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GI- Week 6 > Bernadino: Lower GI Bleeds > Flashcards

Bernadino: Lower GI Bleeds Flashcards

1
Q

What is the most common source of lower GI bleeds?

A

Colonic Source> upper GI source*most deadly> sml bowel source

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2
Q

What are colonic sources of lower GI bleeding?

A 
Diverticular hemorrhage – 30-50%
Angiodysplasia – 20-30%
Ischemia
Postpolypectomy 
Neoplasm
IBD
Infection
Radiation colitis
Anorectal disorders
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3
Q

Where are most diverticula in the colon?

A

sigmoid and left colon 65%

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4
Q

Who does acute colonic diverticulitis MC effect?

A

5-10% > age 40

80% > age 85 higher rates w/ increasing age

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5
Q

What are sxs of acute colonic diverticulitis?

A

Most pts are asymptomatic.

pain
diarrhea
fever
abdominal tenderness

*rarely hemorrhage

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6
Q

What complications are associated w/ acute colonic diverticulitis?

A

abscess
rupture
fistulize to adjacent organs

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7
Q

How do you dx acute colonic diverticulitis?

A

CT

NOT endoscopy or barium enema

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8
Q

How do you tx mild diverticulitis w/out peritoneal signs?

A

Out pt tx for nonelderly pt w/out comorbidities:

oral hydration
liquid diet
10 days of oral antibiotics (metronidazole and ciprofloxacin)(Amox/Clavulanate)

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9
Q

How do you tx severe pain caused by diverticulitis in elderly/comorbidities/immunocomp pts?

A

hospitalize
IV antibiotics
NPO
CT scan

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10
Q

What accounts for 50% of acute lower GI bleeding?

A

Acute diverticular hemorrhage (self limited in 80%)–transfuse and assume it will stop

It recurs in 1/3

Risk of rebleeding after a 2nd bleed is >50%

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11
Q

**How do you treat diverticular hemorrhage that is persistent?

A

Fluids/blood/make sure you’re not missing upper GI bleed–> elevated BUN indicates upper GI bleed

Colonoscopy if persistent – epinephrine, clip, cautery, band

Embolizatoin is standard of care if colonoscopy fails

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12
Q

What is angioectasia (angiodysplasia)?

A

Tortuous, dilated submucosal capillaries / veins lacking smooth muscle> weak> rupture

Most common in the right colon–cecum (can be anywhere)

*unexplained anemia

80% will rebleed without endotherapy

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13
Q

How does angioectasia usually present?

A

Overt hemorrhage or anemia.
Present in less than 1% of screening colonoscopies
Increased frequency with age* up there w/ diverticula

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14
Q

What are comorbidities for angioectasia?

A

Aortic stenosis (Heyde’s syndrome> break up multimer that protects a cofactor, exposing it to degradation in the blood stream)

Chronic renal failure (faulty platelets/faulty vessels)

Advanced age: Common cause of hematochezia in patients older than 65

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15
Q

**How do you tx angiodysplasia?

A

colonoscopy w/ ablation**
- argon plasma, cautery, hemoclip

surgery- subtotal colectomy

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16
Q

What are inflammatory causes of colitis?

A

Crohns
UC
NSAIDS (ileum and R colon)

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17
Q

What are infectious causes of colitis?

A

salmonella
shigella
campylobacter
e. coli

18
Q

**How do you tx infectious colitis?

A

Usually self-limited

Hospitalize if:
-elderly
-immunocomp
-dehydrated
Tx: IV hydration and antibiotics
19
Q

*What causes non-occlusive ischemic colitis?

A 
hypoperfusion
drugs
heart disease
exercise
idiopathic
20
Q

*What causes occlusive ischemic colitis?

A 
embolic
A Fib
mesenteric vein thrombosis
vascular procedure, vasculitis
vasospastic, hypercoagulable state
21
Q

How does ischemic colitis usually present?

A

Acute-severe abdominal pain followed by self limited hematochezia (sudden passing of blood, acute pain= ischemia–L side; R side is MUCH more severe)

  • IMA Right sided ischemia (transverse colon to splenic flexure is the watershed area)
  • usually w/out complications
22
Q

How do you dx ischemic colitis?

