A study on pattern of lower gastrointestinal tract bleeding

A STUDY ON PATTERN OF LOWER

GASTROINTESTINAL TRACT BLEEDING

Dissertation submitted to

The Tamilnadu Dr.MGR Medical University, Chennai In partial fulfillment for the award of

M.S. BRANCH – I

General Surgery

Departmental of General Surgery

DECLARATION

I hereby declare that the Dissertation titled on “ A STUDY

ON PATTERN OF LOWER GASTROINTESTINAL TRACT

BLEEDING” was entirely done by me, under the guidance of Prof. Dr.

P.S. SHANTHI, M.S at Government Royapettah Hospital, in partial

fulfillment of regulation for MS General Surgery Degree Examination

of TamilNadu Dr.M.G.R. Medical University to be held in May 2018.

Place : Chennai

BONAFIDE CERTIFICATE

This is to certify that the dissertation titled “A STUDY ON PATTERN

OF LOWER GASTROINTESTINAL TRACT BLEEDING” is the bonafide

original work of Dr.SWATHI PRAKASH.J in partial fulfillment of the

requirements for M.S BRANCH - I (General Surgery) Examination of the

TamilNadu Dr.M.G.R Medical University to be held in MAY 2018. The period

of study was from January 2017 to September 2017.

Prof. Dr. P.S. SHANTHI M.S Prof. Dr. R.KANNAN M.S Associate Professor, Head of Department,

Department of General Surgery, Department of General Surgery Govt. Royapettah Hospital, Kilpauk Medical College, Kilpauk Medical College, Chennai.

Chennai.

Prof.Dr.P.VASANTHAMANI, M.D.,D.G.O.,MNAMS.,MBA, DEAN

ACKNOWLEDGEMENT

My sincere thanks to Dean, Prof.Dr.P.VASANTHAMANI,

M.D.,D.G.O.,MNAMS.,MBA, Kilpauk Medical College and Hospital for permitting

me to conduct this study in Government Royapettah Hospital, Chennai.

I am extremely thankful to Prof. DR.R.KANNAN M.S Professor and Head of the Department of General Surgery for his valuable guidance, help and kindness throughout this study.

I am deeply indebted to my respected Chief Prof. P.S.SHANTHI M.S. Associate Professor for his immense support, expert opinion and encouragement during the course of my study.

I also thank the Registrar of Department of Surgery Dr.S. SAVITHA.

M.S., who helped me to progress through this study with great interest

I record my heartfelt gratitude to my beloved Assistant Professors

Dr.DHARMARAJAN M.S,. Dr.SURESH BABU M.S. , Dr.KENNY ROBERT, M.S., and for their wholehearted support, valuable suggestion and kindness in completing this dissertation.

I am particularly thankful to my fellow post graduate colleagues Dr. RASU, Dr. LINGESH, Dr. KATHIRVEL, Dr. GOPI, Dr. NARESH KUMAR and friends for their valuable to all the staff members who have made this study possible.

Above all I profusely thank all the patients who have submitted themselves for this study and made it successful.

ABSTRACT

AIM

To study the clinical pattern of lower gastrointestinal tract bleeding

BACKGROUND

Lower gastrointestinal bleeding(LGIB) accounts for approximately 20-33% of

episodes of gastrointestinal haemorrhage. LGIB is statistically less common than

upper gastrointestinal bleeding(UGIB), it has been suggested that LGIB is under

reported because a higher percentage of affected patients do not seek medical

attention. Despite the fact that Bleeding per Rectum is a common complaint in day to

day practice, every attempt should be made to exclude the underlying pathology at

an early stage. Often patients are symptomatically treated without diagnosing the

underlying cause. A Recent study on the clinical pattern of Lower Gastrointestinal

bleeding has not been done. This Study would help in understanding the clinical

pattern of Lower Gastrointestinal bleeding by their endoscopic evaluation for further

management. Colonoscopy is a less complicated and available diagnostic tool that

MATERIALS AND METHODS

The study was conducted in 9 Months in the Department of General Surgery,

Surgical Gastroenterology and Medical Gastroenterology in Govt. Royapettah

Hospital in 119 patients with colonoscopic evaluation, histopathological reports

and data collected as per proforma. The inclusion criteria are Acute Massive

bleeding, Painless intermittent bleeding, Fresh bleeding mixed with stools,

Bleeding per Rectum associated with altered bowel habits, mass abdomen,

weight loss and anemia & Malena without any obvious cause for Upper GI

bleed. The exclusion criteria are Patients presenting with obvious cause of

Upper GI bleed, Patients with bleeding disorders & Patients on anti platelet

drugs. Data analysis was done with 95% confidence interval

RESULTS

A total of 119 patients were included in the study and the following statistical

data is obtained. Excluding haemorroids, Neoplasia of the colon and rectum forms

the most common etiology of lower GI bleed (37%) and inflammatory bowel diseases

forms 14 %. Although no age is exempted majority of patients belongs to 20-60

disease incidence varied grossly, with major etiology for LGI bleed in this study

are anorectal disease ,Neoplasia and Inflammatory bowel disease, but in

western statistics , Diverticulosis and Angiodysplasia are the leading causes.

CONCLUSION

In contrast to western literature, in this study the commonest cause of

Lower GI bleed is colorectal Neoplasia excluding haemorroids Inflammatory bowel

disease especially ulcerative colitis is the second common cause of Lower GI

Bleed.Accuracy of colonoscopy in diagnosing the etiology approached 96 percent,

as only 4 percent of patients remained undiagnosed (patient with positive UGI

Scopy and normal colonoscopy already excluded). Majority of the causes for LGI

bleed are managed conservatively with minimal morbidity and negligible

mortality.Acute bleeding Diverticulitis and Ulcerative colitis are the only two

conditions that warranted emergency surgical intervention.

KEYWORDS

CONTENTS

S.No Title

INTRODUCTION AIM OF STUDY

REVIEW OF LITERATURE

Anatomy of colon and rectum

colonoscopy

Flexible sigmoidoscopy

4. PROFORMA

5 MATERIALS AND METHODS

6. OBSERVATION AND DISCUSSION

7. CONCLUSION

8. BIBLIOGRAPHY

9 MASTER CHART

Page No.

1

2

3

7

12

32

63

65

68

78

80

LIST OF FIGURES

NAME PAGE

SLIDE 1 NORMAL COLONOSCOPIC PICTURE 25

SLIDE 2 CROHNS : MUCOSAL FEATURES 34

SLIDE 3 VASCULAR LESIONS 39

SLIDE 4 AGE AND SEX DISTRIBUTION 70

SLIDE 5 PERCENTAGE OF CASES 72

SLIDE 6 SEX WISE ETIOLOGICAL DISTRIBUTION 73

SLIDE 7 POLYP : ETIOLOGICAL DISTRIBUTION 75

1

LIST OF TABLES

NO NAME PAGE

1 HISTOLOGIC CLASSIFICATION OF POLYPS 45

2 NEOPLASTIC POLYP 46

3 NON NEOPLASTIC POLYP 46

4 COMPLICATIONS AND HAZARDS OF COLONOSCOPY 51

5 ETIOLOGICAL CLASSIFICATION 68

6 DIAGNOSIS, AGE, SEX INCIDENCE OF LOWER GI 69 BLEED

7 COMPARISON WITH WESTERN STUDY 76

INTRODUCTION

Bleeding per Rectum is a common complaint in our daily

clinical practice, every attempt should be made to identify the

2 Hemodynamic assessment and prompt resuscitation should be

the first step in treating those patients with a large-volume blood loss.

