General Surgery/GIT / Blood in Stool Flashcards
What are the common causes of lower GI bleeding in newborns?
- Swallowed maternal blood
- anorectal fissures
- necrotizing enterocolitis
- malrotation with volvulus
- Hirschsprung disease
- coagulopathy
What diagnosis should you suspect in an infant with nonspecific systemic signs, such as apnea, respiratory failure, lethargy, poor feeding, abdominal distention, vomiting, or diarrhea?
Necrotizing enterocolitis (NEC)
What is the hallmark radiographic finding of Necrotizing enterocolitis(NEC)?
- Pneumatosis intestinalis
- gas bubbles in the bowel wall
What is the major risk factor for NEC?
Prematurity
An infant presents with abdominal distension, bilious emesis, and melena. What is your diagnosis?
Malrotation with midgut volvulus
What are the common causes of GI bleeding in infants?
- Allergic colitis
- intussusception
- Meckel diverticulum
- Henoch-Schonlein purpura
- hemolytic uremic syndrome
- lymphonodular hyperplasia
What are the classic exam findings in an infant with intussusception?
- Currant-jelly stools
- mass in abdomen
- vomiting
What is the diagnostic test of choice for intussusception?
Ultrasonography or contrast enema
Guaiac positive stools, cutaneous purpura over buttocks and lower extremities, swelling of feet and joint pains in a child suggest what diagnosis?
Henoch-Schonelin purpura
What test can be used to differentiate fetal from maternal blood?
Apt test
What are the two major causes of iron deficiency in developed countries?
- GI blood loss
- Menstrual blood loss in women
What is the differential diagnosis of occult GI bleeding?
- Colon CA
- esophagitis
- peptic ulcer disease
- gastritis
- IBD
- vascular ectasias
- diverticula
- celiac disease
- portal hypertensive gastropathy
The presence of occult GI bleeding, epistaxis, and oral telangiectasias suggests what hereditary syndrome?
Osler-Weber-Rendu syndrome (also known as HHT: hereditary hemorrhagic telangiectasia)
False positive occult blood tests can result from ingestion of what?
- Red meat
- dietary peroxidases (such as turnips and radishes)
False negative results on occult blood tests can result from ingestion of what vitamin?
Vitamin C
Minimal bright red bleeding per rectum (BRBPR), or “outlet bleeding” includes what complaints?
- Small amounts of blood on toilet paper after wiping
- few drops of blood in toilet bowl, or
- small amounts of blood on surface of stool
Minimal bright red bleeding per rectum in this setting: Painless bleeding with defecation
Internal hemorrhoids
Minimal bright red bleeding per rectum in this setting: Sharp pain with bowel movements
- Anal fissure
- rectal CA
- herpes
- recent anal trauma or
- instrumentation
Minimal bright red bleeding per rectum in this setting: Passage of mucus, straining with defecation, and sense of incomplete evacuation
Rectal ulcer
Minimal bright red bleeding per rectum in this setting: Abdominal pain, change in bowel habits
Colon cancer
Maroon stool with intermixed bright red blood (hematochezia) implies bleeding from what part of the GI tract?
Proximal colon or small intestine
What test can be done in a patient with hematochezia to rule out an upper GI source proximal to the ligament of Treitz?
Nasogastric tube lavage or endoscopy
A history of melena and/or hematemesis suggests bleeding from what source?
Upper GI or slow proximal colon bleeding
What are important things to ask for in the history of a patient with rectal bleeding?
- Age
- systemic symptoms
- change in frequency or caliber of stools
- history of inflammatory bowel disease
- family history of colon cancer
- history of anal trauma
- history of pelvic radiation
What physical exam is required in the evaluation of rectal bleeding?
- External inspection of anus
- digital rectal exam, fecal occult blood testing
- office-based anoscopy or proctoscopy
What special measures should you take in a person with ongoing rectal bleeding, transfusion requirement greater than two units of packed red blood cells, or signs of hemodynamic instability?
- Admit to ICU
- start two large caliber peripheral catheters or central venous line
An elderly patient presents with left-sided abdominal pain and rectal bleeding after a recent episode of hypotension after surgery. What is your likely diagnosis?
Ischemic colitis
What are indications for additional testing in a patient with BRBPR regardless of age?
- Vital sign abnormalities
- constitutional symptoms
- change in frequency of stools
- anemia
- melena
- fecal occult blood positive stools
- family history of familial polyposis
What is the diagnostic test indicated when you cannot find a cause for rectal bleeding in a patient under age 50?
sigmoidoscopy or colononscopy
What is the diagnostic test indicated identified for ANY rectal bleeding in a patient OVER age 50?
Colonoscopy
What is the recommended evaluation for a patient with occult GI bleeding and anemia or upper GI symptoms?
Upper endoscopy and colonoscopy
When should you consider endoscopic evaluation in a premenopausal woman with anemia?
- Positive fecal occult blood test
- anemia out of proportion to menstrual blood loss
- family history of early GI malignancy
What is the grading of internal hemorrhoids?
Grade 1: no prolapse.
Grade 2: prolapse with defecation, but reduce spontaneously.
Grade 3: prolapse with defecation, require manual reduction.
Grade 4: prolapsed and cannot be reduced manually.
What is the initial treatment for bleeding and grade 1 or 2 hemorrhoids?
- Adding fiber to diet or using fiber supplement with psyllium or methylcellulose
- ensuring adequate fluid intake
What is the best initial treatment for irritation and pruritus associated with hemorrhoids?
- Warm sitz baths
- hydrocortisone suppositories
- analgesic creams
What is the treatment of acute thrombosed external hemorrhoids not improving within 24 to 48 hours?
Surgical evacuation of hemorrhoid with excision of skin overlying it
What are the nonsurgical treatment options for grade 1-3 internal hemorrhoids refractory to conservative therapy?
- Rubber band ligation
- infrared coagulation
- laser photocoagulation
- sclerotherapy
- cryosurgery
- bipolar diathermy (Bicap)
Operative therapy is indicated for hemorrhoids with what characteristics?
- Failure of medical and nonoperative therapy
- concomitant anorectal condition requiring surgery
- symptomatic third-degree
- fourth-degree, or mixed internal and external hemorrhoids
