Bernadino: Lower GI Bleeds Flashcards
What is the most common source of lower GI bleeds?
Colonic Source> upper GI source*most deadly> sml bowel source
What are colonic sources of lower GI bleeding?
Diverticular hemorrhage – 30-50% Angiodysplasia – 20-30% Ischemia Postpolypectomy Neoplasm IBD Infection Radiation colitis Anorectal disorders
Where are most diverticula in the colon?
sigmoid and left colon 65%
Who does acute colonic diverticulitis MC effect?
5-10% > age 40
80% > age 85 higher rates w/ increasing age
What are sxs of acute colonic diverticulitis?
Most pts are asymptomatic.
pain
diarrhea
fever
abdominal tenderness
*rarely hemorrhage
What complications are associated w/ acute colonic diverticulitis?
abscess
rupture
fistulize to adjacent organs
How do you dx acute colonic diverticulitis?
CT
NOT endoscopy or barium enema
How do you tx mild diverticulitis w/out peritoneal signs?
Out pt tx for nonelderly pt w/out comorbidities:
oral hydration
liquid diet
10 days of oral antibiotics (metronidazole and ciprofloxacin)(Amox/Clavulanate)
How do you tx severe pain caused by diverticulitis in elderly/comorbidities/immunocomp pts?
hospitalize
IV antibiotics
NPO
CT scan
What accounts for 50% of acute lower GI bleeding?
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%
**How do you treat diverticular hemorrhage that is persistent?
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
What is angioectasia (angiodysplasia)?
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
How does angioectasia usually present?
Overt hemorrhage or anemia.
Present in less than 1% of screening colonoscopies
Increased frequency with age* up there w/ diverticula
What are comorbidities for angioectasia?
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
**How do you tx angiodysplasia?
colonoscopy w/ ablation**
- argon plasma, cautery, hemoclip
surgery- subtotal colectomy
What are inflammatory causes of colitis?
Crohns
UC
NSAIDS (ileum and R colon)
What are infectious causes of colitis?
salmonella
shigella
campylobacter
e. coli
**How do you tx infectious colitis?
Usually self-limited
Hospitalize if: -elderly -immunocomp -dehydrated Tx: IV hydration and antibiotics
*What causes non-occlusive ischemic colitis?
hypoperfusion drugs heart disease exercise idiopathic
*What causes occlusive ischemic colitis?
embolic A Fib mesenteric vein thrombosis vascular procedure, vasculitis vasospastic, hypercoagulable state
How does ischemic colitis usually present?
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
How do you dx ischemic colitis?
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
How do you treat ischemic colitis?
Improve perfusion
- correct underlying cuase
- elective colonoscopy in 6-8 wks to rule out other cuases
**How are neoplasms location dependent?
Right colon – anemia (leaking slowly, don’t see blood)
Left colon – obstruction (crampy pain)
**A pt presents w/ occult, slow bleeding and anemia, and NO hematochezia.
Dx?
Neoplasm
Tx: surgical resection
A pt presents w/ tenesmus, diarrhea and pain, but no bleeding following radiation.
Dx?
Acute radiation proctitis (vessels get thing> bleed)
A pt presents w/ anemia and hematochezia (bright red blood) years after radiation.
Dx?
Chronic radiation proctopathy (seen more often; maybe on coumadin to make it worse; looks like AVMs throughout the colon)
**How do you tx radiation proctitis?
Endoscopic ablation**
What is an anal fissure?
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
What is a hemorrhoid?
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
How do you tx hemorrhoids?
Branding**
stool softening and bulking fiber
**A pt presents w/ bright blood, straining, pelvic fullness and constipation.
Dx?
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
How do you tx a solitary retal ulcer?**
Stool bulking softeners biofeedback topical mesalmine or steroids surgery
What is diverticulosis
presence of diverticula, low fiber> generates a lot of pressure> bulge where wall is weak
What is diverticulitis?
Complication of having diverticulosis
90 y/o F w/ episodes of hematochezia (bright blood)
diverticular hemmorhage
angioectasia
76 y/o M is dizzy after passing bright red stool w/ clots and showing hemodynamic compromise. Acute onset of bleeding.
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
84 y/o w/ RENAL FAILURE and copious rectal bleeding.
AVM** (elderly, renal> hi risk of AVM)
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.
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
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.
Crohns
UC
Polyps
Meckel’s Diverticulum (Techneetian-sp scan)