Colonoscopy is a tool used for diagnosis. It is less complicated,

affordable and available. It should be performed in all cases of lower

GI bleed.

Acute massive rectal bleeding and malena should be ruled out

by Ryles tube aspiration and upper GI endoscopy which are often due

to upper GI pathology

malena can be associated with lower GI bleed due to prolonged

3

AIM OF THE STUDY

To study the clinical pattern of Lower Gastrointestinal Tract

Bleeding in Government Royapettah Hospital

 Etiological distribution of Lower Gastrointestinal Bleeding

(LGIB)

 Distribution with respect to sex, age and religion

 To emphasize the importance of endoscopic evaluation as an

initial

 investigation modality of LGIB to find the cause at the

earliest

4

REVIEW OF LITERATURE

SYMPTOMS OF LOWER GI BLEEDING :-

Passing pure blood or blood mixed in stool, bright red or maroon

colored blood in the stool.

The normal amount of blood lost from the gastrointestinal tract

ranges from 0.5 - 1.5 ml per day and is typically not detected by faecal

occult blood tests.

1. For guaiac-based occult blood tests to be positive, faecal

haemoglobin must exceed 10 mg/g of stool (i.e. 10 ml of

gastrointestinal blood loss per day or greater).

2. Approximately 60 ml of blood is required to produce a single black

5 Gastrointestinal haemorrhage is divided clinically into upper

gastrointestinal bleeding (i.e. starts above the duodenojejunal flexure)

and lower gastro-intestinal bleeding (i.e. starts from below the

duodenojejunal flexure).

Lower gastrointestinal bleeding usually presents with

haematochezia (passage of red blood) and there will be signs of acute

blood loss. Malena can Occur, due to a prolonged gastrointestinal

transit time, with a lower gastrointestinal blood loss.

Upper gastrointestinal haemorrhage is ruled out by performing

endoscopy in a patient who presents with rectal blood loss (i.e. malena

or haematochezia). It can then followed by sigmoidoscopy or

colonoscopy if no abnormality is found.

Endoscopic management of the diverticular haemorrhage (e.g.

adrenaline injection or bipolar coagulation) prevented recurrent

bleeding thus reducing the need for surgery. Haemoclipping and use of

6

ANGIOGRAPHY

Selective mesenteric angiography is usually of value in patients

with brisk haemorrhage (e.g. > 0.5 - 2 ml/min) and if the diagnosis has

not been established by endoscopy (e.g. the bleeding is below the

duodenojejunal flexure). When colonoscopy fails to identify the

location of diverticular bleeding, or it cannot be controlled via

colonoscopy intervention, angiography should be considered. Unlike

nuclear imaging, angiographic localization of bleeding is accurate.

However, because it requires higher rates of bleeding for a positive

study, it is less sensitive.

Transcatheter intra-arterial infusion of vasopressin or

embolization are utilized to control bleeding if the site can be

identified. Embolization of most distal site possible are attempted to

reduce this risk .

Complication rates are higher for angiography than for

7

LABELLED RBC SCAN.

It is usually performed with chromium-51 labeled red blood cells

and is of value in patients with lower gastrointestinal bleeding.

CONTRAST STUDIES

.

Gastrograffin or barium meal studies are rarely used nowadays in

patients with haematemesis or malena as they are significantly less

accurate than endoscopy in the diagnosis of upper gastrointestinal

lesions and will only detect potential bleeding sites in 50% of patients.

NUCLEAR IMAGING

Other diagnostic procedures may be necessary, especially in

patients with massive LGI bleeding. Nuclear imaging with

technetium-labeled red blood cells or technetium sulfur colloid can be utilized to

8 sensitive than angiography, which generally requires blood loss > 1

ml/min for a positive study. However, nuclear scanning localizes

bleeding to a particular area of the abdomen rather than an area within

the colon. As a result, surgeons should not depend on the localization

of bleeding suggested by these scans.

Colonoscopy is recommended prior to nuclear imaging for

the

evaluation of LGI bleeding because of its higher diagnostic yield

and the inaccuracy of nuclear imaging Despite its continued use in

clinical practice, there is little evidence that nuclear imaging reduces

the morbidity and mortality of patients with LGI.

ANATOMY OF THE COLON AND RECTUM

The intestines are tubular organs that are placed in the abdominal

cavity in a systematic way. The small intestine, transverse colon, and

sigmoid colon are mobile by virtue of attachment to the mesentery.

These segments shift position freely, being limited only by their length

9 Their positions and configurations are uncertain and variable and

are determined by extrinsic factors such as the relationships to

surrounding organs; adjacent segments of intestine or masses, and also

the presence of adhesions or invasion by various pathologic processes;

and the contents of the intestinal segment itself. Frequently, the parts of

the colon with a mesenteric attachment are located close to the

abdominal wall. The ascending and descending segments have no

mesentery and are attached to the retroperitoneal wall; this type of

attachment gives these segments a relatively fixed configuration.

The rectum differs from the aforementioned segments in that it

passes through the pelvic connective tissue from the anus to the

peritoneal reflection. Only a short segment of the proximal rectum is

within the abdominal cavity. Beginning at the anus and following the

course of the colon in a retrograde fashion, the rectum turns posteriorly

at the lower end of the coccyx to lie anterior to the sacrum and follows

the gently curved configuration of this bony structure. After passing

through the peritoneal reflection, the rectum joins the sigmoid colon to

10 patient's left) and the sigmoid colon proper.

The configuration and length of the sigmoid colon are extremely

variable. In joining the descending colon, it often forms a bend that

projects inferiorly and leftward. The descending colon has a relatively

straight course ending at the splenic flexure where there is always an

acute angulation as the colon changes direction abruptly to the right and

anteriorly. In contrast to the course at the splenic flexure, the direction

of the colon is posterior and then inferior at the hepatic flexure.

The configuration of the mobile transverse segment between

these two fixed flexures is variable. The course of the ascending colon

and caecum is almost a straight line. The ileocaecal valve, which marks

the junction of the latter two segments, is usually located on the

medioposterior wall of the colon, and is generally oriented in an

inferior direction. The caecum may vary in length and can occasionally

be mobile. At each junction of the several segments of the colon, the

11 Position of the colon within the

abdomen. Note that the attachments

of various sections alternate between

fixed and mobile.

