Approach to Lower GI Bleeding Flashcards
definition of a lower Gi bleed
bleeding below the ligament of treitz in the duodenum
typical presentation of lower GI bleed
- darker red blood/stool if coming from right colon (beacuse more time to pass through Gi tract and oxidize0
- bright red if coming from left colon.
- hematochezia
*sometimes if its a massive UGIB bleed it may present as a LGIB
Is melena a common symptom of LGIB
no. if its black it means that the blood is coming from further up so its probably a UGIB, but it might be a super slow/intermittent LGIB
causes of lower GI bleeding (acute)
perianal, stable or severe/unstable
chronic lower GI bleeding may be due to:
Fe deficiency anemia
DDx for minimal rectal bleeding (may have noticed blood on toilet paper or in toilet bowl, but not coming from intestines)
- Hemarrhoids
- anal fissure
- rectal ulcer
- proctitis
- polyps
- beets
BRBPR should be thought of as from thea norectal source and is usually benign
main reasons behind perianal bleeding in young adults
hemorrhoids- may be constimated, intermittent blood, not anmic
anal fissure – perianal pain, tearing, hard stool, straining
solitary recal ulcer – passage of mucus, hard stool straining, sense of incomplete evacuation.
proctitis (distal colitis)– intermittent BRBPR if mild, mucus, diarrhea
polyps/cancer. small distal polyps can bleed. Cancers may appear hard and irregular.
outlet bleeding
blood on toilet paper or surface of stool
management of minimal rectal bleeding BRBPR
- history– age, anal pain, fam Hx
- physical recal exam: hemorrhoids, fissure, mass
- Lab– rule out anemia. no stool tests for hidden blood, as blood is visible
- investigate – sigmoidoscopy vs colonoscopy
big four reasons for ACUTE significant lower GI bleeding
- diverticulosis
- colitis
- angiodysplasia– death/deficiencies of the vessels.
- cancer/polyps, including following a polypectomy (may be bleeding because of surgery)
diverticulum
diverticulopsis
diverticular disease
diverticulum: a sac
diverticulosis: diverticula (sacs) present (SHOULDNT BE THERE), but usually asymptomatic
diverticular disease: diverticula + symptoms
diverticular disease vs diverticulitis vs diverticular bleeding vs diverticular (segmental) colitis
- diverticular disease: general pain but no overt inflammation
- diverticulitis: inflamed diverticulum, causing pain, LLQ tenderness and increased WBC
- diverticular bleeding: painless hematochezia
- diverticular (segmental) colitis: hematochezia and crampy LLQ pain
epidemiology of diverticulosis– how does age and ethnicity effect it?
age dependent– 70% chance of diverticulosis at 85 years
developedmore in western populations
white = sigmoid colon
asian = right colon
bleeding tends to arise from right colon, whereas abdominal pain usually arises from left/sigmoid colon. Diverticula at dif places manifest as different symptoms
diverticulosis is caused by Pulsions which is:
herniation of submucosa/mucosa BUT NOT MUSCULARIS through naturally occurring defects in wall where vessles penetrate.
- causes abnormal motility: increased pressure in colonic lumen: protrusion because intral lumen pressure is high.
- decreased tensile strength from exaggerated aging changes in bowel wall. Vasa recta are then stretched over the dome of the diverticula. Any trauma can then cause rupture because the vessels are so stretched thin
diverticulitis is often presented as_
appendicitis
diverticula presence is often asymptomatic (70%) or may have painless diverticular bleeing (10%), but diverticulitiz (20%) can be painful, with 3/4 of it being uncomplicated and the other 25% being complicated causing ___ ___ __ or ___
abscess, perforation, fistula, or sepsis.
how does sepsis occur in a pt with diverticulosis? What are the consequences?
stool blocks sac –> stasis –> sepsis. Consequence is actute diverticulitis (inflammation and pain in LLQ and increased WBC)
- simple would be self limited
- complicated may result in microperforation/LLQ appendicitis, perforation, fistula (ex/ to the bladder), or obstruction (from thick wall and narrowed lumen)
*for asians it can happen on the right hand side.
how does segmental colitis occur in a pt with diverticulosis? How do you diagnose it and how do you treat it?
mucosal prolapse, fecal stasis, localized ischemia.
presentation: intermittident hematochezia, chornic bloody diarrhea or LLQ cramping
Dx via sigmoidoscopy
Rx via antibiotics 3 ASA, steroids
management of diverticular disease
fiber!
- complications from bleeding: resuscitate and endoscope
diverticulitis: antibiotics, possible surgery
T/F Acute significant lower GI bleed often never stops and requires immediate intervention
false. 80% of lower GIBs stop spontaneously, but the prognosis is dependent on risk factors:
- hemodynamic instability
- ongoing bleeding
- older pt with comorbid illnesses or coagulopathies
Managing significant heamtochezia
- may be hemodynamically unstable, ongoing bleeding, could have serious comorbid disease. Determine if stable or unstable.
- make sure to resuscitate with IV fluis, blood. Admit. Rule out upper GI source.
If stable and no uppger GI source, do urgent colonoscopy <24 hours. If unstable, they will be intolerant to colonscopy prep. Do a CT angiography, rbc scan. Consult with surgery/
If low risk they;lk have
- no or few high risk featyres
- hemodynamically stable
- no ongoing bleeding
- no serious co morbid disease.
- this is urgent but not emergent. Do a colonoscopy soon
when you’re managing a person with an LGIB, after doing resuscitation you have to do diagnostic studies like sigmoidoscopy or colonoscopy. What’re you looking for to determine cause?
on the imaging, look for “thumb printing” which could be indicative of ischemia. Do a CT of abdomen.
If colonscopy was not diagnostic and theres continued bleeding over >0.5ml/min, might need to do angiography or labelled RBC scan.
when you’re managing a person with an LGIB, after doing resuscitation you have to do diagnostic studies like sigmoidoscopy or colonoscopy. What’re you looking for to determine cause?
on the imaging, look for “thumb printing” which could be indicative of ischemia. Do a CT of abdomen.
If colonscopy was not diagnostic and theres continued bleeding over >0.5ml/min, might need to do angiography or labelled RBC scan.
ischemic colitis is common in people with low flow states including
cardiac co morbities, diabetes, hypotension/vasculitis. also in elderly.If younger, rule out the risk for thromboembloic event (atrial fib)
PS, OE, Dx, and Rx for ischemic colitis
PS: abdominal pain and bloody diarrhea
OE: tenderness
Dx: X ray, endoscopy
Rx: supportive.
occaisonal UPPER GI Bleeds may look like LGIB. How so
rectal bleeding
marked hypovolemia
NG emesis/coffee ground barf
elevated BUN
overall management of acute lower GI bleeding
- initial assessment and appropriate triage
- resuscitate prn
- localize bleeding site via colonscopy (make sure to clean them out before hand) and Ct angiography if lots of bleeding.
- stop bleeding via therapeutic intervention in <24 hours.
IBD diseases
crohns, ulcerative colitis
