Archampong, E.Q.2018-12-192018-12-192013Archampong, E.Q. & Essuman, V.A.. Current Challenges with their Evolving Solutions in Surgical Practice in West Africa: A Reader. Oxford: African Books Collective, 2013. Project MUSE,9789988860288; 9789988860226http://ugspace.ug.edu.gh/handle/123456789/26488In lieu of an abstract, here is a brief excerpt of the content: •117• Chapter 11 Lower Gastrointestinal Bleeding E. Q. Archampong Introduction Historically two categories of gastrointestinal bleeding have been recognized, namely “upper” and “lower”, in relation to origins proximal and distal respectively to the ligament of Treitz. However, recent advances in endoscopic procedures, in particular increasing use of capsule endoscopy, have prompted a rethinking of this classification with a proposal for “upper” “mid” and “lower” categories”.1,2 In this system, upper GI Bleeding (UGIB) is recognised as occurring proximal to the ampulla of Vater, within reach of the oesophagogastro -duodenoscope; mid-GI bleeding (MGIB) is defined as occurring between the ampulla and the terminal ileum, best assessed by capsule endoscopy or double balloon endoscopy (DBE), while lower GI bleeding (LGIB) is newly recognized as occurring within the colon and best evaluated by colonoscopy. In most parts of the world, mid and lower source of bleeding account for 25-30 percent of all GI bleeding.3,4 In developing countries the presentation may be chronic, as longstanding anaemia, but many also present acutely with much haemodynamic instability5,6 demanding urgent resuscitation and management. Although the more sophisticated investigative procedures are not consistently available in developing countries, it is important that whenever possible the new concept of classification be used in patient management. This article reviews recent experience of mid and lower GI bleeding at our centre, with emphasis on initial evaluation, diagnostic procedures and definitive management. Materials and Methods For this review the records of 675 patients who were referred from the surgical and medical outpatients and general services to the •118• Chapter 11 Endoscopy Unit from October 2010 to end of September 2012 were analysed retrospectively. The aetiological distribution of these patients and the symptoms they presented with are depicted in Tables 11.1 and 11.2. Clearly the vast majority of patients complaining of rectal bleeding had haemorrhoids but it is significant that 7.0 percent had colorectal cancer. Nearly 6 percent had significant bleeding from diverticular disease and only a few (1.9 percent) suffered from fissure in ano. Clearly vascular lesions such as angiodysplasias are difficult to identify; only 3 were diagnosed in the two years reviewed. It is note worthy that 2.2 percent of undiagnosed iron deficiency anaemias were traceable to colorectal lesions. Patients with negative findings were separately documented. The demographic and epidemiological distribution of patients seen at the Endoscopy Unit is currently uncertain; it is certainly not representative of the population in the Greater Accra Region. The incidence figures arrived at in this study are therefore only approximations of the true position in the population as a whole. Table 11.1 Aetiological Factors in LGIB FACTOR NUMBER % Haemorrhoids 474 70.2 Diverticular Disease 40 5.9 Colorectal Carcinoma 47 7.0 Polyps (Single) (Multiple) 30 35 5 5.2 Colitis (Practitis) 14 13 2.0 1.9 Angiodysplasia 3 0.4 Granuloma (Amoebic) 2 0.3 Normal mucosa 47 7.0 Total 675 100.0 •119• Lower Gastrointestinal Bleeding Table 11.2 Symptomatology in LGIB NUMBER % Bleeding P.R. 547 18.1 LGIB 91 13.5 Melaena 9 1.3 Anaemia (Occuit Blood) 15 2.2 Not Recroded 13 1.9 Total 675 100 Initial Management and Resuscitation Some 80 percent of patients with acute mid and lower GI bleeding experiencespontaneouscessationofbleedingwithin24hoursofadmission. Patients with continued bleeding—as occurs in diverticular disease, inflammatory diseases or amoebiasis—may however rapidly deteriorate and present in a haemodynamically unstable state, demanding urgent diagnosis and treatment. The principles involving implementation of “ABC” apply, securing the airway and obtaining adequate venous access for appropriate volume resuscitation. The attainment of a reasonable clinical stability is the signal for a thorough history focusing on intake of anticoagulants and antiplatelet agents, and physical examination that would lead on to the diagnosis. Appropriate laboratory tests, in particular haemoglobin, haematocrit grouping and cross matching, and coagulation profile, are conducted. Where haemorrhagic shock threatens on account of continued active bleeding, resuscitation and evaluation are carried out concurrently. In these severely ill patients, especially in the elderly, it is crucial to apply the principles of “damage control” resuscitation, ensuring early exhibition of blood and blood products, and oxygen therapy to help to correct the lethal triad of coagulopathy, metabolic acidosis and hypothermia, and thus influence the outcome is crucial.7 Diagnosis, Localisation, and Interventional Therapies It has been established that in any situation that presents as lower GI bleeding, the source may indeed lie in the...engastrointestinal bleedingbleedingdouble balloon endoscopy (DBE)Book chapter