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DDX Gastrointestinal system > Melena and hematochezia > Flashcards

Melena and hematochezia Flashcards

1
Q

What is melena?

A
  • = passage of dark-colored to black, tarry stools due to hematin (oxidised haemoglobin)
  • Colonic hemorrhage can produce melena if intestines are hypomotile
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2
Q

What are the inflammatory causes of melena?

A

Esophagitis

Gastroenteritis

Eosinophilic gastritis

Inflammatory bowel disease

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3
Q

List ways that blood could be ingested to cause melena….?

A

Sinonasal lesions (URT -epistaxis)

Oral/Pharyngeal lesions

Pulmonary Lesions (LRT hemoptysis)

Diet (e.g. Raw)

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4
Q

What are common infectious causes of melena?

A

Bacterial: Campylobacter, Clostridium, Mycobacterium, Neorickettsia helminthoeca, Salmonella

Fungal/Algal Cryptococcus, Histoplasma, Pythium, Prototheca

Parasitic: Spirocerca, Physaloptera, Ancylostoma, Uncinaria

Viral: Parvovirus

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5
Q

What are the ischemic/traumatic causes of melena?

A

Hypovolemic shock

Thrombosis/infarction

Intussusception

Volvulus

Foreign Body

Racing sled dogs

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6
Q

What are the drugs that can cause melena?

A

Corticosteroids

Non-steroidal anti-inflammatory drugs

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7
Q

What are the neoplastic causes of melena?

A

Adenocarinoma

Gastointestinal stromal tumor

Leiomyoma/leiomyosarcoma

Lymphoma

Mast celltumor

Gastrinoma

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8
Q

What are the metabolic causes of melena?

A

Hypoadrenocorticism

Uremic kidney disease

Liver disease with portal hypertension or portal systemic shunts

Pancreatitis

Hypereosinophilic syndrome

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9
Q

What bleeding disorders are associated with melena?

A

Thrombocytopenia

Thrombocytopathia

DIC

Rodenticide intoxication

Specific factor deficiencies

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10
Q

What are the vascular causes of melena?

A

Vascular ectasia/angiodysplasia

Arteriovenous fistula

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11
Q

What mimics melena?

A

Activated charcoal

Iron supplements

Diarrheal medications containing bismuth

Large quantities of blueberries

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12
Q

What are the defence mechanisms of the GI mucosa?

A
  • Adherent mucus layer
  • Hydrophobic nature of epithelial cells
  • Epithelial secretion of bicarbonate
  • Rapid repaire of epithelial layer by restitution
  • High rate of mucosal blood flow
  • Prostaglandins
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13
Q

How would you gather history of a patient with melena?

A

1st step:

  • Let owner use descriptors or show examples of fecal colour and scorecard
  • Ask specific questions about diet
  • Drug administration
  • Potential toxins (rodenticides or corrosive compounds)

2nd step:

Other clinical signs:

  • Exercise intolerance
  • Stridor
  • Coughing
  • Dyspnea
  • Anorexia
  • Regurgitation
  • Vomiting or diarrhea
  • Epistaxis or hemoptysys
  • Hematuria
  • Ecchymosis
  • Concurrent C-steroids + NSAIDS
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14
Q

What are possible findings on physical exam related to melena that are important to examine?

A
  • Skin, MM, and sclera to check for petechia, ecchymosis, or icterus
  • Fundic exam to identify retinal hemorrhages indicating bleeding disorder, hyperviscosity, or systemic hypertension
  • Skin, mucocutanous junctions, nail beds for masses (mast cell disease)
  • Nares and oral cavity
  • Pale MM
  • Auscultate lung fields
  • Abdomen palpation – pain, organomegaly, or masses
  • Digital rectal exam – melena, fecal test, mucosal abnormalities, sublumber lymph node evaluation
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15
Q

What treatments are considered for patients with melena?

A

Treatment:

  • Depends on underlying cause
  • Medications to treat GI ulceration increase intraluminal acidity and promote mucosal defence mechanisms

Proton pump inhibitors, synthetic prostaglandin, and sucralfate

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16
Q

What diagnostic tests should be performed for patients with melena?