A

Hx: sudden, passed bloody stool, got better in 2 days in the hospital

CT: thickened colon wall

Colonoscopy: confluent, mucosal ulceration friability, usually splenic flexure.

Biopsy

23
Q

How do you treat ischemic colitis?

A

Improve perfusion

  • correct underlying cuase
  • elective colonoscopy in 6-8 wks to rule out other cuases
24
Q

**How are neoplasms location dependent?

A

Right colon – anemia (leaking slowly, don’t see blood)

Left colon – obstruction (crampy pain)

25
Q

**A pt presents w/ occult, slow bleeding and anemia, and NO hematochezia.

Dx?

A

Neoplasm

Tx: surgical resection

26
Q

A pt presents w/ tenesmus, diarrhea and pain, but no bleeding following radiation.

Dx?

A

Acute radiation proctitis (vessels get thing> bleed)

27
Q

A pt presents w/ anemia and hematochezia (bright red blood) years after radiation.

Dx?

A

Chronic radiation proctopathy (seen more often; maybe on coumadin to make it worse; looks like AVMs throughout the colon)

28
Q

**How do you tx radiation proctitis?

A

Endoscopic ablation**

29
Q

What is an anal fissure?

A

Acute (and recurrent) or CHRONIC tear in the anal canal that is usually POSTERIOR (watershed located here)

High sphincter pressure> decreases perfusion> causes perfusion to occur> bright blood> pain passing stool (chronic constipation, straining, diabetic)

Tx: bulk stool to decrease strain, topical nitrates improve flow

30
Q

What is a hemorrhoid?

A

Dilated blexus of submucosal middle and superior hemorrhoidal veins

Pt 45-60

Presents w/:
bleeding
pruritis
pain (not usually)

-advanced age, pregnant, chronic constipation, prolonged sitting/straining

31
Q

How do you tx hemorrhoids?

A

Branding**

stool softening and bulking fiber

32
Q

**A pt presents w/ bright blood, straining, pelvic fullness and constipation.

Dx?

A

Solitary rectal ulcer

Caused by:
RECTAL PROLAPSE (more common in women related to estrogen)
puborectalis spasm/weak pelvic floor
constipation
pt >40, F

ulcer/erythema/nodularity

33
Q

How do you tx a solitary retal ulcer?**

A 
Stool bulking
softeners
biofeedback
topical mesalmine or steroids
surgery
34
Q

What is diverticulosis

A

presence of diverticula, low fiber> generates a lot of pressure> bulge where wall is weak

35
Q

What is diverticulitis?

A

Complication of having diverticulosis

36
Q

90 y/o F w/ episodes of hematochezia (bright blood)

A

diverticular hemmorhage

angioectasia

37
Q

76 y/o M is dizzy after passing bright red stool w/ clots and showing hemodynamic compromise. Acute onset of bleeding.

A

Diff: upper GI bleed (hx, elevated BUN), diverticular hemorrhage, AVM (aortic stenosis)

Work-up: ICU d/t hemodynamic compromise, upper endoscopy to exclude GI bleed

Dx: Colonic bleed

38
Q

84 y/o w/ RENAL FAILURE and copious rectal bleeding.

A

AVM** (elderly, renal> hi risk of AVM)

39
Q

68 y/o M w/ CAD and intermittent abdominal pain w/ a hix of severe lower abdominal pain followed by an hour later by passage of bright red blood per rectum.

A

acute colonic ischemia

Diff:
Acute MS- sick, often acidotic (dead sml bowel), suggestion of atherosclerotic disease at SMA take off, air in wall of small bowel (fine walking/talking) (thrombotic event or low flow state)

Tx: hydrate bowel and surgery

Chronic mesenteric ischemia: M, elderly, smoker post prandial periumbilical pain, weight loss

  • less overlap in sml bowel (SMA) so it is often more severe
    tx: stenting
40
Q

15 y/o M presents to ER w/ first ever episode of severe rectal bleeding. He is dizzy and his Hb is 10.3. He has no pain but has cramps just before a BM.

A

Crohns
UC
Polyps
Meckel’s Diverticulum (Techneetian-sp scan)

GI- Week 6 (14 decks)

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