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25 Cards in this Set
- Front
- Back
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What is the definition of lower GI bleeding? |
Bleeding distal to the ligament of Treitz; vast majority occurs in the colon |
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What are the symptoms of lower GI bleeding? |
- Hematochezia (bright red blood per rectum = BRBPR) - With or without abdominal pain - Melena - Anorexia - Fatigue - Syncope - SOB - Shock |
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What are the signs of lower GI bleeding? |
- BRBPR - Positive hemoccult - Abdominal tenderness - Hypovolemic shock - Orthostasis |
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What are the causes of lower GI bleeding? |
- Diverticulosis (usually R-sided in severe hemorrhage) - Vascular ectasia - Colon cancer - Hemorrhoids - Trauma - Hereditary hemorrhagic telangiectasia - Intussusception - Volvulus - Ischemic colitis - IBD (especially UC) - 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 - Fissure |
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What medicines should be looked for causally with a lower GI bleed? |
- Warfarin - Aspirin - Plavix |
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What are the most common causes of massive lower GI bleeding? |
1. Diverticulosis 2. Vascular ectasia |
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What lab tests should be performed in a patient with lower GI bleeding? |
- CBC - Chem-7 - PT/PTT - Type and cross |
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What is the initial treatment of lower GI bleeding? |
- IVF: lactated Ringer's, PRBCs as needed - IV x2 - Foley catheter to follow urine output - D/c aspirin - NGT |
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What diagnostic tests should be performed for all lower GI bleeds? |
- History and physical exam - 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 with lower GI bleeding? |
Upper GI bleeding - remember NGT aspiration is not 100% accurate (even if you get bile without blood) |
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How can you have a UGI bleed with only clear succus back in the NGT? |
Duodenal bleeding ulcer can bleed distal to the pylorus with the NGT sucking normal non-bloody gastric secretions
If there is any question, perform EGD |
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If a patient with lower GI bleeding has blood in NGT, what is the next step? |
EGD - If positive, treat - If negative, proceed to anoscopy / proctoscopy |
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If a patient with lower GI bleeding has bile and no blood in NGT, what is the next step? |
Anoscopy / Proctoscopy - If positive, treat - If negative and slow bleed --> colonoscopy --> tagged RBC study - If negative and significant bleed --> tagged RBC scan - If negative and massive bleed --> arteriogram |
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If a patient with lower GI bleeding has no bile or blood in NGT, what is the next step? |
EGD - If positive, treat - If negative, anoscopy / proctoscopy
Or go right to anoscopy / proctoscopy if no suspcion for UGI bleed |
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What is the diagnostic test of choice for localizing a slow to moderate lower GI bleeding source? |
Colonoscopy |
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What test is performed to localize bleeding if there is too much active bleeding to see the source with a colonoscope? |
A-gram (mesenteric angiography) |
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What is more sensitive for a slow, intermittent amount of blood loss: A-gram or tagged RBC study? |
Radiolabeled RBC scan is more sensitive for blood loss at a rate of >0.5 mL/min or intermittent blood loss because it has a longer half-life (for arteriography, bleeding rate must be >1.0 mL/min) |
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What is the colonoscopic treatment option for bleeding vascular ectasia or polyp? |
Laser or electrocoagulation; local epinephrine injection |
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What is the treatment if bleeding site is KNOWN and massive or recurrent lower GI bleeding continues? |
Segmental resection of the bowel |
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What is the surgical treatment of massive lower GI bleeding WITHOUT localization? |
Exploratory laparotomy with intra-operative enteroscopy and total abdominal colectomy as last resort |
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What percentage of cases spontaneously stop bleeding? |
80-90% stop bleeding with resuscitative measures only (at least temporarily) |
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What percentage of patients require emergent surgery for lower GI bleeding? |
Only ~10% |
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Does melena always signify active colonic bleeding? |
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? |
Options of injecting substance (epinephrine) or coagulating vessels is an advantage with C-scope to control bleeding |
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What is the therapeutic advantage of doing an A-gram in a patient with lower GI bleeding? |
Ability to inject vasopressing and/or embolization, with at least temporary control of bleeding in >85% |
