่วนท่ีอยู่เหนือต่อ ligament of Treitz
Lower GI bleeding (LGIB)
มีต ำแหน่งเลือดออกตั้งแต่ล ำไส้เล็กส่วนท่ีอยู่ต่ ำกว่ำ ligament of Treitz ล ำไส้ใหญ่ rectum จนถึงปำกทวำรหนัก
Obscure GI bleeding (OGIB)
ภำวะเลือดออกในทำงเดินอำหำรที่ไม่สำมำรถหำต ำแหน่งของเลือดออกได้ชัดเจนทั้งจำกกำรส่องกล้องหรือภำพถ่ำยรังสีของล ำไส้เล็ก
ต ำรำเลือดออกในทำงเดินอำหำร, 2553.
Gastroenterology. 2007 Nov;133(5):1697-717.
New definition
Upper GI bleeding
Oesophagus to ampulla of
Vater
Mid GI bleeding
Ampulla of Vater to
terminal ileum
Lower GI bleeding
Colonic bleeding
Gastroenterology. 2007 Nov;133(5):1697-717., Endoscopy. 2006 Jan;38(1):73-5.
Clinical presentation
• Overt GI bleeding
Passing of blood per rectum
Red blood
Maroon stool
Melaena
Occult GI bleeding
Positive faecal occult blood test (FOBT)
Iron deficiency anaemia
ต ำรำเลือดออกในทำงเดินอำหำร, 2553.
Causes
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Diverticulosis
A sac-like protrusion that herniates through the colonic
wall through the spaces weakened by the vasa recta.
Incidence increases with age.
5% at age 40 65% at age 85
Can be found in small intestine obscure GI bleeding
Lancet. 2004 Feb 21;363(9409):631-9.
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Diverticulosis
90% of colonic diverticula are in the left colon.
50%-90% of diverticular LGIB occurs from right-sided
colonic diverticula.
Most patients are asymptomatic.
LGIB occurs in 3-5% of patients with diverticular disease.
Lancet. 2004 Feb 21;363(9409):631-9.
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Langenbecks Arch Surg. 2001 Feb;386(1):8-16.
Langenbecks Arch Surg. 2001 Feb;386(1):8-16.
Diverticulosis
Factors increased injury
NSAIDs
Hard stool stercoral ulcer
Usually presents as acute, painless haematochezia
Usually ceases spontaneously, but may be severe in elderly
Comorbid diseases
Use of anticoagulants or NSAIDs
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Langenbecks Arch Surg. 2001 Feb;386(1):8-16.
Recurrent risk
Am J Gastroenterol. 1997 Mar;92(3):419-24.
Angiodysplasia
Intestinal vascular ectasia, angioectasia
A degenerative lesion of previously normal blood vessels
May occur anywhere in the colon
Profound at caecum and right colon (56-100%)
0.1- to 1-cm dilated submucosal veins, venules, or
capillaries
Tortuous, thin walled vessels lined mostly by endothelium
Rarely exhibit smooth muscle in the walls
Arch Intern Med. 1995 Apr 24;155(8):807-12.
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Angiodysplasia
Patients are usually more than 60 years of age at
presentation.
Majority are in their 7th or 8th decade of life.
Low grade, painless bleeding with recurrence
Majority: spontaneously ceased
15% of patients can have massive bleeding.
Arch Intern Med. 1995 Apr 24;155(8):807-12.
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Angiodysplasia
An important cause of haemorrhage in patients with
chronic renal failure
Platelet dysfunction in uraemia
Use of ASA
Use of heparin with haemodialysis
Arch Intern Med. 1995 Apr 24;155(8):807-12.
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Angiodysplasia vs. diverticulosis
Angiodysplasia Diverticulosis
Nature of bleeding Venous Arterial
Recurrence Less massive at any 1 time;
more likely to recur; ≥ 3
episodes in 80%
Usually more severe; less
likely to recur; ≥ 3
episodes in 30%
Angiography Bleeding site seen in 6-20%;
vascular tuft and/or early
filling of large vein is seen
Bleeding site seen in 35-
75%; no vascular tuft or
early filling of vein is seen
Site of bleeding Almost always right colon
(97-100%)
Majority are in right colon
(45-65%)
Associated diseases Reported increased
association with
cardiovascular disease
No predominant
association
Arch Intern Med. 1995 Apr 24;155(8):807-12.
Ischaemic colitis
An acute, self-limited compromise in intestinal blood flow
accounts for 3% to 9% of LGIB in the elderly
Colonic atherosclerosis is almost universal in the elderly
and predisposes to ischemic colitis.
Mesenteric artery emboli, thrombosis, or trauma
Mesenteric Hypoperfusion e.g. CHF, shock
History of a hypotension supports the diagnosis.
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
World J Gastroenterol. 2008 Dec 28;14(48):7302-8.
Ischaemic colitis
Lower abdominal cramp followed by haematochezia or
bloody diarrhoea
Watershed areas of the colon
Right-sided colon
Splenic flexure
Recto-sigmoid junction
complicated by perforation or stricture
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
World J Gastroenterol. 2008 Dec 28;14(48):7302-8.
Inflammatory diseases of the colon
Infectious colitis
< 10% of patients with bloody stool
Campylobacter
Salmonella, Shigella
E. coli O157: H7 TTP
Clostridium difficile (long-term care facility, hospital, Hx of antibiotic
use)
Inflammatory bowel diseases
Bimodality with 2nd peak at 60-70 years of age
15% of patients develop symptoms at age > 65 years
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Stercoral ulcer & solitary rectal ulcer
syndrome
Stercoral ulcer
Hard impacted stool in the rectum
Manipulation
Foreign body injury e.g. rectal tube placement
Solitary rectal ulcer syndrome
Rectal prolapse
Constipation
Straining
Gastroenterol Clin North Am. 2009 Sep;38(3):541-5.
