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23 Cards in this Set
- Front
- Back
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what is the definition of lower GI bleeding?
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bleeding distal to the ligament of treitz; vast majority occurs in the colon
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what are the sx of lower GI bleeding?
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hematochezia (BRBPR), w/ or w/o abdominal pain, melena, anorexia, fatigue, syncope, SOB, shock
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what are the signs of lower GI bleeding?
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BRBPR, + hemoccult, abd tenderness, hypovolemic shock, orthostasis
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what are the cause of lower GI bleeding?
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diverticulosis (usually RIGHT-sided in severe hemorrhage), vascular ectasia, colon cancer, hemorrhoids, trauma, hereditary hemorrhagic telangiectasia, intussusception, volvulus, ischemic colitis, IBD (especially ulcerative colitis), anticoagulation, rectal cancer, Meckel's diverticulum (w/ectopic gastric mucosa), stercoral ulcer (ulcer from hard stool), infectious colitis, aortoenteric fistula, chemotherapy, irradiation injury, infarcted bowel, strangulated hernia, anal fissure
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what medicines should be looked for causally w/a lower GI bleed?
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coumadin, aspirin, plavix
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what are the most common causes of massive lower GI bleeding?
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1. DIVERTICULOSIS 2. vascular ectasia
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what lab tests should be performed?
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CBC, chem-7, PT/PTT, type and cross
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what is the initial treatment for lower GI bleeding?
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IVFs: lactated ringer's; packed RBCs as needed, IVx2, foley cath to follow urine output, d/c aspirin, NGT
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what diagnostic tests should be performed for all lower GI bleeds?
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history, PE, NGT aspiration (to rule out UGI bleeding; bile or blood must be seen; otherwise perform EGD), anoscopy/proctoscopic exam
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what must be ruled out in patients w/lower GI bleeding?
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UPPER GI BLEEDING. remember, NGT aspiration is not 100% accurate (even if you get bile w/o blood)
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how can you have a UGI bleed w/only clear succus back in the NGT?
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duodenal bleeding ulcer can bleed distal to the pylorus w/the NGT sucking normal nonbloody gastric secretions. if there is any question, perform EGD.
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what would an algorithm for dx and tx of lower GI bleeding look like?
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history, PE, labs --> NGT --> if bloody, EGD. if bile, no blood, anoscopy/proctoscopy. if clear (no bile/no blood): EGD. next step w/anoscopy and proctoscopy: slow bleed - colonoscopy; significant bleed - tagged RBC scan; massive bleed: arteriogram.
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what is the diagnostic test of choice for localizing a slow-moderate lower GI bleeding source?
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colonoscopy
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what test is performed to localize bleeding if there is too much active bleeding to see the source w/a colonoscope?
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a-gram (mesenteric angiography)
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what is more sensitive for a slow, intermittent amt of blood loss: a-gram or tagged RBC study?
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radiolabeled RBC scan is more sensitive for blood loss at a rate of >=0.5 mL/min or intermittent blood loss b/c it has a longer 1/2-life (for arteriography, bleeding rate must by >=1.0 mL/min)
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what is the colonoscopic tx option for bleeding vascular ectasia or polyp?
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laser or electrocoagulation; local epinephrine injection
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what is the tx if bleeding site is known and massive or recurrent lower GI bleeding continues?
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segmental resection of the bowel
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what is the surgical treatment of massive lower GI bleeding w/o localization?
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exploratory laparotomy w/intraoperative enteroscopy and total abdominal colectomy as last resort
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what % of cases spontaneously stop bleeding?
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80-90% stop bleeding w/resuscitative measures only (at least temporarily)
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what % of patients require emergent surgery for lower GI bleeding?
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only ~10%
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does melena always signify active colonic bleeding?
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no - the colon is very good at storing material and often will store melena/maroon stools and pass them days later (follow patient, UO, HCT, and vitals)
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what is the therapeutic advantage of doing a colonoscopy?
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options of injecting substance (epinephrine) or coagulating vessels is an advantage w/c-scope to control bleeding
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what is the therapeutic advantage of doing an A-gram?
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ability to inject vasopressin and/or embolization, w/at least temporary control of bleeding in >85%
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