Undifferentiated lower gastrointestinal bleeding: Difference between revisions
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*Cause of bleeding found in <50% of cases | *Cause of bleeding found in <50% of cases | ||
===False Positive Guaiac=== | |||
#Red meat | #Red meat | ||
#Red jello | #Red jello | ||
#Fruit and vegetables | #Fruit and vegetables | ||
# | #*Melon, broccoli, radish, beets | ||
#Iron (causes GI bleed by irritation) | #Iron (causes GI bleed by irritation) | ||
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==DDX== | ==DDX== | ||
#Upper GI | #[[Upper GI Bleeding}} | ||
#Diverticular disease | #Diverticular disease | ||
##Painless bleeding | ##Painless bleeding | ||
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#Vascular ectasia | #Vascular ectasia | ||
##Angiodysplasia, AVM | ##Angiodysplasia, AVM | ||
#Inflammatory bowel disease | #[[Inflammatory bowel disease]] | ||
#Colitis | #Colitis | ||
##Infectious | ##Infectious | ||
##Ischemic | ##[[Mesenteric ischemia|Ischemic]] | ||
###90% of cases occur in age >70yo | ###90% of cases occur in age >70yo | ||
###Colon is predisposed to ischemia due to poor vascular ciculation, high bacterial count | ###Colon is predisposed to ischemia due to poor vascular ciculation, high bacterial count | ||
Line 50: | Line 50: | ||
##Associated w/ A fib, CHF, MI, age >60yo | ##Associated w/ A fib, CHF, MI, age >60yo | ||
##CT only 64% Sn, angiography is imaging study of choice | ##CT only 64% Sn, angiography is imaging study of choice | ||
#Meckel Diverticulum | #[[Meckel Diverticulum]] | ||
#Malignancy / polyps | #Malignancy / polyps | ||
#Hemorrhoids | #[[Hemorrhoids]] | ||
##Massive hemorrhage is unusual | ##Massive hemorrhage is unusual | ||
#Aortoenteric fisulta (after AAA repair) | #Aortoenteric fisulta (after AAA repair) | ||
##Low grade fever, abd pain, back pain, h/o graft, BRBPR | ##Low grade fever, abd pain, back pain, h/o graft, BRBPR | ||
#Foreign body | #Foreign body | ||
#Rectal ulcer (HIV, | #Rectal ulcer ([[HIV]], [[Syphilis]], [[STI]]) | ||
#Anal fissure | #[[Anal fissure]] | ||
==Workup== | ==Workup== |
Revision as of 02:18, 4 March 2015
Background
- Loss of blood from the GI tract distal to the ligament of Treitz
- Upper GI bleeds are most common source for blood detected in the lower GI system
- 80% of lower GI bleeding will resolve spontaneously
- Cause of bleeding found in <50% of cases
False Positive Guaiac
- Red meat
- Red jello
- Fruit and vegetables
- Melon, broccoli, radish, beets
- Iron (causes GI bleed by irritation)
Diagnosis
History
- Type of blood
- Hematochezia
- Bright red or maroon-colored bleeding that comes from the rectum
- Usually represents lower GI bleeding
- May represent UGIB if bleeding is brisk
- Usually accompanied by hematemesis and hemodynamic instability
- Melena
- Usually represents bleeding from upper GI source
- May represent bleeding from lower GI source due to slow bleeding
- Hematochezia
- Medications
- Salicylates, NSAIDs, warfarin
Physical Exam
- Consider anoscopy if source of bleeding cannot be identified on external exam
DDX
- [[Upper GI Bleeding}}
- Diverticular disease
- Painless bleeding
- Up to 90% of episodes resolve spontaneously
- Can result in massive hemorrhage
- Vascular ectasia
- Angiodysplasia, AVM
- Inflammatory bowel disease
- Colitis
- Infectious
- Ischemic
- 90% of cases occur in age >70yo
- Colon is predisposed to ischemia due to poor vascular ciculation, high bacterial count
- Causes: aneurysmal rupture, vasculitis, hypercoagulable, CV insult, IBS, slow motility
- Most cases resolve on own; 20% of cases requires surgical intervention
- Mesenteric Ischemia
- Medical emergency that often leads to bowel necrosis
- Causes: thrombosis/embolism of SMA, mesenteric vein thrombosis, low arterial flow
- Associated w/ A fib, CHF, MI, age >60yo
- CT only 64% Sn, angiography is imaging study of choice
- Meckel Diverticulum
- Malignancy / polyps
- Hemorrhoids
- Massive hemorrhage is unusual
- Aortoenteric fisulta (after AAA repair)
- Low grade fever, abd pain, back pain, h/o graft, BRBPR
- Foreign body
- Rectal ulcer (HIV, Syphilis, STI)
- Anal fissure
Workup
- Labs
- CBC
- Chemistry
- BUN may be elevated if bleeding occurs from site high in GI tract
- Coags
- LFTs
- Type and screen
- CBC
- ECG (if concern for silent ischemia in pts likely to have CAD)
- Imaging
- CTA
- Requires brisk bleeding rate (0.5 cc/min) for detectio
- Proctoscopy (22cm from anal verge)
- Sigmoidoscopy (60cm from anal verge)
- CTA
Treatment
- IVF
- Major Bleed and Supratheraputic INR
- Correct coagulopathy
- Vitamin K 10 mg IV (best availability in critical pt)
- FFP
- Consider pRBCs/platelets for unstable and low H/H
- Correct coagulopathy
- Consider NGT - high possibility for surgery to request
- Hematochezia unexpectedly originates from upper GI source 10-15% of cases
- Emergent Sigmoidoscopy/colonoscopy (next 24 hours)
- Surgery if endoscopy fails or not available
Disposition
- Discharge:
- Bleeding from hemorrhoids, anal fissures, or known IBD (hemodynamically stable)
- No gross blood on rectal exam (hemodynamically stable)
See Also
Source
- Tintinalli