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MBBS 3: Surgery > Lower GIT Bleeding > Flashcards

Lower GIT Bleeding Flashcards

1
Q

What is lower GI bleeding?

A

Bleeding that occurs distal to the ligament of Treitz
Note:
Normal fecal blood loss 1.2ml / day
Significant - > 10ml/ day
- Range from scant bleeding to massive hemorrhage

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2
Q

Incidence?

A

20-30% of episodes of GI hemorrhage
- Incidence rises steeply with age

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3
Q

Common source of lower GI bleeding?

A

colon
> 80 - 85% originate distal to ileocecal valve
> Only 0.7% to 9% originate from small intestines
Note:
80 % LGIB resolve spontaneously
- 20% will re-bleed

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4
Q

Presentation?

A
  1. Hematochezia
    blood passing from rectum to anus
    - Range from bright-red blood to old clots
  2. Melena
    Black, tarry stools
    - Bleeding is slower or from a more proximal source
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5
Q

Categorisation?

A

intensity
1. Massive bleeding
2. Moderate Bleeding
3. Occult Bleeding

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6
Q

Presentation of massive bleeding?

A

Presents as large volume of bright red blood PR
- Bleeding > 1.5L/day

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7
Q

Signs and symptoms of massive bleeding?

A
  1. Hemodynamic instability and shock
  2. ↓ hematocrit level of 6g/dl or less
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8
Q

Treatment for massive bleeding?

A

Transfusion of at least 2 units of packed red blood cells/whole blood

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9
Q

Common causes of massive bleeding?

A

Common causes – D/A

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10
Q

Epidemiology of massive bleeding?

A

Massive hemorrhage common in patients > 65 yrs with multiple medical problems

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11
Q

Presentation of moderate bleeding?

A
  1. hematochezia
  2. malena
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12
Q

Sign and symptoms of moderate bleeding?

A
  1. Hemodynamically stable
  2. Initial ↓in hematocrit level of 8g/dL or less
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13
Q

Describe occult bleeding?

A
  • Occurs in the absence of overt bleeding and identified on lab test
  • Detected by routine chemical tests of the stool, with or without systemic evidence of chronic blood loss
    > Investigating for Iron deficiency anaemia
  • 10ml. of blood loss is necessary to have stool occult blood positive
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14
Q

Inflammatory aetiology?

A
  1. Ulcerative colitis
  2. Crohn’s disease
  3. infective colitis
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15
Q

Vascular aetiology?

A
  1. Ischemic colitis
  2. angiodysplasia
  3. hemangioma
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16
Q

Neoplastic aetiology?

A
  1. Adenoma
  2. carcinoma
  3. polyps
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17
Q

Clotting disorder aetiology?

A
  1. Hemophilia
  2. Warfarin therapy Leukemia
  3. DIC
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18
Q

Congenital aetiology?

A
  1. Polyp
  2. Meckel’s diverticulum
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19
Q

Miscellaneous aetiology?

A
  1. Hemorrhoids
  2. anal fissure
  3. injury to rectum
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20
Q

What is an anal fissure?

A

Tear in the lining of the rectum caused by passage of hard stools

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21
Q

Signs and symptoms of an anal fissure?

A

Sharp knife-like pain and bright red rectal bleeding with bowel movements

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22
Q

Management of anal fissure?

A

Medical :
1. stool bulking agents
2. ↑water intake
3. stool softeners
4. topical nitroglycerin ointment or diltiazem to relieve sphincter spasm and promote healing

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23
Q

What are hemorrhoids?

A

Cushions of submucosal tissue containing venules, arterioles and smooth muscle fibres located in anal canal

24
Q

Location of hemorrhoids?

A
  1. left lateral
  2. right anterior
  3. right posterial
25
Q

Function of hemorrhoids?

A

act as part of continence mechanism aid in complete closure of anal canal at rest
- Normal part of anorectal anatomy
Note:
Rx required if symptomatic

26
Q

Risk factors for hemorrhoids?

A
  1. excessive straining
  2. ↑abd pressure
  3. hard stools
    Note:
    can cause painless bright red rectal bleeding with bowel movements
27
Q

Types of hemorrhoids?

A
  1. External
    - distal to dentate line
    - covered with anoderm
  2. Internal
    - proximal to dentate line
    - covered by anorectal mucosa
    > Prolapse and bleed
    > Rarely painful unless thrombosis & necrotic, severe prolapse incarceration and/or strangulation
28
Q

How do you grade hemorrhoids?

