Undifferentiated lower gastrointestinal bleeding
Revision as of 14:30, 28 September 2015 by Neil.m.young (talk | contribs)
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
- Hematochezia
- Medications
- Salicylates, NSAIDs, warfarin
Differential Diagnosis
Undifferentiated lower gastrointestinal bleeding
- Upper GI Bleeding
- Diverticular disease
- Vascular ectasia / angiodysplasia
- Inflammatory bowel disease
- Infectious colitis
- Mesenteric Ischemia / ischemic colitis
- Meckel's diverticulum
- Colorectal cancer / polyps
- Hemorrhoids
- Aortoenteric fistula
- Nearly 100% mortality if untreated
- Consider in patients with gastrointestinal bleeding and known abdominal aortic aneurysms or aortic grafts
- Rectal foreign body
- Rectal ulcer (HIV, Syphilis, STI)
- Anal fissure
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
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