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Surgical Recall > Chapter 49: Lower Gi Bleeding > Flashcards

Chapter 49: Lower Gi Bleeding Flashcards

1
Q

What is the definition of lower GI bleeding?

A

Bleeding distal to the ligament of Treitz; vast majority occurs in the colon

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2
Q

What are the symptoms?

A
  • Hematochezia
    • (bright red blood per rectum [BRBPR])

with or without:

  • abdominal pain
  • melena
  • anorexia
  • fatigue
  • syncope
  • shortness of breath
  • shock
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3
Q

What are the signs?

A
  • BRBPR
  • positive hemoccult
  • abdominal tenderness
  • hypovolemic shock
  • orthostasis
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4
Q

What are the causes?

A
  1. Diverticulosis (usually right-sided in severe hemorrhage)
  2. vascular ectasia
  3. colon cancer
  4. hemorrhoids
  5. trauma
  6. hereditary hemorrhagic telangiectasia
  7. intussusception
  8. volvulus
  9. ischemic colitis
  10. IBD (especially ulcerative colitis)
  11. anticoagulation
  12. rectal cancer
  13. Meckel’s diverticulum (with ectopic gastric
    mucosa)
  14. stercoral ulcer (ulcer from hard stool)
  15. infectious colitis
  16. aortoenteric fistula
  17. chemotherapy
  18. irradiation injury
  19. infarcted bowel
  20. strangulated hernia
  21. anal fissure
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5
Q

What medicines should be looked for causally with a lower GI
bleed?

A

Coumadin®, aspirin, Plavix®

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6
Q

What are the most common causes of massive lower GI bleeding?

A
  1. Diverticulosis
  2. Vascular ectasia
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7
Q

What lab tests should be performed?

A
  • CBC
  • Chem-7
  • PT/PTT
  • type and cross
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8
Q

What is the initial treatment?

A
  1. IVFs:
  • Lactated Ringer’s
  • packed red blood cells as needed
  • IV × 2
  1. Foley catheter to follow urine output
  2. discontinue aspirin
  3. NGT
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9
Q

What diagnostic tests should be performed for all lower GI bleeds?

A
  • History
  • physical exam
  • NGT aspiration
    • to rule out UGI bleeding; bile or blood must be seen otherwise, perform EGD
  • anoscopy/proctoscopic exam
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10
Q

What must be ruled out in patients with lower GI bleeding?

A

Upper GI bleeding! Remember, NGT aspiration is not 100% accurate (even if you get bile without blood)

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11
Q

How can you have a UGI bleed with only clear succus back in the
NGT?

A

Duodenal bleeding ulcer can bleed distal to the pylorus with the NGT sucking normal nonbloody gastric secretions! If there is any question, perform EGD

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12
Q

What would an algorithm for diagnosing and treating lower GI
bleeding look like?

A
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13
Q

What is the diagnostic test of choice for localizing a slow to
moderate lower GI bleeding source?

A

Colonoscopy

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14
Q

What test is performed to localize bleeding if there is too much
active bleeding to see the source with a colonoscope?

A

A-gram (mesenteric angiography)

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15
Q

What is more sensitive for a slow, intermittent amount of blood loss:
A-gram or tagged RBC study?

A

Radiolabeled RBC scan is more sensitive for blood loss at a rate of ≥0.5 mL/min
or intermittent blood loss because it has a longer half-life

(for arteriography, bleeding rate must be ≥1.0 mL/min)

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16
Q

What is the treatment if bleeding site is KNOWN and massive or
recurrent lower GI bleeding continues?

A

Segmental resection of the bowel

17
Q

What is the surgical treatment of massive lower GI bleeding
WITHOUT localization?

A

Exploratory laparotomy with intraoperative enteroscopy and total abdominal colectomy as last resort

18
Q

What percentage of cases spontaneously stop bleeding?

A

80% to 90% stop bleeding with resuscitative measures only (at least temporarily)

19
Q

What percentage of patients require emergent surgery for lower GI
bleeding?

A

Only ≈10%

20
Q

Does melena always signify active colonic bleeding?

A

NO!

the colon is very good at storing material and often will store
melena/maroon stools and pass them days later

(follow patient, UO, HCT, and vital signs)

21
Q

What is the therapeutic advantage of doing a colonoscopy?

A

Options of injecting substance (epinephrine) or coagulating vessels is an advantage with C-scope to control bleeding

22
Q

What is the therapeutic advantage of doing an A-gram?

A

Ability to inject vasopressin and/or embolization, with at least temporary control of bleeding in >85%

23
Q

45-year-old male with dark blood per rectum

Name the diagnostic modality:

A

NGT aspiration to evaluate for upper GI bleed (if blood, then EGD; if bile and no blood, then work up for lower GI bleed)

24
Q

45-year-old male with significant massive blood per rectum; NGT
reveals bile and no blood

Name the diagnostic modality:

A

Angiography to find lower GI source

Surgical Recall (168 decks)

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