Endoscopic view

Endoscopically, a regular

arrangement of folds demarcates the haustra or sacculations of the

colon The characteristic segmentation of the colon is produced by the

longitudinal muscle of the bowel.. The taeniae coli are slightly shorter

than the colon proper and therefore account for the sacculated or

haustrated shape of the colon. When visible, the taeniae always run

parallel to the lumen and so indicate its course when this is not readily

evident at a flexure or acute angulation. The taeniae coli have their

origin at the base of the appendix (the appendix has a complete coat of

longitudinal muscle) and may be seen endoscopically as converging at

12 Crescent-shaped folds, termed semilunar folds or interhaustral

septa, also contribute to the pattern of regular segmentation of the colon

that characterizes its endoscopic appearance ,These septa or folds are

sometimes incorrectly termed haustral folds. In the distal segments of

the colon, each fold is circumferential; the septa are usually semilunar

in shape in the proximal colonic segments.

Endoscopically, the folds in the transverse colon form a

triangular pattern that is created by tension in the longitudinal muscle

fibers of the taeniae coli. This appearance is characteristic of the

transverse colon,

The average caliber of the colon is 7.5 cm; the segment with the

greatest diameter is usually the caecum, followed by the ascending

colon and rectum

The mucosal surface is smooth and devoid of villi. Scattered

solitary lymph follicles may be found, especially in the rectum and near

the ileocaecal valve, but these are less numerous than those in the

13 the colon except at the point of attachment to the mesentery; the serosa

is incomplete over the ascending and descending colonic segments,

where they meet the posterior abdominal wall, and over the rectum.

COLONOSCOPY - HISTORY

Endoscopic examination of the colon was introduced into routine

endoscopic practice in the early 1970s. Since then, the colonoscope has

been transformed by improvements in design and construction, and the

technique of colonoscopy has evolved in parallel with these technologic

modifications. In the early 1970s, endoscopic examination of the colon

was considered a special and difficult examination.

Now it is regarded as a standard procedure. It has also become

appropriate to use the term lower panendoscopy rather than

colonoscopy, as it is customary to insert the instrument tip beyond the

ileocaecal valve into the terminal ileum for distances as much 20 to 30

cm. The greater ability and knowledge of colonoscopists coupled with

superior instrument design have led to the use of colonoscopy in lieu of

14

INSTRUMENTS FOR COLONOSCOPY

There are more than 20 fiberoptic and more than 10 videoimage

colonoscopes available commercially. These have different purposes

and capabilities.

Instruments for routine examinations are available in four

insertion tube lengths, approximately 180 cm, 140 cm, 100 cm, and 70

cm. Selection of an instrument depends on the segment of colon to be

examined. The shortest instrument is used for endoscopy of the rectum

and sigmoid colon in most cases; the longest is used for total

colonoscopy and lower panendoscopy.

When the patient has a short sigmoid colon, a medium-length

instrument (140 cm) is usually satisfactory for examination of the

whole colon. Many endoscopists prefer this length of instrument for

most routine examinations of the colon and terminal ileum. However,

routine use of an intermediate-length instrument requires greater

expertise and disciplined technique, with constant efforts to maintain

15 Sometimes, it is not possible to reach into the right side of the

colon with an intermediate-length instrument because the sigmoid

colon is long and redundant or the transverse colon is especially long

and ptotic, or both. For this type of technical problem some

colonoscopists use a stiffening tube

Some colonoscopists also prefer the longer instrument for lower

panendoscopy, especially when the colon is long and redundant. The

technique of colonoscopy does not differ in relation to differences in

the length of available instruments; the technique for insertion is

precisely the same whether the instrument is medium or long.

Most currently available colonoscopes are about 13 mm in

diameter. Certain limitations exist with respect to the manufacture of

colonoscopes; it is difficult to diminish caliber and still maintain

satisfactory tip angulation, image quality, and an accessory channel of

16 All modern colonoscopes have a four-way tip angulation system.

The maximum up/down deflection of the instrument tip is usually 180

degrees. However, if lateral bending of the tip is added after maximum

upward (or downward) deflection, the bending angle of the instrument

reaches 230 degrees. This is more than adequate for most acute

angulations that will be encountered,

Advancement of the instrument when there is a loop in the colon

(and hence the instrument) is referred to as pushing through the loop. A

less flexible or "stiffer" instrument tends to resist loop formation.

The stiffening tube must be placed over the insertion tube of the

colonoscope before beginning the procedure, as it is not possible to do

so after the insertion of the colonoscope. The stiffening tube is drawn

backward to a position just ahead of the control section. Placement of

the stiffening tube on the shaft of the colonoscope reduces the usable

length of the insertion tube. Therefore, the longer instrument (180 cm)

17

PREPARATION

The procedure for preparation of the colon by either the purge or

the lavage method is sometimes supplemented by use of enemas. A

warm, tap- water enema is very safe and does not induce histologic

changes in the rectal or colonic mucosa. Hypertonic sodium phosphate

enemas (e.g., Fleet Enema, C.B. Fleet Co., Lynchburg, Virginia) may

also be used to empty the rectum and lower left colon.

Colonic lavage has become the most commonly used method of

preparation. A large volume of appropriate fluid is ingested or instilled

via a nasogastric tube at a fast rate until clear, watery diarrhea results.

One of the main advantages of this method is that the colon can be fully

prepared in 4 to 6 hr.

18 saline or electrolyte solutions balanced to reflect the concentration of

electrolytes in the serum. Although effective for cleansing the colon,

these solutions, including the balanced electrolyte solution, produced a

net gain in weight and absorption of significant quantities of sodium and

chloride.

In order to make the solution isosmotic with the plasma, a

nonabsorbable solute is required. The addition of PEG avoids this problem,

and this chemical substance is therefore used in most of the commercially

available colonic lavage solutions.

TECHNIQUE OF COLONOSCOPY

The endoscopist must know the indications and contraindications

for lower panendoscopy a thorough knowledge of the complications,

the countermeasures for dealing with potential complications, and the

19

INSERTION INTO THE RECTUM

Patient in a left lateral position on the

examination table, standing at the patient's back, the examiner should

grasp the distal end of the insertion tube with the right hand with the

index finger extended so that its tip is about 2 cm from the end of the

insertion tube. The instrument tip is then placed at a 90-degree angle on

the anal ring; the patient is asked to bear down as if about to have a

bowel movement, and the instrument is advanced into the rectum while

the operator simultaneously changes the angle of insertion, so that the

insertion tube points toward the umbilicus at the conclusion of the

maneuver. Air insufflation into the rectum should be kept to a

minimum.

The proximal margin of the rectum is located

about 15 cm from the anus. It is impossible to know by observation

alone whether the tip of the colonoscope has left the pelvis and

entered the colon within the abdominal cavity. The rectosigmoid

junction is usuallylocated at 15 to 20 cm from the anus, where there is

20 rectosigmoid bend, a "walking-stick" phenomenon may develop

INSERTION INTO THE SIGMOID COLON

Previously, the rectosigmoid junction presented a greater

technical problem, The current wide-angle lens systems make it easier

to recognize the correct direction, Since it is difficult to obtain a tubular

view of the colon with an instrument with this limited capability, it was

necessary to withdraw the instrument after every few centimeters of

forward motion to confirm that the tip was aligned in the correct

direction, The rectosigmoid junction is in a sense the key to the colon.

