Common Causes of Lower Gastro-Intestinal Bleeding

Lower gastrointestinal bleeding (LGIB) can arise from various conditions affecting the colon, rectum, and anus. The common causes include:

1. Diverticular Disease: Diverticulosis can lead to diverticulitis or diverticular bleeding.
2. Hemorrhoids: Swollen veins in the lower rectum or anus can cause bright red blood during bowel movements.
3. Colorectal Polyps: Benign growths that may bleed, especially if they are large or dysplastic.
4. Colorectal Cancer: Malignant tumors can cause bleeding, often associated with changes in bowel habits.
5. Inflammatory Bowel Disease (IBD): Includes ulcerative colitis and Crohn’s disease, both of which can cause significant bleeding.
6. Infectious Colitis: Infections from bacteria, viruses, or parasites can lead to inflammation and bleeding.
7. Angiodysplasia: Abnormal blood vessels in the gastrointestinal tract that can rupture and bleed.
8. Ischemic Colitis: Reduced blood flow to the colon leading to tissue damage and potential bleeding.

Analyzing Patient History for LGIB

When assessing a patient with suspected LGIB, it is crucial to gather a comprehensive history:

1. Symptoms:
   • Onset of bleeding (acute vs chronic)
   • Nature of the blood (bright red vs dark/maroon)
   • Associated symptoms (abdominal pain, diarrhea, weight loss)
2. Medical History:
   • Previous episodes of GI bleeding
   • History of IBD, colorectal cancer, or polyps
   • Use of medications (NSAIDs, anticoagulants)
3. Family History:
   • Family history of colorectal cancer or polyps
4. Social History:
   • Dietary habits
   • Alcohol use
   • Smoking status

By interpreting these findings, one may identify specific causes such as hemorrhoids for bright red blood on toilet paper or diverticular disease for maroon-colored stools.

Management Strategy for LGIB

The management strategy for a patient suffering from lower gastrointestinal bleeding includes:

1. Initial Assessment:
   • Stabilization of vital signs
   • Establishing IV access for fluid resuscitation if necessary
2. Diagnostic Evaluation:
   • Perform a digital rectal examination to assess for hemorrhoids or masses.
   • Order laboratory tests including CBC to evaluate hemoglobin levels.
3. Endoscopy:
   • Depending on the severity and source suspected, perform a colonoscopy for direct visualization and possible intervention.
4. Surgical Intervention:
   • If endoscopic measures fail and there is ongoing significant bleeding, surgical intervention may be required.
5. Follow-Up Care:
   • Monitor hemoglobin levels post-management and provide appropriate follow-up care based on findings.

Diagnosing Inflammatory Bowel Disease

Diagnosis of inflammatory bowel disease (IBD), including ulcerative colitis and Crohn’s disease involves:

1. History Taking:
   • Symptoms such as diarrhea (often bloody), abdominal pain, urgency, weight loss.
2. Physical Examination:
   • Abdominal tenderness; check for perianal disease in Crohn’s patients.
3. Differentiation Between Types:
   • Ulcerative colitis typically presents with continuous lesions starting from the rectum.
   • Crohn’s disease may present with skip lesions affecting any part of the GI tract.

Ordering Investigations for IBD

Appropriate investigations include:

1. Laboratory Tests:
   • Complete blood count (CBC) to check for anemia.
   • C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to assess inflammation.
2. Imaging Studies:
   • Colonoscopy with biopsy is essential for diagnosis; it allows direct visualization and histological assessment.
3. Radiological Imaging:
   • MRI enterography or CT enterography may be used particularly in suspected Crohn’s disease to assess small bowel involvement.

Management Plan for IBD

A comprehensive management plan includes:

1. Medications:
   • Aminosalicylates (e.g., mesalamine) for mild cases.
   • Corticosteroids for moderate-severe flares.
   • Immunomodulators (e.g., azathioprine) or biologics (e.g., infliximab) for maintenance therapy.
2. Nutritional Support:
   • Dietary modifications tailored to individual tolerance; consider nutritional supplements if malnutrition is present.
3. Surgery Consideration:
   • Surgical options may be necessary in cases of complications like strictures or abscesses in Crohn’s disease; colectomy may be indicated in severe ulcerative colitis cases unresponsive to medical therapy.
4. Regular Monitoring & Follow-Up Care – Regular follow-ups with gastroenterology are essential to monitor disease activity and adjust treatment as needed.

Stoma Formation Principles

When considering stoma formation following surgery:

1. Site Selection – The stoma should ideally be placed on the right side of the abdomen where there is adequate skin surface area away from bony prominences.
2. Type of Stoma – An ileostomy is typically formed when the entire colon is removed; a colostomy may be performed when part of the colon remains intact depending on pathology involved.

Complications of Stoma

Complications associated with stomas include:

1. Skin irritation around the stoma site due to leakage.
2. Stenosis at the stoma site leading to obstruction.
3. Prolapse where the stoma protrudes excessively outside the abdominal wall.
4. Parastomal hernia where abdominal contents protrude through weakened abdominal muscles near the stoma site.

Counseling Regarding Stoma Formation

Counseling should encompass:

1. Explanation about what a stoma is and why it is necessary post-surgery due to carcinoma rectum resection.
2. Discussion about lifestyle changes including dietary adjustments post-stoma formation.
3. Instruction on proper stoma care techniques including cleaning and changing bags effectively while addressing concerns regarding body image issues related to having a stoma.

Types and Classification of Intestinal Fistulas

Intestinal fistulas can be classified into several types based on their origin:

1. Enteric Fistulas: Between two segments of intestine.
2. Entero-cutaneous Fistulas: Between intestine and skin surface.
3. Entero-vaginal Fistulas: Between intestine and vagina.
4. Entero-urinary Fistulas: Between intestine and urinary tract structures.

Management Options

Management strategies depend on fistula type but generally include:

1. Conservative Management: Nutritional support via TPN if needed; maintaining skin integrity around fistula sites; monitoring output closely until spontaneous closure occurs if possible.
2. Surgical Intervention: May be required if conservative measures fail after an appropriate duration or if complications arise such as infection or obstruction related directly due to fistula presence.