Lower GI Bleeding

Question 1

What is lower GI bleeding?

Answer 1

Bleeding distal to the ligament of Treitz, typically from the colon.

Question 2

What are the symptoms of lower GI bleeding?

Answer 2

Hematochezia, +/- abdominal pain, melena, anorexia, fatigue, syncope, SOB, shock.

Question 3

What are the signs of lower GI bleeding?

Answer 3

BRBPR, positive hemoccult, abdominal tenderness, hypovolemic shock, orthostasis.

Question 4

What are the causes of lower GI bleeding?

Answer 4

Diverticulitis, intussusception, volvulus, Meckel’s diverticulum, aortoenteric fistula, strangulated hernia, vascular ectasia, hemorrhoids, hereditary hemorrhagic telangiectasia, infarcted bowel, colon cancer, rectal cancer, trauma, ischemic colitis, IBD, anticoagulation, stercoral ulcer, infectious colitis, chemotherapy, irradiation, anal fissure.

Question 5

What medicines should be looked for causally with a lower GI bleed?

Answer 5

Coumadin, aspirin, Plavix.

Question 6

What are the most common causes of massive lower GI bleeding?

Answer 6

1. Diverticulosis

2. Vascular ectasia

Question 7

What lab tests should be performed for lower GI bleeding?

Answer 7

CBC, BMP, PT/PTT, T&C

Question 8

What is the initial treatment of lower GI bleeding?

Answer 8

IVFs (e.g. lactated Ringer’s); packed RBCs; Foley; d/c aspirin, NGT

Question 9

What diagnostic tests should be performed for all lower GI bleeds?

Answer 9

H&P, NGT aspiration (r/o UGI bleeding; if no bile or blood, perform EGD), anoscopy or proctoscopy

Question 10

What must be ruled out in patients with lower GI bleeding?

Answer 10

Upper GI bleeding.

Question 11

How can you have a UGI bleed with only clear succus back in the NGT?

Answer 11

Bleeding DU can bleed distal to the pylorus with the NGT sucking normal non-bloody gastric secretions.

Question 12

What is the diagnostic test of choice for localizing a slow to moderate lower GI bleeding source?

Answer 12

Colonoscopy

Question 13

What test is performed to localize lower GI bleeding if there is too much active bleeding to see the source with a colonoscopy?

Answer 13

A-gram (mesenteric angiography)

Question 14

What is more sensitive for a slow, intermittent amount of lower GI blood loss: A-gram or tagged RBC study?

Answer 14

Radiolabeled RBC scan (for arteriography, bleeding rate must be > 1.0 mL/min).

Question 15

What is the colonoscopic treatment option for a bleeding vascular ectasia or polyp?

Answer 15

Laser or electrocoagulation; local epinephrine injection.

Question 16

What is the treatment if bleeding site is known and massive or recurrent lower GI bleeding continues?

Answer 16

Segmental resection of the bowel.

Question 17

What is the surgical treatment of massive lower GI bleeding without localization?

Answer 17

Exploratory laparotomy with intraoperative enteroscopy and total abdominal colectomy as last resort

Question 18

What percentage of cases of lower GI bleeding spontaneously stop bleeding?

Answer 18

80-90% stop bleeding with resuscitative measures only

Question 19

What percentage of patients with lower GI bleeding require emergent surgery?

Answer 19

10%

Question 20

Does melena always signify active colonic bleeding?

Answer 20

NO. The colon is good at storing material and can pass melena days after bleed.

Question 21

What is the therapeutic advantage of doing a colonoscopy? (2)

Answer 21

Have the option of injecting epinephrine or coagulating vessels

Question 22

What is the therapeutic advantage of doing an A-gram for a lower GI bleed? (2)

Answer 22

Have the option to injecting vasopressin or embolization