21 remainder of the examination will often be less difficult in proportion,

The problem is sometimes compounded by adhesions due to previous

surgery or radiation or by carcinomatous invasion of the pelvis.

Frequently, a long tunnel view will be obtained in the midsigmoid

as the loop is being formed. When advancement is persistent and

uninterrupted by attempts to straighten and control the loop, the loop

may become large enough to accommodate 50 to 60 cm of the length of

the insertion tube entirely within the sigmoid colon.

Lateral view of the colonoscope in the

sigmoid colon. Each of the common sigmoid

colon loops has this appearance in lateral

22 Complex sigmoid colon loops: alpha loop (left) and

double-reverse-alpha loop (right).

"Jiggling" (repeated withdrawal of short segments of the colonoscope

with clockwise

rotation and tip

23

straightening keep

the sigmoid

colon relatively straight during insertion.

INSERTION INTO THE TRANSVERSE COLON

Passage of the instrument tip into the transverse colon is

relatively easy. A straightened sigmoid colon is a prerequisite for entry

and passage of the transverse colon. When this has been accomplished,

the length of insertion tube within the colon will be only about 50 or 60

cm.

INSERTION INTO THE DESCENDING COLON

Endoscopically, the descending colon may have a somewhat

greater diameter than the sigmoid colon, the interhaustral septa are

24 colon, and a long tunnel view of the lumen may be obtained on entry

Because of the marked deflection capability for the distal tip of

newer colonoscopes, it is usually not difficult to direct the instrument

into the descending colon.

ADVANCEMENT TO THE HEPATIC FLEXURE

The combination of withdrawal (with a slight degree of rotation),

the effect of suction, and the fulcrum-like effect produced by the fixed

splenic flexure is often enough to position the instrument tip right at the

hepatic flexure Manual counterpressure on the abdominal wall may

also straighten the loop; The outer wall of the hepatic flexure is

frequently denoted by a bluish mucosal tint

INSERTION INTO THE ASCENDING COLON AND

CECUM

It is usually necessary to make use of the deflection controls to

25 Suction of air from the ascending colon shortens the distance to

the caecum deep inspiration can be effective in pushing the instrument

downward toward the caecum once the instrument tip has turned the

hepatic flexure. Because the ascending colon is fixed to the

retroperitoneal wall and posterior in position, Tran illumination is often

lost after the tip passes the hepatic flexure. However, when the tip

reaches the somewhat more mobile caecum, transillumination again

occurs in the right lower quadrant If the preparation is adequate, the

orifice of the appendix can be seen as a round opening or a slit behind a

26 SLIDE 1

NORMAL COLONOSCOPIC PICTURE

Ano rectal

junction, seen at retro flexion

Three semilunar folds,

the"valves of Houston".

Normal

vascular pattern

Triangular folds

characterist ic of the transverse colon.

Hepatic flexure showing the bluish

indentation by the liver.

27

ENDOSCOPIC APPEARANCE OF NORMAL

COLORECTAL MUCOSA

Endoscopically, the normal colorectal mucosa has a

transparent, glistening surface that is uniformly salmon-pink except

where the colon is in contact with other organs such as the liver or

spleen. The normal surface reflects the light of the endoscope.

A progressively branching vascular network is present

throughout the colon; this can be recognized in all portions of the large

bowel, The vessels that compose this visible vasculature course along

the surface of the submucosa just beneath the superficial mucosal layer.

Arborization and interlacing capillaries and venules are characteristic

of the surface topography of the normal mucous membrane.

28 Vascularity is more prominent in the rectum than in

any other area; there, larger blood vessels are present whose caliber

increases in diameter distally. (SLIDE1-FIG3)

One characteristic that never varies in healthy

subjects is the smoothness of the surface. No nodules or irregular

projections should be seen, with the exception of the tiny, regular,

smooth elevations that may be found in an occasional adolescent or

young adult patient with lymphoid hyperplasia.

Throughout the entire colon, the interhaustral septa are

ordinarily "paper-crease" sharp in their semicircular or triangular

configuration.

No bleeding is present in the normal large intestine, nor

is there pus or mucus on the bowel wall. Only rarely does the

preparation process for the examination cause alternations in the

29 These changes may consist of mild erythema or slight

edema, recognized as loss of the normal bright, glistening appearance

of the mucosal surface. Bleeding in response to gentle contact with the

instrument tip or biopsy probe (contact bleeding, "friability") never

develops as a result of preparation with cathartics and enemas.

CLINICAL FEATURES

COLORECTAL CARCINOMA

Colorectal carcinoma is the second most common cause of

cancer death. Risk factors include family history, adenomatous

polyposis syndromes, chronic ulcerative colitis and Crohn’s disease.

The vast majority of colorectal carcinomas begin as benign adenomas,

which grow over time and undergo malignant transformation.

Adenomas of >1 cm are at risk and >2 cm malignancy is

likely (50%). Fifty per cent of carcinomas are in the rectum or sigmoid

30 carcinoma are at risk of synchronous (carcinoma elsewhere in large

bowel) and metachronous (colonic carcinoma at a later date) lesions

and it is important to evaluate the entire colon at the time of diagnosis.

Symptomatic individuals usually present with advanced

lesions. Endoscopic findings may easily follow Borrmann's

nomenclature. Advanced lesions are usually greater than 2 cm,

indurated, present with irregular surface and spontaneous ulcerations,

and usually bleed after biopsy.

There is little mobility following manipulation with the

snare, and for those lesions eventually considered for total excision

through endoscopic mucosal resection, little or no elevation may be

observed after submucosal injection of saline.

Advanced CRC represents a lesion with detected

invasion into the muscularis propria. Oncologic colon resection is

recommended treatment for colon lesions. For advanced rectal lesions,

surgical treatment is indicated. This approach encompasses local

31 advanced rectal lesions, pre- or postoperative adjuvant treatment is

recommended for cure.

The presence of early CRC remains the challenge for

diagnostic colonoscopy. Since endoscopic resection may be sufficient

treatment in some situations, there is a need for precise endoscopic

diagnosis of the level of invasion. EUS, chromoscopy, and magnifying

colonoscopy (MC) are useful tools in the diagnosis of CRC as well as

for immediate staging.

CROHN'S DISEASE AND ULCERATIVE COLITIS.

UC primarily affects the mucosal layer, whereas Crohn's disease

involves the submucosa as well as the mucosa. Because mucosal

involvement is not prominent early in the course of Crohn's disease,

there is a tendency for the surface vascular pattern to remain intact. One

32 This ulcer is usually not more than 3 to 4 mm in diameter and is

characteristically surrounded by a narrow border of erythema

It has been demonstrated by scanning electron microscopy

that the aphthous ulcers of granulomatous colitis originate in the

submucosal lymphatic follicles and penetrate the mucosa via an

inflammatory eruption through this superficial layer. Cobblestoning is a

manifestation of submucosal involvement in Crohn's disease,

Endoscopists use the term cobblestoning to refer to uniform nodules

caused by submucosal edema

A finding of flat low-grade dysplasia during ulcerative colitis

surveillance is a strong predictor of progression to advanced neoplasia.