A

extent of prolapse
1. 1st degree
- no prolapse, just prominent vessels
2. 2nd degree
- prolapse (come out) with strain but spontaneously reduce (go back in)
3. 3rd degree
- prolapse with strain and have to be pushed back in
4. 4th degree
- prolapsed out and cannot be reduced or pushed back in

29
Q

Management of hemorrhoids?

A
  1. Dietary fibre
  2. Stool softner
  3. ↑ fluid intake
  4. Avoidance of straining
  5. Dietary fibre
  6. Stool softner
  7. ↑ fluid intake
  8. Avoidance of straining
30
Q

What is Hemorrhoidectomy?

A

Required for large, symptomatic, combined hemorrhoids

31
Q

Inflammatory bowel disease?

A
  1. Ulcerative colitis
  2. Crohns Disease
  3. Indeterminate colitis
32
Q

Incidence of IBD?

A

Common in US, Northern Europe
Incidence lower : Africa, Asia, South America
Common in the 3rd and 7th decade

33
Q

Causes of IBD?

A
  1. Environment
  2. genetic
  3. immunological/multifactorial
34
Q

Presentation of IBD?

A

Characterized by intestinal Inflammation

35
Q

What is Ulcerative colitis?

A
36
Q

Mucosal ulcerative colitis?

A
  • colonic mucosa and sub-mucosa are infiltrated with inflammatory cells
  • Mucosa may be atrophic, crypt abscesses are common
37
Q

Endoscopic ulcerative collitis?

A

mucosa is frequently friable and may possess multiple inflammatory pseudocyst

38
Q

Long standing colitis?

A

colon is foreshortened and mucosa replaced by scar

39
Q

Ulcerative colitis may affect what?

A
  1. Rectum – Proctitis
  2. Rectum & sigmoid – proctosigmoiditis
  3. Rectum & Left colon – Left sided colitis
  4. Rectum & varying length of colon (extending proximal to splenic flexure) – pancolitis
40
Q

Signs and symtoms?

A

Symptoms related to - degree of mucosal inflammation, extent of colitis

41
Q

Typical presentation of ulcerative colitis?

A
  1. bloody diarrhea
  2. crampy abdominal pain
42
Q

Proctitis?

A

tenesmus `

43
Q

Fulminant colitis?

A

severe abd pain and fever

44
Q

Physical findings in ulcerative colitis?

A

range from minimal abd tenderness to frank peritonitis

45
Q

Diagnosis of ulcerative colitis?

A

colonoscopy and mucosal biopsy
1. U/C key feature : involvement of rectum & rectum
2. Rectal sparing or skip lesions : Crohn’s disease

46
Q

What is Crohns Disease?

A

Trans mural inflammatory disease
Affect any part of GI: mouth to anus
- Chronic inflammation → fibrosis, stricture & fistula → colon/small intestines

47
Q

Pathologic findings of Crohns disease?

A
  1. mucosal lacerations
  2. inflammatory cell infiltrates
  3. noncaseating granulomas
48
Q

Endoscopic appearance of Crohns disease?

A
  1. Deep serpiginous ulcer
  2. “cobblestone” appearance
  3. Skin lesions
  4. Rectal sparing
49
Q

Symptoms of Crohns disease?

A

depend on severity of inflam. and/or fibrosis & location of inflammation
1. Acute inflammation
- bloody diarrhea, crampy abd pain, fever
2. Stricture
- symptoms of obstruction
3. Weight loss from obstruction + protein loss
4. Perianal Crohn’s
- pain, swelling and drainage from fistulas/abscesses

50
Q

What is infective colitis?

A

Pseudomembranous colitis caused by C. difficile ( gram –ve anaerobic bacillus)

51
Q

Presentation of infective colitis?

A
  1. diarrhea (bloody or non-bloody)
  2. crampy abd pain,
  3. malaise
52
Q

Stool analysis for infective colitis?

A

identify microorganism

53
Q

What is diverticular disease?

A

outpouchings that project from the bowel wall
- Their development is caused by decreased fibre diet.

54
Q

Diverticulosis?

A

presence of diverticular without inflammation

55
Q

Diverticulitis?

A

Inflam. & infection associated with diverticular

MBBS 3: Surgery (42 decks)

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