Neoplasms
10% to 20% of cases of LGIB
Often present as a change in stool frequency, stool caliber
or weight loss
Initial presenting symptom in up to 26% of patients with
colorectal neoplasms
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Rev Esp Enferm Dig. 2011 Aug;103(8):408-15.
Seminars in Oncology. 2004 Apr; 31(2):206-219.
Post-radiation colitis & proctitis
Higher incidence of malignancy requiring radiation
Prostate cancer
Gynaecologic malignancy
Genito-urinary cancer
Can be acute or develop years after treatment has ended
Treatment
Argon plasma coagulation
Formalin application
Sucralfate enema
Hyperbaric oxygen therapy
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Clin Colon Rectal Surg. 2007 Feb;20(1):64-72.
Post-polypectomy bleeding
The incidence of colonic polyps and thus the necessity of
colonoscopic polypectomy rises with advancing age.
LGIB is a complication of colonoscopic polypectomy in
approximately 0.7% to 2.5% of cases
More commonly follows sessile polyp removal
Haematochezia soon after the procedure, but can develop
up to 1 week
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Haemorrhoids
Prevalence decreases with age
Intermittent low-volume haematochezia, which often
coats the stool
Haemorrhoids
Colonic pseudo-obstruction
Constipation
LGIB
Stercoral ulcer &
solitary rectal
ulcer syndrome World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Evaluation
History
Complicated by the
presence of visual,
auditory and cognitive
impairment
May be necessary to call
the primary care provider,
caregiver and perhaps
even the pharmacist
Extent of bleeding
Duration of symptoms,
Presence of co-morbid
disease
Prior surgical history
Drug allergies
Recent and current use of
medication (clopidogrel,
warfarin and NSAIDS)
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Evaluation
Physical examination
Orthostatic hypotension
20-40% of blood loss
Signs of cardiopulmonary
compromise
Chronic liver stigmata
Evidence of coagulopathy
Digital rectal examination
Proctoscopy
MMSE (optional)
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Evaluation
CBC
Metabolic profile
Group match
Coagulogram
Electrocardiogram
CXR
Faecal occult blood test
Cardiac enzyme
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Identification of bleeding site
Colonoscopy
Radionuclide scan
Abdominal angiography
Wireless capsule endoscopy
Push enteroscopy
Double-balloon enteroscopy
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Colonoscopy
Urgent colonoscopy performed within 24 h of
hospitalization following a rapid purge is the best test for
evaluation of LGIB, once the patient has been resuscitated
and haemodynamically stabilised.
Accuracy 72-86%
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Age Ageing. 2005 Sep;34(5):510-3.
225/247 patients with colonoscopy
Age > 80 years
Only 1 patients with complication (perforation)
Endoscopy. 2006; 38 (3): 226-230.
Complication rate = 0.2% in each group
Am J Gastroenterol. 2005;100:2395–2402.
RBC scan & abdominal angiography
Can be performed where colonoscopy is not feasible due
to massive bleeding
For visualising the bleeding source
RBC scan: bleeding rate 0.1 to 0.5 mL per minute
Abdominal angiography: bleeding rate > 1 mL per minute
Accuracy
RBC scan: 24-78%
Abdominal angiography: 27-77%
Am J Surg. 2007 Mar;193(3):404-7.
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
RBC scan & abdominal angiography
Bleeding cannot be ruled out when these tests are
negative.
Am J Surg. 2007 Mar;193(3):404-7.
Rebleeding rate 27%
Management
Adequate resuscitation and haemodynamic stabilisation
are cornerstones.
In the majority of cases, LGIB stops spontaneously with
appropriate resuscitation and supportive care.
The timing of tests and the type of intervention should be
custom tailored
Patient’s functional status
Impact on clinical outcome
Available diagnostic strategies
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Issues to be concerned in the elderly
Intervention should not be withheld because of age alone.
Older patients are more likely to have cardiac pacemakers with or without defibrillators.
Consultation with cardiologist
Driven to automatic pacing by placing a magnet on the skin overlying the device whenever monopolar electrosurgical devices are used
Continuous ECG monitoring during the procedure
Initial dosage of sedative drugs should be lower and titration should be more gradual.
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Treatment modalities
Colonoscopy
Thermal coagulation
Band ligation
Metallic clips
Epinephrine injection
Sclerosing agent injection
Fibrous glue
Abdominal angiography
Vasopressin infusion
Embolisation
Surgery
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Algorithm
Arch Intern Med. 1995 Apr 24;155(8):807-12.
Poor prognostic factors
Unstable haemodynamics
Continuous
haematochezia
Older age
Comorbid diseases
LGIB in hospitalised
patients
On antiplatelet or
anticoagulant
No abdominal sign
Anaemia (Hct < 35%)
High serum Cr
leucocytosis
ต ำรำเลือดออกในทำงเดินอำหำร, 2553.
World J Gastrointest Endosc. 2010 May 16;2(5):147-54.
Conclusion
LGIB is a significant worldwide cause of increased
morbidity and mortality in the elderly.
The incidence of LGIB increases with age and
corresponds to the increased incidence of specific
gastrointestinal diseases.
Comorbid diseases
Polypharmacy
In the majority of elderly patients with LGIB appropriate
evaluation and management will lead to a successful
outcome.
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