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EM Gastrointestinal > 2 LGIB, part 1 > Flashcards

2 LGIB, part 1 Flashcards

1
Q

LGIB

A

Bleeding distal to the ligament of Treitz

More common than UGIB

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2
Q

What is the most common source of all causes of blood detected in the lower GI system

A

UGIB

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3
Q

Most common cause of established lower GI bleeding

A

Diverticular disease

  1. Colitis
  2. Hemorrhoids
  3. Adenomatous polyps/Malignancies
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4
Q

Characterize Diverticulosis (5)

A
  1. Painless
  2. Erosion into penetrating artery of diverticulum
  3. May be massive; 90% resolve spontaneously
  4. MOST on left colon
  5. RIGHT more prone to bleeding

Increased morbidity and mortality in: those w comorbids, need for transfusion, anticoagulant, NSAIDs

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5
Q

Characterize Vascular estasia (3)

A
  1. Arteriovenous malformations, angiodysplasias
  2. Present in small bowel
  3. Risk factor: Valvular heart disease
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6
Q

What is the most common cause of intestinal ishcemia?

A

Ischemic colitis

usually transient

RF: Aneurysmal rupture, vasculitis, hypercoagulable states, prolonged strenuous exercise, cardiovascular insult, IBS

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7
Q

Diagnosis of Ischemic colitis is done by?

A

Endoscopy

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8
Q

Mesenteric ischemia can lead to bowel necrosis by what mechanisms? (4)

A
  1. Thrombosis or embolism of SMA
  2. Mesenteric venous thrombosis
  3. Nonocclusive mesenteric ischemia
  4. Low arterial flow with vasoconstriction

Diagnosis: High index of suspicion, >60yo, Afib, CHF, MI, Post prandial ab pain, weight loss

CT is 92% specific 65% sensitive

Poor prognosis, survival of 50% in 24 hours

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9
Q

Study of choice in mesenteric ischemia

A

Angiography

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10
Q

Meckel’s diverticulim is most commonly found where?

A

Terminal ileum

embryonic tissue

Most commonly ectopic gastric tissue which secretes enzymes that erode the mucosal wall

Rare, but important in younger population

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11
Q

Most common source of anorectal bleeding

A

Hemorrhoids

Bleeding is assocaited with bowel movement
Massive hemorrhage is unusual

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12
Q

Factors associated with high morbidity in LGIB (10)

A
  1. Hemodynamic instability
  2. Repeated hematochezia
  3. Gross bleeding
  4. Initial Hct <35%
  5. Syncope
  6. Non-tender abdomen (predictive of severe bleeding)
  7. Hx of diverticulosis or angioectasia
  8. Elevated Crea
  9. NSAID or aspirin use
  10. > 2 comorbids
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13
Q

Bleeding + non-tender abdomen suggests?

A

Bleeding involving vasculature

Diverticulosis or angiodysplasia

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14
Q

Bleeding + Abdominal Tenderness suggests

A

Inflammatory bowel disorders

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15
Q

Bleeding source higher in the GI tract may elevate BUN levels by what mechanism?

A

Digestion and absorption of hemoglobin

BUN:Crea ratio of >30:1

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16
Q

Utility of barium studies in LGIB?

A

Not helpful and can interfere with subsequent endoscopy or angiography

17
Q

What are the initial diagnostics indicated in LGIB? (3)

A
  1. Angiography
  2. Scintigraphy
  3. Endoscopy

choice depends on ability, consultant preference and availability

18
Q

Diagnosis using Angiography requires a bleeding rate of?

A

0.5ml/min

Detects site of bleeding and guides surgical management

Allows transcatheter arterial embolization and infusion of vasoconstrictive agents

Serious complications can occur in up to 10% of cases

19
Q

What can be used in detecting site of bleeding in obscure hemorrhage?

A

Technetium labelled red cells scans

20
Q

Scintigraphy can localize the site of bleeding at what rate?

A

0.1ml/min

21
Q

What has potential value over Angiography?

A

Scintigraphy

however, requires a 3ml pool of blood

22
Q

Remarks for CT scan in LGIB

A

Useful in unstable cases
Can detect bleeding at a rate of 0.4ml/min

Used prior to angiography
sensitivity 100% specificity 99%
93% accuracy in detecting bleeding site

23
Q

When do you correct coagulopathy in LGIB?

A

INR >1.5
PC <50,000

24
Q

When to initiate blood transfusion in LGIB? (3)

A
  1. Continued active bleeding
  2. No improvement after crystalloids
  3. Hemoblogin <7g/dl

Transfusion is based more on the clinical picture and estimated blood lo

25
Q

Remarks on Flexible Sigmoidoscopy (2)

A

Evaluate distal colonic and rectal sources of bleeding

Cannot identify more proximal structures

26
Q

Remarks on Colonoscopy

A

Can diagnose diverticulosis and angiodysplasia
Allows for ablation of bleeding sites
Done in 12 to 24 hours of admission

Ablation: injection sclerotherapy, electrocoagulation, heater probe therapy, banding, clipping

Consider endoscopy if no finding

27
Q

What is the scoring system used to risk stratify patients with LGIB to determine if they can be discharged?

A

No relieable scoring system exists to risk stratify which patient with lower GI bleeding may be discharged home safely

EM Gastrointestinal (12 decks)

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