Early colectomy should be recommended for such patients.

Endoscopically, classic UC starts in the rectum and

progresses proximally, sometimes as far as the ileo-cecal valve, in a

circumferential and contiguous fashion with diffused and continuous

inflammation. Endoscopic features suggestive of UC include

33 granular appearing mucosa, increased friability, and small superficial

erosions and ulcers surrounded by diffuse inflammation .

These classic visual features are used to endoscopically

score the extent of the disease. The Mayo Scoring System was derived

in order provide an objective measure describing the endoscopic extent

of the disease. Lemmens et al. sought to evaluate the correlation

between endoscsopy and histology with use of the Mayo Scoring

System . This retrospective study included 236 biopsy sets from 131

patients with known UC.

Endoscopy was performed by IBD specialists and

graded using the Mayo Scoring System. Biopsy specimens were

analyzed by expert gastrointestinal pathologists using the Geboes and

Riley histologic scoring systems. They found that at both extremes,

inactive and severely active disease, there was a very high concordance

rate.

For mild disease, however, there were important

differences, as histologic examination seemed to have detected more

34 for a combined histologic and endoscopic scoring system when

assessing disease activity.

Inflammation in CD can span the entire gastrointestinal

tract with nearly 55% of cases involving the terminal ileum and colon,

40% involving exclusively the ileum, and 25% involving the colon

alone . Rectal involvement occurs in up to 50% of patients with CD .

It should be noted that while terminal ileal involvement

is strongly suggestive of CD, it might also occur in patients with UC,

particularly pan-colitic UC, by way of “backwash” of cecal contents or

“backwash ileitis” . The exact pathogenesis of “backwash ileitis”

remains poorly understood, however it is believed that in patients with

pan-colitic UC, the terminal ileum becomes inflamed stemming from

chronic exposure to cecal contents

Endoscopically, classic CD appears as “skip

lesions” or areas of inflammation interposed between islands of normal

mucosa, “cobblestone” appearance of the mucosal surface due to

submucosal inflammation and edema, and deep, longitudinal,

35

SLIDE 2

CROHN'S: MUCOSAL FEATURES

Left: Mucosal inflammation causes redness, friability (ease of

bleeding) and edema (swelling), giving rise to a granular

appearance

Middle: more extensive (right). Repeated ulceration causes

destruction of mucosa, giving the swollen surviving mucosa a

raised

36

Ulcerative Colitis: Mucosal lesion

Left: Mucosal granularity, exudate and superficial ulceration. There is often an abrupt transition to relatively normal-appearing

mucosa

Middle: With increasing severity, ulcers may appear as punctuate

Right: The repeated cycle of ulceration, alternating with the deposition of granulation tissue during the healing phase, results

in the development of raised areas of inflamed tissue that

37 Several endoscopic features can be used to differentiate between

UC and Crohn's disease with a high degree of certainty. The most

important are

1. Ulcers never occur in UC in an area of otherwise normal mucosa.

Ulcers may occur in diffusely abnormal mucosa in both forms of

colitis, but if the surrounding mucosa is normal, the diagnosis is never

UC.

2. Aphthous ulcers are pathognomonic of Crohn's colitis.

3. Cobblestoning is pathognomonic of Crohn's colitis.

4. Granularity and friability are common early in the course of UC,

but may be late findings in granulomatous colitis.

5.Pseudopolyps occur in both forms of colitis(SLIDE2)

COLONOSCOPIC BIOPSY

Whenever colonoscopy is utilized in the differential diagnosis of

IBDs, several biopsies should be obtained for histopathologic

38 as to location in the colon. Histologic evaluation of biopsy specimens

may be useful in distinguishing between acute self-limited colitis and

idiopathic IBD

DIVERTICULAR DISEASE

Patchy, mottled red areas may be noted on the tips of several

adjacent hypertrophied folds in the sigmoid colon in patients with

diverticulosis. These small areas almost never bleed spontaneously and

are usually not friable. The redness is characteristically uniform and

confluent on the edge of folds and becomes discontinuous over a

distance of a few millimeters, proceeding toward the haustral pouches.

When viewed closely, the red areas consist of myriad tiny red dots,

each of which resembles petechiae. When a broad segment of mucosa

is involved, friability may develop, and rarely, spontaneous bleeding

39

ISCHEMIC COLITIS

With mild ischemia, there may be only slight granularity and loss

of vascular pattern; in severe cases, the blue-black coloration of

incipient gangrene may be seen. The mucosa may be hemorrhagic,

friable, and ulcerated and sharply demarcated from normal mucosa at

each end of the involved segment. A pseudomembrane may overlie the

ischemic area and, when removed, reveals a reddened, friable mucosa

40 SLIDE 3

41

Angiodysplasia

Rectal Varices

Internal

Hemorrhoids

Vascular

malformations Dilated venous collaterals Non-bleeding internal

which may be found

seen at sigmoidoscopy in

an hemorrhoids

throughout the elderly woman with gastrointestinal tract Cirrhosis

Miscellaneous

Ischemic Colitis

Postirraditaion

Pseudomembranous

Stricture

Colitis

mucosal changes of who had undergone Typically adherent to the ischemia (inadequate

blood radiation therapy for colonic mucosa in

supply) in increasing colorectal carcinoma,

antibiotic-associated colitis

severity, from patchy

presented with recurrent

42

SOLITARY ULCERS

Solitary ulcers are most often found in the rectum during the

investigation of rectal bleeding. They are often multiple, usually

superficial, irregularly shaped with an intensely red margin, and may

be several centimeters in diameter. Characteristically, there is no

surrounding inflammation, and they are usually located on the lip of

the rectosigmoid fold. They are rarely found in the dilated rectal

ampulla. Ischemia may be the cause in elderly patients with fecal

stasis and rectal prolapse.

DISCRETE VASCULAR LESIONS

Vascular Ectasias

The vascular ectasia of the colon is the most common vascular

abnormality of the GI tract and probably the most frequent cause of

recurrent colonic bleeding in patients over 60 years of age. Vascular

43 "Angiodysplasias" have been reported in adolescents (small

bowel, left colon), but none of these reports has corroborating

histologic documentation.

Vascular ectasias are almost always confined to the caecum or

ascending colon, and they are usually multiple and less than 5 mm in

diameter.

