Undifferentiated lower gastrointestinal bleeding: Difference between revisions
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*80% of lower GI bleeding will resolve spontaneously{{Citation needed|reason=Reliable source needed|date=May 2016}}
*80% of lower GI bleeding will resolve spontaneously{{Citation needed|reason=Reliable source needed|date=May 2016}}
*Cause of bleeding found in <50% of cases{{Citation needed|reason=Reliable source needed|date=May 2016}}
*Cause of bleeding found in <50% of cases{{Citation needed|reason=Reliable source needed|date=May 2016}}
**diverticulosis majority, other conditions include colitis, polyps, cancer, hemorrhoids, fissures  
**[[Diverticulosis]] cause majority, other conditions include [[colitis]], polyps, [[colorectal cancer]], [[hemorrhoids]], [[anal fissures]]
*Hematochezia originates from briskly bleeding upper GI source in 10-15% of cases{{Citation needed|reason=Reliable source needed|date=May 2016}}
*Hematochezia originates from briskly bleeding upper GI source in 10-15% of cases{{Citation needed|reason=Reliable source needed|date=May 2016}}


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***Usually accompanied by hematemesis and hemodynamic instability
***Usually accompanied by hematemesis and hemodynamic instability
*Melena
*Melena
**Usually represents bleeding from upper GI source
**Usually represents bleeding from upper GI source (see [[upper GI bleed]])
**May represent slow bleeding from lower GI source
**May represent slow bleeding from lower GI source


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**BUN may be elevated if bleeding occurs from site high in GI tract
**BUN may be elevated if bleeding occurs from site high in GI tract
*Coags
*Coags
*LFTs
*[[LFTs]]
*Type and screen
*Type and screen
*Fibrinogen
*Consider:
*[[ECG]] (if concern for silent ischemia in patients likely to have CAD)
**[[ECG]] (if concern for silent ischemia in patients likely to have CAD)
*CTA
**Fibrinogen
**Requires brisk bleeding rate (0.5 cc/min) for detection{{Citation needed|reason=Reliable source needed|date=May 2016}}
**CTA
*Tagged red blood cell scan
***Requires brisk bleeding rate (0.5 cc/min) for detection{{Citation needed|reason=Reliable source needed|date=May 2016}}
**Tagged red blood cell scan (not typically an emergency study)


===Definitive studies===
===Definitive studies===
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==Management==
==Management==
*[[IVF]]
''Categorize as stable versus unstable using [[shock index]]: <1 stable; >1 unstable or suspect active bleeding''
*Consider transfusing [[pRBCs]]/[[platelets]] for unstable patients or with very low hemoglobin (<7)
*Unstable
*Consider NGT - high possibility for surgery to request
**Resuscitate, CT angiogram, if CTA does not identify source of bleeding, upper endoscopy if hemodynamic instability <ref> Oakland K, Chadwick G, East JE, et al.  Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019;67:776-789. </ref>
*Emergent sigmoidoscopy/colonoscopy (next 24 hours)
**Consider transfusing [[pRBCs]]/[[platelets]] for unstable patients or with very low hemoglobin (<7).  with cardiovascular disease use trigger of 8 and target of 10 hemoglobin. 
*Surgery if endoscopy fails or not available
**Emergent sigmoidoscopy/colonoscopy (next 24 hours)
**Surgery if endoscopy fails or not available
*Stable
**Calculate risk score to determine disposition
***Oakland score
***Glasgow-Blatchford score


===Major Bleed and Supratheraputic INR===
===Major Bleed and Supratherapeutic INR===
*[[Coagulopathy (main)|Correct coagulopathy]]
*[[Coagulopathy (main)|Correct coagulopathy]]
**[[Vitamin K]] 10mg IV (best bioavailability in critical patient)
**[[Vitamin K]] 10mg IV (best bioavailability in critical patient)
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*Bleeding from [[hemorrhoids]], [[anal fissures]], or known [[IBD]] (hemodynamically stable)
*Bleeding from [[hemorrhoids]], [[anal fissures]], or known [[IBD]] (hemodynamically stable)
*No gross blood on rectal exam (hemodynamically stable)
*No gross blood on rectal exam (hemodynamically stable)
*Minor, self-terminating bleed with no other indication for admission ([[shock index]] >1; low risk score calculated)


===Admission===
===Admission===
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==See Also==
==See Also==
[[Upper GI Bleeding]]
{{GI bleeding pages}}


==References==
==References==
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[[Category:GI]]
[[Category:GI]]
[[Category:Symptoms]]

Revision as of 14:06, 12 March 2022

Background

Medication Risk Factors

Clinical Features

Type of blood

  • Hematochezia
    • Bright red or maroon-colored bleeding that comes from the rectum
    • Usually represents lower GI bleeding
    • May represent upper GI source if bleeding is brisk
      • Usually accompanied by hematemesis and hemodynamic instability
  • Melena
    • Usually represents bleeding from upper GI source (see upper GI bleed)
    • May represent slow bleeding from lower GI source

Differential Diagnosis

Undifferentiated lower gastrointestinal bleeding

Evaluation

Workup

  • CBC
  • Chemistries
    • BUN may be elevated if bleeding occurs from site high in GI tract
  • Coags
  • LFTs
  • Type and screen
  • Consider:
    • ECG (if concern for silent ischemia in patients likely to have CAD)
    • Fibrinogen
    • CTA
    • Tagged red blood cell scan (not typically an emergency study)

Definitive studies

  • Consider:
    • Anoscopy if source of bleeding cannot be identified on external exam
    • Proctoscopy (22cm from anal verge)
    • Sigmoidoscopy (60cm from anal verge)

False Positive Guaiac

  • Red meat
  • Red jello
  • Fruit and vegetables
    • Melon, broccoli, radish, beets
  • Iron (causes GI bleed by irritation)

Management

Categorize as stable versus unstable using shock index: <1 stable; >1 unstable or suspect active bleeding

  • Unstable
    • Resuscitate, CT angiogram, if CTA does not identify source of bleeding, upper endoscopy if hemodynamic instability [1]
    • Consider transfusing pRBCs/platelets for unstable patients or with very low hemoglobin (<7). with cardiovascular disease use trigger of 8 and target of 10 hemoglobin.
    • Emergent sigmoidoscopy/colonoscopy (next 24 hours)
    • Surgery if endoscopy fails or not available
  • Stable
    • Calculate risk score to determine disposition
      • Oakland score
      • Glasgow-Blatchford score

Major Bleed and Supratherapeutic INR

Special situations

  • Marathon runners - 16% will have hematochezia within 24-48 hrs of race and 85% will be guaiac positive[2]
    • Non-actionable unless abdominal pain present

Disposition

Discharge

  • Bleeding from hemorrhoids, anal fissures, or known IBD (hemodynamically stable)
  • No gross blood on rectal exam (hemodynamically stable)
  • Minor, self-terminating bleed with no other indication for admission (shock index >1; low risk score calculated)

Admission

  • Melena
  • Significant anemia
  • Hemodynamic instability

See Also

Gastrointestinal Bleeding Pages

References

  1. ↑ Oakland K, Chadwick G, East JE, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019;67:776-789.
  2. ↑ Sullivan SN, Wong C. Runners' diarrhea. Different patterns and associated factors. J Clin Gastroenterol 1992;14:101-104.
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