Hematochezia Flashcards
Hematemesis differential diagnosis
VINDICATE
V: esophageal varices, alcoholic, aortic aneurysms
I: reflex, esophagitis, ulcers, gastritis, acute pancreatitis
(hemorrhagic)
N: neoplasm (lung, stomach, blood cancers)
D: degenerative (stomach atrophy)
I: intoxication (lye, foreign body, alcoholic gastritis,
aspirin, warfarin)
C: congenital (hiatal hernia, telangiectasia)
A: autoimmune (scleroderma, ileitis, ITP)
T: trauma (foreign body, nasogastric tube trauma,
perforation/laceration)
E: endocrine (Zollinger-Ellision syndrome)
Rectal bleeding differential diagnosis
VINDICATE
V: hemorrhoids→ bright red stools, internal or external,
bleeding with bowel movements
I: perirectal abscess, anal fissure, ulcer, colitis
N: neoplasms, colon cancer, polyps
D: degenerative
I: intoxication, antibiotics (gentamicin, clindamycin),
jejunal ulcers, potassium chloride pills
C: congenital, Meckel diverticulum
A: autoimmune, colitis, inflammation, ulcerative colitis
T: foreign body
E: endocrine, Zollinger Ellison Syndrome (jejunum
ulcerations)
What is an overt bleed?
Visible bright red or maroon blood in feces or emesis
What is an occult bleed?
No visible blood in feces or emesis
What is an obscure bleed?
Iron deficiency anemia (IDA) or positive FOBT result
What is an obscure/occult bleed?
IDA recurrent or persistent
Positive FOBT
w or w/o visible bleeding
No source found during endoscopy
What is an obscure/overt bleed?
IDA persistent; positive FBOT; no visible blood in feces; no source identified
Blood visible in feces and emesis; bleeding recurrent or persistent; no source found during endoscopy
Symptoms of upper GI bleed (UGIB)
anemia hypovolemia hematemesis melena hematochezia
Causes of UGIB
NSAIDs ASA/antiplatelet Anticoagulants Esophagitis Esophageal varices
Causes of LGIB
Cancer Diverticulosis Polyps Colitis Ulcers
What is esophageal varices?
Dilated submucosal veins due to portal hypertension.
What is colitis?
Infectious colitis is due to campylobacter, salmonella or shigella.
Ischemic can be caused by IBD
Diverticulosis
A rupture in the diverticular sac.
Hematochezia symptoms
Presyncope, dyspnea, angina, postural hypotension, shock with no overt source.
Hematochezia history taking
- Amount, duration, source of bleeding.
- Dizziness, abdominal pain, chest pain, SOB, diaphoresis and weakness.
- Hx of bleeding and other illness (cirrhosis, cancer, coagulopathies, connective tissue disease)
- PMH, surgical, allergies, meds
- Hx ETOH, tobacco, illicit drug use
Hematochezia physical exam findings
- Note general appearance and mental status.
- VS tachycardia, hypotension
- Skin color, temp, turgor, moisture, cap refill
- Oral mucosa (hereditary hemorrhage telangiectasia or blue rubber bleb nevus syndrome - family hx of GIB)
- Signs of cirrhosis ie: spider nevi, palmar erythema, scleral icterus
- Abdomen. Cullen’s sign, rigidity, tenderness, cramping in the periumbilical area, abd distension
- Rectal exam-hemorrhoids, fissures, rectal carcinoma, gross blood, melena. FOBT
Hematochezia diagnostics
CBC Type and cross serum glucose electrolytes (increased BUN w/ normal Cr =UGI source) LFTs PT, aPTT ABG EKG NG lavage H. pylori
What is the diagnostic test of choice for UGIB?
Endoscopy
What are diagnostic modalities for LGIB?
Sigmoidoscopy Colonoscopy Nuclear scintigraphy Selective mesenteric angiography Enteroscopy
What will a bleeding scan (radionuclide evaluation) show?
Slow bleed
A patient has both occasional “coffee ground” emesis and melena stools. What is the most probably source of bleeding in this patient?
a. Hepatic
b. Lower GI
c. Rectal
d. Upper GI
ANS: D
Coffee ground emesis is usually old blood from an upper GI source and melena is black, shiny, foul-smelling as a result of blood degradation and is usually upper GI in origin. Lower GI and rectal bleeding will cause bright red blood in stools. Hepatic bleeding usually does not affect the GI tract.
What is an initial action when admitting a patient to the hospital who has a GI bleed, hypotension, and a hematocrit decrease of 6% from baseline?
a. Administer packed red blood cells
b. Place a Foley catheter to monitor output
c. Place two large-bore intravenous lines
d. Prepare for surgical repair of the bleed
ANS: C
The first interventions should involve restoring circulatory status to normal in patients with hypotension and low hematocrit. Placement of two large-bore intravenous lines or a central line is essential to allow transfusions of PRCs and fluids. The other interventions will be carried out, but are not the initial action.
A 50-year-old, previously healthy patient has developed chronic gastritis. What is the most likely cause of this condition?
a. H. pylori infection
b. NSAID use
c. Parasite infestation
d. Viral gastroenteritis
ANS: A
H. pylori accounts for approximately 100% of chronic superficial gastritis, 90% to 95% of duodenal ulcers, and 89% of gastric ulcers. NSAID use is an important cause, but not likely in a previously healthy individual. Parasites are the leading cause worldwide, but not in the U. S. Viral gastroenteritis usually does not cause chronic gastritis and usually has lower GI symptoms.
A school age child has a 3month history of dull, aching epigastric pain that worsens with eating and awakens the child from sleep. A complete blood count shows a
hemoglobin of 8 mg/dL. What is the next step in management?
A. Administration of H2RA or PPI medications
B. Empiric therapy for H. pylori (HP)
C. Ordering an upper GI series
D. Referral for esophagogastroduodenoscopy (EGD)
ANS: D