A

CBC:

  • Anemia: common, mild-severe, +/- regenerative
  • Chronic low grade haemorrhage => iron deficiency => microcytic, hypochromic, non-regenerative anaemia
  • Thrombocytopaenia:
    • Mild=> likely secondary from consumption
    • Mod/Severe = >likely primary cause of bleeding
  • Leukocytosis: , normal, or & +/- left shift depending on underlying disease
  • Eosinophilia: due to hemorrhave, parasiism, sysemic mycosis, MCT, eosinophilic gastritis, or hypereosinophilic syndrome

Biochem:

  • BUN
  • Hypoproteinemia
  • hepatic enzyme activities (liver dz)
  • Azoetmia
  • Hyponatremia+hyperkalemis => hypoadrenocorticism, or salmonellosis and/or whipworm infections

Urinalysis:

  • Differentiates azotemia
  • Check or concurrent disease

Prolonged coags:

=> Differentiate rodenticide intoxication or DIC

Fecal flotation:

  • Identify parasite ova

Next phase of tests depends on owners finances:

  • Direct saline preparation
  • Stained cytological smear -> parasites, enterotoxigenic bacteria, and other organisms
  • Radiographs thorax & abdomen differentiate between resp and GI source of melena.

T rads: Defined lung pattern is likely with hemoptysis & screen metastatic disease.

Abdo abdnormalities: radiopaque foreign bodies, abnormal organ shape/size, mass effects, and abnormal gas and fluid patterns

  • Abdo ultrasound –evaluate foreign bodies, abnormal organ architecture, masses, lymphadenopathy, or intussusception

Advanced: specific serologic testing, fecal culture, CT, rhinosope, bronchoscopy, GI endoscopy, and ex lap.

17
Q

Define hematochezia

A

Definition:

Bright red colored stools due to presence of haemoglobin

Hematochezia is mostly colonic but could be small intestinal if intestines are hypermotile.

18
Q

What are the inflammatory causes of hematochezia?

A

Inflammatory

Inflammatory bowel disease

Histiocytic ulcerative colitis

Idiopathic colitis

Perianal fistula

Mucocutaneous lupus erythematosus

19
Q

What are the infectious causes of hematochezia?

A

Bacterial: Campylobacter, clostridium, mycobacterium, salmonella

Fungal/Algal: Cryptococcus, Histoplasma, Pythium, Prototheca

Parasitic: Ancylostoma, Uncinaria, Trichuris, coccidia, Tritrichomonas, Leishmania, Heterobilharzia Americana, Entamoeba histolytica

Viral: parvovirus

20
Q

What are the ischemic/traumatic causes of hematochezia?

A

Hypovolaemic shocl

Thrombosis/infarction

Intussusception

Caecal inversion

Volvulus

Foreign body

Pelvic fracture

Rectoanal stricture

Racing sled dogs

21
Q

What are the neoplastic causes of hematochezia

A

Adenocarcinoma

Gastrointestinal stroma tumor

Leiomyoma/Leiomyosarcoma

Lymphoma

Plasmacytoma

Colorectal polyp

22
Q

What are the vascular causes of hematochezia?

A

Vascular ectasa/angiodysplasia

Arteriovenous fistula

23
Q

What are the metabolic causes of hematochezia?

A

Hypoadrenocorticism

Uremic kidney disease

Liver disease, particularly with portal hypertension or portosystemic shunts

Pancreatitis

24
Q

What bleeding disorders cause hematochezia?

A

Thrombocytopenia

Thrombocytopathia

DIC

Rodenticide intoxication

Specific factor deficiencies

25
Q

What can mimic hematochezia?

A

Ingestion of red food colouring

Large amounts of Beets

Perineal bite wound or anal sac abscess

26
Q

What treatment options are available for hematochezia?

A

Treatment:

Depends on underlying cause

Acute hematochezia:

Broad spectrum anthelmintic

Metronidazole

Bland diet with soluble fiber

27
Q

What diagnostic options are available for hematochezia?

A
  • Acute hematochezia = blood streaking on surfaces of faeces and no other clinical signs or physical exam abnormalities

faecal flotation and direct saline preparation

  • Severe hematochezia (raspberry jam), chronic, +/- other clinical signs should be worked up like melena

DDX Gastrointestinal system (9 decks)

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