Bright Red blood Per Rectum Flashcards
Learn about lower GI bleeding
What are the DDX for lower GI bleeding
- Diverticulosis
- Neoplasia(Colorectal adenocarcinoma)
- Colitis (infectious, inflammatory, ischemic)
- Anorectal( Hemorrhoids, Anal fissure, Rectal varices, Rectal ulcer)
- Angiodysplasia
- Iatrogenic(post polypectomy or biopsy)
What is the mnemonic for LGIB
H-DRAIN Hemorrhoid Diverticulosis Rectal(ulcer, varices) Anal(fissure), Angiodysplasia Infection, ischemic, inflammatory colitis Neoplasia, polyp
How is age an important factor in LGIB
In Older patients the causes are Diverticulosis, Angiodysplasia or malignancy
In younger patients the causes are IBD, infection, haemorrhoids or anal fissures
What is significant about the onset and duration of bleeding
Acute and large amount of bleeding is usually associated with Diverticulosis(arterial bleeding)
Angiodysplasia and malignancy are more chronic and present with anemia or dark stoles
What does the color and amount of blood tell us about the source of LGIB?
- Upper GI,Small bowel and right colon- dark maroon mixed with stools
- Right colon, Rectum, Anus, Massive Upper GI bleed with rapid transit– copious bight red blood(hematochezia)
- Rectum, Anus – spots on toilet paper, dripping post defecation
- Angiodysplasia– Scant, dark red
5- polyp, colorectal ca– occult
What is the fate of right diverticula as compared to the left?
The right is more likely to bleed and the left is more likely to get infected
What is an occult blood?
Bleeding detected by faecal occult blood testing or by finding IDA(iron def anemia) and not seen by patient
What may be the cause of occult blood?
In older pts. Suspect malignancy (esp. Colorectal)
In younger pts. IBD or Familial cancer syndromes (FAP, HnpCRca)
What are the associated symptoms with LGIB that help us in ruling out diagnoses
Systemic symptoms- fever and bloody diarrhoea
Recurrent symptoms
Weight loss with bowel habits and/or anemia
Bleeding timing - following straining, painless,
Anal pain, tenesmus
Abdominal pain
Why is past history or colonoscopy important
Recent history (<5 yrs) of normal screening makes colon ca unlikely
Why is history of liver cirrhosis symptoms important
Liver disease can lead to coagulopathy and portal HTN..portal HTN may cause varices in rectal veins
What is the significance of family history
Colorectal Ca and IBD can be hereditary
What drugs(medications) exacerbate GI bleeding
Anticoagulant(warfarin, aspirin, clopidogrel) and NSAIDs
What does abdominal tenderness suggest in the setting of LGIB
Colitis(IBD, ischemic, infectious)
What is the significance of finding IDA in association with LGIB
In man or a post menopausal woman raises suspicion for malignancy (colorectal).
What are the initial steps in management of LGIB
If patient demonstrates significant blood loss - two large bore needle placement and fluid resuscitation (NS or RL) followed by packed RBC (as needed) Send lab tests for Type and cross CBC Chemistry INR/PTT
What results do we expect in CBC
Microcytic anemia (IDA due to occult blood loss by Colorectal Ca. Or chronic bleed from Angiodysplasia)
Leukocytosis - infection or inflammation
After fluid resuscitation and sending blood for lab test what is the next step
NG tube placement
Why is NG tube placement recommended for all patients presenting with large volume hematochezia?
10% of pt presenting with hematochezia are due to massive upper GI bleed…aspirated gastric content by NG tube helps to rule out upper GI bleed…if blood or coffee grounds are aspirated the patient has UGIB
How does the hemodynamic stability of the patient affect subsequent management and diagnostic workup?
If unstable- admission in ICU with expeditious workup to localize source of bleeding
What is the first diagnostic test of choice in an unstable pt.?
Colonoscopy– if urgent- no bowel prep, may fail to visualise source site but can generally determine if it is from colon or small bowel
What other diagnostic tests can we perform if colonoscopy fails to localize active bleeding site?
Arteriography
Nuclear scintigraphy - tagged RBC scan with technetium 999
What if all tests fail to identify the exact source? What is the next step
Depends on whether the bleeding has stopped and pt is stable or bleeding is still there and patient is unstable
Bleeding has stopped and patient is stable, what’s the next step?
If source is thought to be small bowel(blood above illeocecal valve on colonoscopy), small bowel studies are performed such as
Meckel’s nuclear scan
Capsure endoscopy
Enteroscopy
If source is not clear but somewhere in colon
Repeat colonoscopy
Nuclear scan and/or arteriography