The clinical importance of the vascular ectasia is that this lesion

and diverticulosis are the most common causes of lower GI hemorrhage

in the elderly

Bleeding from ectasias is most often recurrent and low grade,

although massive hemorrhage is the initial manifestation in

44

HEMANGIOMA

The hemangioma is the second most common vascular lesion of

the large bowel. Considered by some to be true neoplasms,

hemangiomas are generally thought to be hamartomas because they are

usually present at birth. Colonic hemangiomas occur as solitary lesions,

DIEULAFOY'S LESION

Dieulafoy lesion have been identified in the esophagus, duodenal

bulb, jejunum, colon, and rectum those in the latter two sites are the

cause of massive bleeding. Dieulafoy's lesions of the colon and rectum

appear to be similar to the classic lesion and consist of a large,

caliber-persistent vessel underlying a tiny mucosal defect. Histologic evaluation

reveals no aneurysm formation, inflammation, atherosclerosis, arteritis,

or surrounding inflammation, but only a thick-walled vessel with

varying degrees of medial sclerosis and muscular hypertrophy or intimal

45 thrombus adjacent to the mucosal defect. Endoscopy usually does not

define the precise nature of the lesion, as the mucosal defect is small and

bleeding is often massive.

METHODS OF DIAGNOSIS OF POLYPS AND

TUMORS

Colonic polyps are usually asymptomatic, although those larger

than 1 cm in diameter may bleed intermittently. On examination, many

patients with colorectal bleeding are found to have another potential

cause, such as hemorrhoids, in addition to polyps. It is unusual for

polyps to cause pain or altered bowel habit, symptoms that are more

often attributable to coexistent functional bowel disorder when polyps

are found coincidentally in conjunction with these complaints. Larger

sessile polyps and cancers may cause overt or occult bleeding per

46

HISTOLOGIC CLASSIFICATION OF

POLYPS(Table 1)

NONNEOPLASTIC

POLYPS

NEOPLASTIC

POLYPS

Hyperplastic (metaplastic) Adenomatous polyp

Juvenile Tubular adenoma

Peutz-Jeghers Tubulovillous adenoma

Postinflammatory _{Villous adenoma}

Flat adenoma

47

NON NEOPLASTIC POLYP(Table 2)

Hyperplastic Polyp

Pedunculated

Tubular

Sessile Villous

Adenoma

Adenoma

Small polypoid nodule Several similar polyps on villous adenoma in the

indistinguishable from a

stalks. Although the

head of splenic flexure

small sessile adenoma this polyp was erythematous and inflammatory in appearance

NEOPLASTIC

POLYP (Table 3)

Malignant Polyp

Constricting

Colonic

Lymphoma

Adenocarcinoma

Sessile polyp in the

sigmoid Constricting Nodular, ulcerated,

colon, it histologically adenocarcinoma of the

constricting neoplasm found

contained submucosal

sigmoid colon in a 61 year-

in the proximal ascending

adenocarcinoma

old woman with several

Biopsy revealed this to be a

months of abdominal pain

malignant lymphoma, large

48

NEOPLASTIC POLYPS

It is generally accepted that, except in ulcerative colitis,

most colorectal carcinomas originate from preexisting adenomatous

tissue. The dysplastic epithelial surface of an adenoma may appear

similar to that of infiltrating carcinoma and behave identically in tissue

culture.

As a result, severe dysplasia in an adenoma has

sometimes been referred to as intramucosal carcinoma, carcinoma in

situ, or focal carcinoma. This is clinically misleading because

metastasis is never associated with such lesions.

Until the dysplastic cells invade across the muscularis

mucosae dividing the epithelial surface from the submucosa, the

pathologist is not justified in diagnosing carcinoma.

As described for hamartomatous polyps, the phenomenon of

49 be confusing, although the misplaced tissue is often nondysplastic and

is not surrounded by the fibrous (desmoplastic) reaction that occurs

around carcinomatous tissue.

The relationship between size of an adenoma and risk of

malignancy probably represents a statistical correlation between the

mass of the polyp and the number of potentially cancerous cells

present.

Malignancy rarely occurs in tiny adenomas, and the

overall malignancy rate for adenomas in endoscopic series is about 5%

In 2003, the Paris Endoscopic Classification arose to

describe polyp morphology, which can potentially guide the

endoscopist toward its malignancy potential

A recent study by van Doom et al. evaluated the

50 seven expert endoscopists . The seven expert endoscopists assessed 85

endoscopic video clips depicting polyps.

Afterwards, they underwent a digital training module and

then assessed the same 85 polyps again. A calculated Fleiss kappa of

0.42 and a mean pairwise agreement of 67% suggested moderate

interobserver agreement among the seven experts.

In addition, the proportion of lesions labeled as “flat”

lesions ranged between 13–40% (p<0.001). The interobserver

agreement did not change significantly after the digital training module,

which led the investigators to conclude there to be only moderate

interobserver agreement among experts for this classification system

and that use of this classification system in daily practice is

questionable and unsuitable for comparative endoscopist research.

Thus, the need for a simplified classification system is

51

TOTAL COLONOSCOPY IN CANCER PATIENTS

The whole colon must be examined in patients with colorectal

cancer because of the possibility of synchronous adenomas or cancers.

Previously, barium enema was the procedure of choice for this purpose,

but because of significant inaccuracy compared with colonoscopy, its

use is considered outdated, except where endoscopy is unavailable or

when an endoscope cannot be passed through a cancerous segment of

the colon.

CONTRAINDICATIONS TO COLONOSCOPY

Acute inflammation of the colon (fulminant), including

ulcerative colitis, Crohn's colitis, ischemic colitis, diverticulitis, and

radiation colitis Peritonitis Pregnancy (second and third trimester)

52

disease. Recent myocardial infarction Pulmonary embolus Shock Large

aortic or ileac aneurysm Recent pelvic or colonic surgery

COMPLICATIONS AND HAZARDS OF

COLONOSCOPY (Table 4)

Recognized Complications and Hazards of Colonoscopy

DIAGNOSTIC

COLONOSCOPY

THERAPEUTIC

COLONOSCOPY

Hemorrhage Perforation

Perforation Hemorrhage

Diastatic serosal tears Mucosal burns

Postcolonoscopy distention Incomplete polypectomy

Vasovagal reflex Explosion

Splenic trauma Accidental removal of a

53

FLEXIBLE SIGMOIDOSCOPY

The flexible sigmoidoscope has two obvious advantages, the ability to

examine a longer segment of bowel and a marked decrease in patient

discomfort.

1 For these reasons, and despite a significant difference in cost, flexible

sigmoidoscopy has largely replaced rigid sigmoidoscopy.

2 However, the rigid instrument plays an important role in the

examination of the distal rectum and anus. Anoscopy is often

complementary to sigmoidoscopy

INSTRUMENT LENGTH

Sigmoidoscopes are manufactured in different lengths; the two

most popular are 35 cm and 60 cm. The rectum and a portion of the

distal sigmoid colon can be visualized with the 35-cm flexible

sigmoidoscope. This instrument is preferred by those who do not

54 relatively easy to use. The 60-cm sigmoidoscope allows for a more

extensive examination, sometimes to the splenic flexure. During

training, the instrument feels a little more cumbersome than the 35-cm

sigmoidoscope.

