WCS 61 Per rectal bleeding

Question 1

LGIB definition

Answer 1

bleeding from the gut distal to ligament of treitz

Question 2

per rectal bleeding anatomical possibility

Answer 2

UGIB hemorrhage
small bowel
colorectal
anorectal outlet

Question 3

history to ask for LGIB

Answer 3

occult vs overt
duration acute vs chronic
massive vs slow bleeding
obscure GIB

quantity
GI symptoms
anorectal symptoms
hemodynamics
hx of previous bleeding, previous ix,
systemic symptoms, other comorbidities, drugs (NSAIDS, coagulopathies)
fam hx
sexual social hx

Question 4

outlet bleeding character

Answer 4

fresh blood ON stool
small amounts
anorectal symptoms
no hemodynamic distrubances

Question 5

acute LGIB causes

Answer 5

• angiodysplasia
• diverticular disease
• acute anal fissure

Question 6

management of acute LGIB

Answer 6

• resuscitation and stabilize hemodynamics
• -venous access
• • IV crystalloid solution for volume expansion
• • type and screen for transfusion
• • monitor (BP, pulse, urine output, CVP, hb, hematocrit, LRFT, coagulation)
• localization of bleeding site
• • history, p/e, ix
• • colonoscopy, upper endoscopy
• • angiography
• • radionuclide scan
• • CT, small bowel contrast
• therapeutic intervention (endoscopic, angiographic, surgical)

Question 7

indications for transfusion

Answer 7

• profuse bleeding
• persistent hemodynamic instability despite crystalloid resuscitation
• symptomatic anemia
• ami / unstable angina with low Hb

Question 8

p/e for LGIB

Answer 8

• hemodynamic status (vitals)
• pallor
• abdominal exam
• DRE, proctoscopy

Question 9

LGIB if upper endoscopy and colonoscopy showed negative findings what to do next

Answer 9

repeat
enteroscopy
intraoperative endoscopy

Question 10

Therapeutic modalities in colonoscopy for angiodysplasia, diverticulitis

Answer 10

• sclerotherapy
• heat probe
  hemoclips
• electrocoagulation
• laser
• argon beam coagulation

Question 11

what is angiography for LGIB

Answer 11

selective catheterization of celiac artery, SMA, IMA by seldinger technique

Question 12

positive test for angiography

Answer 12

extravasation of contrast

Question 13

complications for angiography

Answer 13

• contrast allergy
• renal failure
• bleeding from puncture site

Question 14

therapeutic angiography

Answer 14

• embolization

- vasopressin injection

Question 15

LGIB indications for surgery

Answer 15

hemodynamic instability

• transfusion requirement >=6 units
• persistent bleeding
• rebleeding within 1 week

Question 16

LGIB surgery options with and without localization

Answer 16

with localization –> segment resection
without localization –> subtotal colectomy if bleeding is colonic origin; intraop colonoscopy or enteroscopy for localization

Question 17

common causes for LGIB

Answer 17

colorectal

• diverticular disease
• angiodysplasia
• post polypectomy
• colorectal neoplasm
• ischemic colitis
• IBD colitis
• radiation colitis
• infective colitis

anorectal sources

• hemorrhoids
• anal fissures
• rectal ulcer
• rectal varices
• anorectal neoplasm
• IBD proctocolitis
• radiation proctocolitis
• infective proctocolitis

small bowel sources

• Meckel’s diverticulitis
• jejunoileal diverticula
• vascular lesions (angiodysplasia, hemangioma)
• small bowel neoplasms
• small bowel ulcers (NSAID)
• Crohn’s disease
• Aortoenteric fistula
• TB enteritis

massive hemorrhage UGIB

Question 18

why does diverticulosis cause bleeding

Answer 18

ruptured vasa rectum

Question 19

how to dx diverticular disease

Answer 19

by endoscopy/ angiography

Question 20

treatment for diverticular disease or angiodysplasia

Answer 20

• endoscopic therapy

- surgical resection

Question 21

where does diverticulum occur in asians?

Answer 21

right colon

Question 22

what is angiodysplasia? what is it associated with?

Answer 22

acquired ectasia of vessels in submucosa due to degeneration

asso with vascular malformations in GI tract and aortic stenosis

Question 23

bleeding characteristics between angiodysplasia and diverticular disease

Answer 23

angiodysplasia less severe bleeding but more rebleeding

Question 24

surgical treatment for crohns disease

Answer 24

total colectomy +/- anastomosis

segmental small bowel resection

Question 25

colitis causes

Answer 25

• ibd
• idiopathic ulcer
• infective
• radiation
• ischemic

Question 26

how does radiation proctocolitis cause bleeding

Answer 26

damaged rectal mucosa form vascular telangiectasis

Question 27

treatment for radiation proctocolitis

Answer 27

endoscopic treatment: IR/argon beam/laser coagulation

4% formalin local application

surgery for unstoppable bleeding: diversion/ proctectomy

Question 28

rectal varices treatment

Answer 28

• scleroinjection

- surgical shunting for uncontrolled bleeding

Question 29

obscure GIB definition. what to do

Answer 29

bleeding of unknown origin that persists or recur after negative initial endoscopy –> repeat upper endoscopy and colonoscopy

Question 30

diagnosis for small bowel bleeding

Answer 30

• angiography
• rbc scan
• small bowel enema
• ct scan
• push/intraop/capsule single/double balloon enteroscopy
• enteroclysis

Question 31

routes for intraop enteroscopy

Answer 31

• transanal
• peroral
• through enterotomy
• lap assisted