Lower GI Bleed - Bernadino

Question 1

What are the causes of lower GI bleeding?

Answer 1

• Upper GI Source – 10%
• Small Bowel Source – 5%
• Colonic Source – 85%
  
  • Diverticular hemorrhage (30-50%)
  • Angiodysplasia (20-30%)
  • Neoplasm
  • IBD
  • Ischemia
  • Infection
  • Radiation colitis
  • Anorectal disorders
  • Post polypectomy

Question 2

What are the clinical features of Acute Diverticulitis?

Sx

Complications

Dx

Answer 2

• Diverticulosis affects 5-10% > age 40 and 80% > age 85.
• Symptoms of diverticulitis or hemorrhage occur in about 20%.
• Symptoms:
  
  • Pain, diarrhea, fever & abdominal tenderness
  • Hemorrhage is rare
• Complications: abscess, rupture or fistulize to adjacent organs
• Diagnosis is made by CT, not endoscopy or barium enema

Question 3

What is the treatment for Diverticulitis?

Answer 3

• Mild diverticulitis without peritoneal signs:
  
  • oral hydration, liquid diet, 10 days of oral antibiotics (metronidazole and ciprofloxacin)(Amox/Clavulanate)
• Severe pain; elderly, comorbidities, no PO intake:
  
  • hospitalize, IV antibiotics, NPO, CT scan
• Peritonitis; sepsis; perforation
  
  • surgical intervention

Question 4

How often does Acute Diverticular Hemorrhage occur?

Answer 4

• Accounts for 50% of acute lower GI bleeding
• Massive bleeding occurs in 5% of patients with diverticulosis
• Hemorrhage is self-limited in 80%
• Bleeding recurs in 1/3
• Risk of rebleeding after a 2nd bleed is > 50%

Question 5

What is the treatment for Diverticular Hemorrhage?

Answer 5

• Resuscitation
• Reverse anticoagulation
• Transfuse
• Consider / Exclude upper GI bleed
  
  • History, NG, BUN
• Observation (80% self-limited)
• Colonoscopy if persistent – epinephrine, clip, cautery, band
• Bleeding scan, angiography and embolization
• Surgery – attempt to localize with bleeding scan or colonoscopy

Question 6

What is Angioectasia/Angiodysplasia?

Answer 6

• Angioectasia = Angiodysplasia
  
  • Tortuous, dilated submucosal capillaries / veins lacking smooth muscle.
  • Spider-like, peripherally expanding 5-10-mm.
  • Anywhere, most common in the right colon
  • Present as overt hemorrhage or anemia.
  • Present in less than 1% of screening colonoscopies
  • Increased frequency with age.
  • 80% will rebleed without endotherapy.

Question 7

What are the comorbidities associated with Angiodysplasia?

Answer 7

• Aortic stenosis (Heyde’s syndrome)
• Chronic renal failure
• Advanced age:
  
  • Most common cause of hematochezia in patients older than 65

Question 8

What is the treatment for Angiodysplasia?

Answer 8

• Colonoscopy with ablation
  
  • Argon plasma
  • Cautery
  • Hemoclip
• Surgery – subtotal colectomy

Question 9

What is ischemic colitis?

Answer 9

• Lack of blood flow
  
  • typically in watershed areas

Question 10

How does Ischemic Colitis present?

Answer 10

• Non-occlusive: hypoperfusion, drugs, heart disease, exercise, idiopathic
• Occlusive: embolic, A Fib, mesenteric vein thrombosis, vascular procedure, vasculitis, vasospastic, hypercoagulable state
• Classic: Usually acute, severe abdominal pain → followed by self-limited hematochezia.
• May have mild – moderate, focal tenderness, fever, WBC, ileus
• Usually without complication: rarely stricture or perforate

Question 11

How do you diagnose Ischemic Colitis?

Answer 11

• History
• CT: Thickened colon wall
• Colonoscopy: confluent, mucosal ulceration friability, usually splenic flexure.
• Biopsy

Question 12

What is the treatment of Ischemic Colitis?

Answer 12

• Management: Improve perfusion (volume)
  
  • Correct underlying cause.
  • If self-limited, early colonoscopy not indicated (high risk)
  • Elective colonoscopy in 6-8 weeks – rule out other cause, stricture
  • If peritonitis, sepsis - Surgery

Question 13

What symptoms are typical in Lower GI bleeds caused by Neoplasm?

Answer 13

• Location-dependent symptoms
  
  • Right colon – anemia
  • Left colon – obstruction
• Occult, slow bleeding or anemia
• Rarely hematochezia
• Cause in <10% of hematochezia in age > 50

Question 14

What is Radiation Proctitis? How does it present?

Answer 14

• Acute radiation proctitis – during radiation Rx
  
  • tenesmus, diarrhea, pain, rarely bleeding
• Chronic radiation proctopathy – delayed mos-yrs
  
  • Anemia, hematochezia

Question 15

What is the treatment for Radiation Proctitis?

Answer 15

• Endoscopic ablation
• Formaldehyde, SCFA, steroids

Question 16

What are the three Ano-Rectal Disorders that cause Lower GI bleeds?

Answer 16

1. Fissure
2. Hemorrhoids
3. Solitary rectal ulcer

Question 17

Where are most Anal Fissures?

Answer 17

Usually posterior, less often anterior

Question 18

What are the common comorbidities associated with Anal Fissure?

Answer 18

• Chronic constipation
• diabetes
• Crohn’s

Question 19

What is the treatment for Anal Fissures?

Answer 19

• Stool softening and bulking (fiber)
• Topical nitrates, calcium channel blocker (NTG, diltiazem, nifedipine)
• Botulinum toxin
• Lateral sphincterotomy – risk of incontinence
• Sphicter dilation – mixed efficacy

Question 20

What are Hemorrhoids?

Answer 20

Dilated plexus of submucosal middle and superior hemorrhoidal veins

Question 21

What is the clinical presentation of Hemorrhoids?

Answer 21

• Symptoms: Bleeding, pruritis, pain ( if thrombosis)
• Peak age range (45-60), rare < 20 yo
• Associated with:
  
  • advancing age, diarrhea, pregnancy, prolonged sitting, straining, and chronic constipation

Question 22

What is the treatment for Hemorrhoids?

Answer 22

• Stool softening and bulking (fiber)
• Banding, surgical hemmorrhoidectomy

Question 23

What is the clinical presentation of Solitary Rectal Ulcers?

Answer 23

• Varying appearance
  
  • erythema
  • nodularity
  • ulcer
• Etiology: rectal prolapse, puborectalis spasm, constipation, 4th decade
• Symptoms: bright blood, straining, pelvic fullness, constipation

Question 24

What is the treatment for Solitary Rectal Ulcers?

Answer 24

• Stool bulking, softeners, biofeedback
• Topical mesalamine or steroids
• Surgery