Lower GI Bleeding

Question 1

What are the most common causes for LOWER GI bleeding?

Answer 1

• proctitis
• hemorrhoids
• polyps
• diverticulosis
• tumor
• colitis
• all easily treated

Question 2

Can you use the same media used for hemoccult testing, and use it to test for blood in the upper GI tract?

Answer 2

NO, because any fluid that you remove from the upper GI tract will always turn the media blue (aka positive test), due to the pH difference.

Question 3

What test do you use to to test for upper GI bleeding?

Answer 3

gastroccult

Question 4

When is proctitis commonly seen?

Answer 4

• following radiation treatment for prostate cancer.

Question 5

Is bright red blood coming form the rectum always indicative of a lower GI bleed, and dark blood indicative of an upper GI bleed?

Answer 5

NO! Blood is a cathartic (stimulates the GI tract), meaning the faster you bleed, the more likely it will move through the GI tract more quickly, and the LESS deoxygenated it gets, meaning the more bright red it will appear.

Question 6

How can you instantly treat a thrombosed hemorrhoid?

Answer 6

• cut it with the tip of a sharp knife, squeeze it, and the clot will come out, providing INSTANT relief to the patient!

Question 7

What is important to remember about hemorrhoids and proctitis?

Answer 7

• they can be signals of pathology elsewhere. About 1/3 of the time you will have pathology higher in the colon. So send these patients for colonoscopy.

Question 8

Should all polyps be removed?

Answer 8

YES via colonoscopy :)

Question 9

** What 2 tests will you have to rely on to look for lower GI bleeding?

Answer 9

1. ARTERIOGRAPHY= better test because it not only shows you where the bleed is, but you can also thrombose the vessel with a little wire.
2. TECHNETIUM SCAN= tag RBCs with radioisotope to show us if blood is leaking out of the circulation.

Question 10

How fast must blood be leaking for technetium scan to pick up a lower GI bleed?

Answer 10

1/2 cc/min (aka 2 or 3 bloody bowel movements per hour; it’s a lot).

Question 11

Even though arteriography is the better test for a lower GI bleed, what is a problem with it?

Answer 11

• the bleed has to occur at 1 cc/min, which is even faster than what the technetium scan.
• aka arteriography is less sensitive than technetium scan.

Question 12

If a patient gets colon cancer in your office, who’s fault is it?

Answer 12

YOUR FAULT AS THE DOCTOR, because this should never get to this point. All you have to do is screen your patient by putting a finger in their rectum, even if they are just coming to see you for the common cold.

Question 13

Can you cure Crohn’s disease via surgery?

Answer 13

NO

Question 14

Can ulcerative colitis be cured with surgery?

Answer 14

YES via a total colectomy.

Question 15

So what do we want to do to identify a lower GI bleed first?

Answer 15

1. DIRECT VISUALIZATION (proctoscopy)
2. arteriography or technetium scan (these are good for the life cycle of the red blood cells that are tagged).
3. colonoscopy

Question 16

*** Does most GI bleeding stop on its own?

Answer 16

YES 80%

Question 17

What can we do to the colon, if we can’t connect the two ends of the colon back together?

Answer 17

• COLOSTOMY= opening in the colon for which feces to move out.

Question 18

What are the 3 types of colostomies?

Answer 18

1. loop
2. end
3. double barrel

Question 19

*** What is an END colostomy?

Answer 19

• close off an end of bowel (sigmoid colon), and leave an opening at the descending colon in order to allow better healing. This is called a HARTMAN’S POUCH or SINATRA’S PROCEDURE bc Frank Sinatra had this done.

Question 20

*** What is a DOUBLE BARREL colostomy?

Answer 20

• two separate stomas are created. Both ends of the bowel are brought through the abdomen to the skin surface as two separate sections. The proximal stoma, which is functional, diverts feces to the abdominal wall.
• usually indicates bad disease.

Question 21

*** What is a LOOP colostomy?

Answer 21

• a stoma in which the entire loop of colon is exteriorized and both the proximal limb and the distal limb open into a common stoma opening and are not transected.