The instrument is advanced with the right hand. The control

section is held in the palm of the left hand. The left thumb is placed on

the larger (closest) tip deflection knob (usually referred to as the

up-down control).

The index and middle fingers of the left hand operate the

suction and air/water insufflation valves (trumpet fashion) at the top of

the control section. Although endoscopists use many variations in

holding and operating the control section of an endoscope the approach

described earlier is relatively common.

55 section is held in the palm of the left hand. The left thumb is placed on

the larger (closest) tip deflection knob (usually referred to as the

up-down control). The index and middle fingers of the left hand operate

the suction and air/water insufflation valves (trumpet fashion) at the top

of the control section. Although endoscopists use many variations in

holding and operating the control section of an endoscope Technique of

Upper Gastrointestinal Endoscopy, the approach described earlier is

relatively common.

INDICATIONS

The indications for flexible sigmoidoscopy are multiple. The

procedure is an excellent adjunct to rectal examination and anoscopy in

the investigation of symptoms referable to the anorectal area such as

bleeding per rectum associated with pain, pruritus, and tenesmus.

56 Push enteroscopy can also be employed in such patients, with a

higher diagnostic yield than the radiographic techniques previously

noted. This technique involves passing a pediatric colonoscope or

enteroscope as far as possible beyond the ligament of Treitz. This

procedure allows visualization of the proximal to mid jejunum (about

60 cm). The diagnostic yield for obscure bleeding is approximately

40%, with angiodysplasia being the most common finding .Push

enteroscopy also allows endoscopic treatment if an endoscopically

treatable lesion, such as angiodysplasia, is seen

CAPSULE ENDOSCOPY

Wireless video-capsule endoscopy was approved by the US Food

and Drug Administration in 2000 (Given Imaging, Ltd., Yogneam,

Israel). It provides diagnostic imaging of the entire small intestine. The

indications for wireless capsule endoscopy continue to evolve. The

57 gastrointestinal bleeding.

The capsule is administered by mouth after an overnight fast. It

takes two images per second, and a signal is transmitted to an external

recorder, which the patient wears on a belt. The exam takes 8 hours to

complete, and the images are downloaded, processed, and viewed using

a computer workstation. The capsule is disposable and is excreted in

the stool.

Despite these advances, the complication rate is higher for

angiography than for colonoscopy. Colonoscopy is recommended

before angiography not only because of the lower complication rate but

because of the higher diagnostic yield, as well. Angiography can be

considered when colonoscopy is not feasible or as an alternative to

surgery in those with persistent bleeding

For patients who continue to bleed, surgery may become

necessary. For this reason, it is important to involve surgeons when

patients present with massive LGI bleeding. Segmental colectomy is

58 to surgery with colonoscopy or angiography or intraoperatively.

Subtotal colectomy is reserved for patients in whom no bleeding site

has been identified.

VIDEO CAPSULE ENDOSCOPY

Video capsule Endoscopy is a new technique in which

adisposable videocapsule is used that is swallowed by the patient. This

allows visualization of the segment of the small bowel that is not within

the reach of standard upper and lower endoscopy

.The main current indication for capsule endoscopy is an obscure

source of gastrointestinal bleeding.VCE may be particular ly helpful in

identifying the cause of bleeding when standard upper endoscopy and

60 Acute lower gastrointestinal bleeding (ALGIB) is still a

diagnostic and therapeutic challenge. In clinical practice, ALGIB can be

defined as any gastrointestinal bleeding of recent onset (within the last

12-24 h) originating beyond the ileocecal valve . This bleeding may

lead to systemic manifestations, such

as hemodynamic instability,anemia , and the need for blood transfusion.

Patients with ALGIB present with rectal bleedingor

melena, depending on the volume of bleeding and the speed of colonic

transit. In some patients, there may be abdominal pain and

hemodynamic instability. Anemia characterizes more severe cases.

There are some data from clinical history that may

suggest the cause of bleeding. For example, the use of aspirin or

non-steroidal anti-inflammatory drugs is associated with ALGIB Often,

Mainly due to diverticular disease , as well as with upper

gastrointestinal bleeding (UGIB). Patients with acute

61 and tendernessover the affected bowel, most often involving the left

side. Mild to moderate amounts of rectal bleeding or bloody diarrhea

usually develop within 24 h of the onset of abdominal pain. In patients

with a history of prostate cancer or cervical cancer, it may be related to

actinic proctitis , even if irradiation preceded the bleeding by many

years. A history of recent polypectomy should guide the investigation of

ALGIB towards the point of resection.

The clinical consequences of ALGIB are

variable and dependent upon the severity of bleeding and on patient

baseline clinical conditions. About half of patients presented anemia and

hemodynamic compromise; However, these changes are less evident in

patients with ALGIB than in those with UGIB .

Studies describe clinical predictors of ALGIB

62 <100 mmHg, active rectal bleeding during the first 4 h of observation,

and initial hematocrit <35%.

The incidence of ALGIB is estimated at 20 cases

per 100,000 adults, which represents one quarter of one third of patients

hospitalized for gastrointestinal bleeding. However, ALGIB more

commonly affects the elderly, with an incidence as high as 200 per

100,000 of those in their ninth decade of life. The case-fatality rate for

patients with ALGIB is 3.6% and patients with active bleeding during

hospitalization have a higher risk of death.

Bleeding tends to be self-limited and spontaneously

stops in about 80% of cases. Once the bleeding stops spontaneously,

elective colonoscopy is indicated. In those patients who keep bleeding,

the diagnosis should be done regardless of the hemorrhage.

Although colonoscopy has been considered

63 recent data show that this procedure is feasible and allows for diagnosis

in most cases. Colonoscopy has been shown to be safe, effective, and

useful, especially when done in the first 12-24 h after admission.

Colonoscopy generally has complication rates below

3% and high diagnostic utility in identifying the source of ALGIB. The

optimal timing for endoscopicexamination has not been

determined. However, recent data demonstrates that colonoscopy

performed within the first 24 h from admission may result in a definitive

diagnosis in up to 96% of patients.

The accuracy of colonoscopy in investigating cases of

ALGIB varies from 72% to 86%, and cecal intubation is achieved in

64 PROFORMA I FOR CLINICAL STUDY

Name : Age : Sex : IP No. GE No.

