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LMCC Part II > LGIB > Flashcards

LGIB Flashcards

1
Q

define LGIB

A

bleeding distal to the ligament of trietz

*causes of UGIB can also produce a LGIB

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2
Q

define hematochezia

A

passage from bright red blood per rectum

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3
Q

how does bleeding from right colon usually look? from the left?

A

right colon–maroon

left colon–bright red

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4
Q

define melena

A

passage of dark tarry stools per rectum due to blood being altered by intestinal juices

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5
Q

what is the number 1 cause of LGIB

A

colonic diverticulosis (NOT diverticulitis)

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6
Q

common etiologies of LGIB

A 
colonic divertoculosis 1
AV malformation/angiodysplasia 2
mesenteric thrombosis/ischemia
colitis 3 
neoplastic lesions of the colon and rectum 
--usually occult bleeding 
--colonic polyps 4
nonneoplastic ano-rectal lesions 
--hemorrhoids, fissures, proctitis, iatrogenic 
small intestinal lesions
--meckel's diverticulum, crohns
bleeding diathesis
--DIC, leukemia, thrombocytopenia, HSP
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7
Q

what are the types of colitis that may cause LGIB

A

radiation induced

ulcerative–hx IBD

bacterial

ischemic–common in elderly with atherosclerosis

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8
Q

what types of bacteria cause bloody colitis

A 
shigella
campylobacter
E. histolytica
salmonella
CMV
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9
Q

what to ask on history for LGIB

A

hematemesis–r/o UGIB source

NSAID or etoh ingestion–r/o gastritis

hx PUD–r/o bleeding duodenal ulcer

hx persisten vomiting–r/o mallory weiss or boerhaave syndrome

change in bowel habits–r/o colon cancer

hx smoking–r/o ischemic disease of the colon

hx AAA repair–r/o aortoenteric fistula

hx liver disease–r/o esophageal varices

hx bleeding disorder

hx severe trauma or burn

family or personal history of FAP, HNPCC, colon cancer, crohns or UC

recent travel

diet–uncooked meats, unpasteurized foods to r/o bacterial infection

infectious symptoms

B symptoms

hx blood clots–r/o mesenteric ischemic

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10
Q

what is initial management of LGIB

A

vitals including postural

begin infusion of crystalloid NS or RL

send blood for CBC, PT/PTT, type and screen, crossmatch, lytes, BUN, creatinine, liver enzymes

insert NG tube and drain stomach (can r/o UGIB in 90% of cases)

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11
Q

what to look for on physical exam for LGIB

A

look for ominous signs: altered LOC, pallor, cool limbs, tachycardia, hypotension

RECTAL EXAM and send for FOB

signs of chronic liver disease

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12
Q

what types of investigations, beyond blood work, may be indicated in LGIB

A

upper GI endoscopy may be necessary to absolutely r/o upper GI source–> if lower GI source is obvious then may be omitted

anoscopy

sigmoidoscopy or colonoscopy (not helpful in persistent bleeding)

if bleeding is brisk and intermittent, arteriography may serve to locate the source

radionuclide scanning for low grade intermittent bleeding

barium enema if bleeding stops–avoid if bleeding persists

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13
Q

initial treatment of LGIB

A

volume rescuscitation

abx if infectious, steroids if inflammatory

indication for surgery if persistent, refractory bleeding

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14
Q

list the types of LGIB

A
  1. anatomic
    - -i.e diverticulosis
  2. vascular
    - -angiodysplasia
    - -ischemic
    - -radiation induced
  3. neoplasm
  4. inflammatory
    4a. infectious–salmonella, shigella
    4b. non infectious–crohns
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15
Q

where is the bleeding coming from if patient presents with maroon stools

A

LGIB from the right side of the colon

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16
Q

where is the bleeding coming from if patient presents with bright red blood per rectum

A

LGIB from left side of the colon

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17
Q

where is the bleeding coming from if patient presents with melena

A

cecal bleeding

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18
Q

is bright red blood per rectum ALWAYS from left side of the colon

A

no, may be from an UGIB or right side of colon if bleeding is brisk and massive

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19
Q

what might you think of in a patient wiht painless PR bleeding and minimal sx

A

diverticular bleed

angiodysplasia

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20
Q

what non surgical modalities can be used to dx LGIB

A

colonoscopy
radionuclide scans
angiography

21
Q

what is the diagnostic method of choice in patients who are hemodynamically stable with LGIB

A

fibreoptic flexible colonoscopy

22
Q

what is the diagnostic method of choice in patients who are hemodynamically unstable and i those with brisk ingoing LGIB

A

angiography with or without a preceeding radionuclide scan

*this is also performed if angiography has failed to ID the bleeding site

23
Q

indications for surgery in context of LGIB

A

active persistent bleeding with hemodynamic instability that is refractory to aggressive resuscitation

persistent recurrent bleeding

transfusion of more than 4 units of packed red blood cells in a 24 hour period with active or recurrent bleeding

transfusion of more than 6 units of PRBCs during the same hospitalization

24
Q

define massive LGIB

A

passage of a large volume of red or maroon blood per rectum

hemodynamic instability and shock

initial decrease in hematocrit

transfusion of at least 4U of PRBCs

bleeding that continues for 3 days

significant rebleeding in 1 week

25
Q

what should be included in the physican exam for JGIB

A 
skin
oropharynx
nasopharynx
abdomen
perineum
anorectum

*include NG tube insertion, DRE and anoscopy/proctoscopy in the initial physical examination in all patients

26
Q

what % of patients with diverticular disease experience bleeding? what % stop spontaneously?

