Undifferentiated lower gastrointestinal bleeding: Difference between revisions

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===False Positive Guaiac===
===False Positive Guaiac===
#Red meat
*Red meat
#Red jello
*Red jello
#Fruit and vegetables
*Fruit and vegetables
#*Melon, broccoli, radish, beets
**Melon, broccoli, radish, beets
#Iron (causes GI bleed by irritation)
*[[Iron]] (causes GI bleed by irritation)


==Management==
==Management==

Revision as of 11:14, 28 April 2016

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

Clinical Features

  • 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
  • Medications
    • Salicylates, NSAIDs, warfarin

Differential Diagnosis

Undifferentiated lower gastrointestinal bleeding

Diagnosis

Workup

  • CBC
  • Chemistries
    • BUN may be elevated if bleeding occurs from site high in GI tract
  • Coags
  • LFTs
  • Type and screen
  • ECG (if concern for silent ischemia in pts likely to have CAD)
  • CTA
    • Requires brisk bleeding rate (0.5 cc/min) for detectio

Physical Exam

  • 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

  • IVF
  • Consider pRBCs/platelets for unstable and low H/H
  • 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

Major Bleed and Supratheraputic INR

  • Correct coagulopathy
    • Vitamin K 10 mg IV (best availability in critical pt)
    • FFP
  • Special situations
    • Marathon runners - 16% will have hematochezia within 24-48 hrs of race and 85% will be guaiac positive[1]
      • 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)
  • Admission:
    • Melena, significant anemia, hemodynamic instability

See Also

Upper GI Bleeding

References

  1. Herbert M et al. EM:RAP March 2015.