Address : Occupation : Provisional diagnosis : Colonoscopic Diagnosis : Pathological Diagnosis :

Complaints :

And

Bleeding per Rectum with---- Duration

Pain abdomen Yes/No Vomiting Yes/No Weight loss Yes/No Haematemesis Yes/No

Constipatio

Yes/No Jaundice Yes/No

n

Malena Yes/No Diarrhoea Yes/No

Palpable lump in the

Yes/No abdomen

Tenesmus Yes/No Altered bowel habits Yes/No

General examination :

Pulse Pallor

Lymphadenopathy

BP jaundice

clubbing pedal edema

CVS RS CNS

Abdomen lump visible free fluid

peristalsis

family history social status marital status

personal history smoking alcohol diet

medical history

Investigation

HB PCV Bl.Grouping LFT BT / CT

65

PROFORMA II FOR COLONOSCOPY STUDY

Name : Age : Sex : GE No. : Date :

Endoscopist Endoscopist Provisional diagnosis : Staff

Scope : Colonoscope :

Sigmoidoscope :

Provisional diagnosis :

Endoscopic diagnosis :

Procedure : Endoscopist

Emergency

Routine Assistant :

Follow up Staff

Therapeutic

Colonoscopic picture

Postoperative _taken

Findings : Specimen taken

Brush cytology : forceps biopsy : Site of biopsy : Pathology No : Study : Complete / Incomplete

Normal / Abnormal

Next follow up needed / not needed

Advise : Medical

Surgical Final diagnosis : Site of lesion :

66

MATERIALS AND METHODS

It is prospective study based on the cases of lower

gastrointestinal bleeding Observed at Government royapettah

Hospital during the period of January 2017 to September 2017.

Patients

Our study group consisted of 119 cases of lower

gastrointestinal bleeding that referred for General surgery, Medical

and surgical Gastroenterology departments for colonoscopy

evaluation.

Our study group consisted of Male and Female patients of

diverse age group ranging from 5 years to 90 years. This study

observed the age and sex incidence and etiology

EQUIPMENT AND MATERIALS

1.Colonoscope

2.flexiblesigmoidose

3.upper GIendoscope

67 Data sources: Articles and a review of studies through MEDLINE

search of the English language literature on the internet.

Methods

Patient presenting with anorectal diseases and the young

patients were evaluated with sigmoidoscopy and others by

colonoscopy

Inclusion Criteria

:

Patient presenting with

Painless intermittent

bleeding

Occult blood positive

Acute Massive bleeding

Fresh bleeding mixed with

Stool

Bleeding per rectum associated with altered bowel habits,

mass abdomen, weight loss and anemia

68

Exclusion Criteria

:

Patients presenting with obvious cause of upper GI bleed

Patients with bleeding disorders

69

OBSERVATION AND DISCUSSION

A total of 119 patients were included in the study and the

following statistical data is obtained

ETIOLOGICAL CLASSIFICATION (Table 5)

Description No. of Case %

adenocarcinoma 24 20

Polyp 20 17

Crohns 2 2

Ulcerative Colitis 15 12

Non Specific Colitis 17 14

Fissure in ano 5 4

Haemorroids 21 18

Rectal varices 5 4

Angiodysplasia 2 2

Normal Study 5 4

Diverticulosis 2 2

Others 1 1

Total 119 100

Excluding haemorroids, Neoplasia of the colon and

rectum forms the most common etiology of lower GI bleed is

70

Diagnosis, Age, Sex incidence of Lower GI Bleed (Table 6)

Ag e gr oup( inY ea rs ) ad en o car ci n o m a P ol

yp Crohns

U lc er ativ e C o litis N on S pe ci fic C oli tis F is sur e i n a no H ae m or roi ds R ect al v ar ices A ngi od yspl asi a N or m al S tudy D iv er tic u lo sis O th er s T ot al

M F M F M F M F M F M F M F M F M F M F M F M F M F

< 10 3 3 3 3

11 - 20 1 1 1 1 1 1 3 3

21 - 30 1 2 2 2 4 3 2 1 2 1 1 12 9

31 - 40 1 2 2 3 1 6 2 5 1 1 1 1 1 21 6

41 - 50 3 2 2 1 1 1 1 1 4 2 2 1 15 6

51 - 60 5 3 1 1 2 2 2 1 3 1 1 1 15 8

61 - 70 2 2 2 2 1 1 1 8 3

71 - 80 1 1 1 1 2

81 - 90 1 1

> 90

Total

13 11 13 7 1 1 8 7 12 5 4 1 16 5 4 1 2 3 2 2 1 79 40

24 20 2 15 17 5 21 5 2 5 2 1 119

71

AGE INCIDENCE AND SEX DISTRIBUTION

Although no age is exempted majority of patients belongs to 20-60 yrs

P

er

ce

n

ta

g

e

AGE & SEX DISTRIBUTION (SLIDE 4)

AGE AND SEX DISTRIBUTION Male _Female

20 18 16 14 12 10 8 6 4 2

0 < 10 11 - 20 21 - 30 31 - 40 41 - 50

51 - 60 61 - 70 71 - 80 81 - 90 > 90

Age Group

72 The bleeding does not cause always cause hemodynamic

instability , most are submissive

Right colon cancer patients mostly present with melanotic stools,

Adenomas of the left colon usually present with bright-red rectal

bleeding

Among the 119 patients, 37 were carcinoma colon , 20 had

polyp , 17 were identified to be inflammatory bowel disease , 31 were

anorectal diseases. ulcerative colitis occurred in 15 patients , crohns in

2 patients and others 1 henoch schonlein purpura

Right sided diverticulosis is common in this study and all cases

found to be right colon whereas Diverticulosis is common on Left sided

73 The pie diagram shows the various etiological causes and

distribution in this study

PERCENTAGE OF CASES (SLIDE 5)

Percentage of Cases

Diverticulosis 2%

Normal Study

4% _Others

Angiodysplacia 1%

2% adenocarcinom

a

Rectal varices 20%

4% Heamorroids

18%

Polyp 17%

Fissure in ano Crohns

4% Non Specific Ulcerative 2%

Colitis Colitis

14% 12%

The next common cause being polyp in 17% of patient followed by

inflammatory bowel disease contributing 14% of the total cases with

74

Other causes include non specific colitis in 14% , rectal varices 4%,

angiodysplasia and Diverticulosis

SEX WISE ETIOLOGICAL DISTRIBUTION

Sex Wise Etiological Distribution(SLIDE 6)

16 14 P erc en ta g e 12 10 8 6 4 2 0 ad en o car ci n o m a Po ly p C rohns Ul cer at iv e No n S p eci fi c Fi ss u re i n a n o Heam o rr o id s R ect al v ar ices A ngi od ys p la ci a N o rm al St u d y D iv er ti cu lo si s Ot h er s Description

75 Based on age ratio in terms of diseases, the male population are

found to be more than females for adenocarcinoma, polyp,

inflammatory bowel disease and Diverticulosis. Haemorroids, rectal

varices and vascular ectasia also predominantly occurred in males.

Colonoscopy was performed 6 to 12 hours after hospitalization or

the onset of hematochezia. All patients of hematochezia with definite

signs of hemorrhage, active bleeding, a non-bleeding visible vessel, or

an adherent clot were treated conservatively except 1 patien whom

underwent Right hemi colectomy for diverticulitis with continued or

recurrent bleeding.

Out of 17 patients of inflammatory bowel disease 8 had definite

signs of hemorrhage, all are treated conservatively except 1 patient who

76

POLYP

Polyp : Etilogical Distribution(SLIDE 7)

hyperplastic polyp 19%

Juvenile polyp

angiomatous 34%

polyp 3% inflammatory

polyp 11%

malignantpolyp adenomatous

8% polyp