A

20% bleed

80% stop spontaneously

  • *in 5%, bleed can be massive
  • *right sided diverticula account fo 50-90% of bleeding, despite most diverticula being on the left side
27
Q

do people usually get massive hemorrhage from IBD

A

no its rare

UC presents as bloody diarrhea, and it is less common in Corhns

28
Q

main clinical manifestations of ischemic colitis

A

abdo pain
bloody diarrhea

not associated with significant blood loss or hematochezia

29
Q

name the benign anorectal diseases that can cause rectal bleeding

A

hemorrhoids
anal fissures
anorectal fistulas

30
Q

what % of patients with LGIB had hemorrhage from anorectal disease

A

11%

31
Q

who should you consult for LGIB

A

general surgery

32
Q

top four ddx for significant LGIB

A
  1. diverticulosis
  2. hemorrhoids/anorectal disease
  3. IBD
  4. carcinoma
  5. angiodysplasia
33
Q

risk factors for diverticular bleed

A

lack of dietary fiber

constipation

advanced age

use of NSAIDs/ASA

34
Q

what are the two leading causes of SIGNFICANT bleeding from lower GI tract

A

diverticulosis (30-50%)

angiodysplasia

35
Q

what is the most common cause of LGIB in patients below 50?

A

hemorrhoids

*but this is rarely significant usually is a minor bleed

36
Q

what the most important step in initial treatment of massive LGIB

A

ID the bleeding site

37
Q

what to ask on PMHx for LGIB

A 
PUD
liver disease
cirrhosis
coagulopathy
IBD
previous med use

if has had cancer, ask about hx radiation, chemo

38
Q

how does angiodysplasia bleeding often present

A

mild and intermittent

39
Q

how might anorectal disease with LGIB present

A

stools streaked with blood

perianal pain

blood drops on toilet paper or in toilet bowl

40
Q

why do you place an NG tube when evaluating LGIB

A

because brisk UGIB can present as LGIB

so you look at the aspirate or lavage to examine for presence of blood or bile —> these aspirates usually correlate well with upper GI hemorrhage proximal to the ligament of Trietz

therefore, insert an NG tube to confirm the presence or absence of blood in the stomach

41
Q

why would you do a gastric lavage with an NG tube

A

do gastric lavage with warm isotonic fluids to obtain bilious discharge

because this would include fluid beyond the pylorus, and if no blood is present, an UGIB source makes sense only if the bleeding has stopped

42
Q

what other tubes should be inserted

A

place Foley to monitor urine output

careful DRE, anoscopy and rigid proctosigmoidoscopy should exclude an enorectal source of bleeding

43
Q

steps in the management of LGIB

A
  1. aggressive volume rescusitation
  2. place NG–check for UGIB
  3. DRE and anoscopy
  4. if intermittent bleed–> colonoscopy and manage from there (chill)
  5. if moderate–> do scintigraphy
  6. if massive bleed–> do mesenteric angiography
44
Q

what other imaging test could you order

A

CT angio

prior to planning endoscopic or radiologic therapy, can localize the site of blood loss with CT angiography–use this in patients who are hemodynamically unstable or who have signs of shock after initial resuscitation

if no bleeding source IDed and bleed continues, think UGIB and do endoscopy

45
Q

how should you manage a hemodynamically unstable patient with active LGIB

A

admit to ICU

early consults with GI and general surgery

RESUSCITATE with fluid

rapid assessment of vital signs including UOP

46
Q

what is one of th emost important elements in the management of patients with massive UGIB and LGIB

A

the initial resuscitation

should do two large bore IVs with isotonic crystalloid fluid (NS)

consider transfusing PRBCs

47
Q

what does orthostatic hypotension in GIB indicate

A

blood loss of more than 1 L

48
Q

what are signs of hemodynamic compromise

A

postural changes with dyspnea, tachycardia, tachypnea

decrease in BP of more than 10mmHg or increase in HR more than 10 bpm is indicative of at least 15% of blood volume loss

severe postural dizziness with postural pulse increase of at least 30 bpm suggests blood loss of more than 630 mL

49
Q

do you admit people with major bleeds

A

yes–admit for colonoscopy on the next available list

LMCC Part II (52 decks)

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