Approach to Lower GI Bleeding

Question 1

definition of a lower Gi bleed

Answer 1

bleeding below the ligament of treitz in the duodenum

Question 2

typical presentation of lower GI bleed

Answer 2

• darker red blood/stool if coming from right colon (beacuse more time to pass through Gi tract and oxidize0
• bright red if coming from left colon.
• hematochezia

*sometimes if its a massive UGIB bleed it may present as a LGIB

Question 3

Is melena a common symptom of LGIB

Answer 3

no. if its black it means that the blood is coming from further up so its probably a UGIB, but it might be a super slow/intermittent LGIB

Question 4

causes of lower GI bleeding (acute)

Answer 4

perianal, stable or severe/unstable

Question 5

chronic lower GI bleeding may be due to:

Answer 5

Fe deficiency anemia

Question 6

DDx for minimal rectal bleeding (may have noticed blood on toilet paper or in toilet bowl, but not coming from intestines)

Answer 6

• Hemarrhoids
• anal fissure
• rectal ulcer
• proctitis
• polyps
• beets

BRBPR should be thought of as from thea norectal source and is usually benign

Question 7

main reasons behind perianal bleeding in young adults

Answer 7

hemorrhoids- may be constimated, intermittent blood, not anmic

anal fissure – perianal pain, tearing, hard stool, straining

solitary recal ulcer – passage of mucus, hard stool straining, sense of incomplete evacuation.

proctitis (distal colitis)– intermittent BRBPR if mild, mucus, diarrhea

polyps/cancer. small distal polyps can bleed. Cancers may appear hard and irregular.

Question 8

outlet bleeding

Answer 8

blood on toilet paper or surface of stool

Question 9

management of minimal rectal bleeding BRBPR

Answer 9

1. history– age, anal pain, fam Hx
2. physical recal exam: hemorrhoids, fissure, mass
3. Lab– rule out anemia. no stool tests for hidden blood, as blood is visible
4. investigate – sigmoidoscopy vs colonoscopy

Question 10

big four reasons for ACUTE significant lower GI bleeding

Answer 10

1. diverticulosis
2. colitis
3. angiodysplasia– death/deficiencies of the vessels.
4. cancer/polyps, including following a polypectomy (may be bleeding because of surgery)

Question 11

diverticulum
diverticulopsis
diverticular disease

Answer 11

diverticulum: a sac
diverticulosis: diverticula (sacs) present (SHOULDNT BE THERE), but usually asymptomatic
diverticular disease: diverticula + symptoms

Question 12

diverticular disease vs diverticulitis vs diverticular bleeding vs diverticular (segmental) colitis

Answer 12

• diverticular disease: general pain but no overt inflammation
• diverticulitis: inflamed diverticulum, causing pain, LLQ tenderness and increased WBC
• diverticular bleeding: painless hematochezia
• diverticular (segmental) colitis: hematochezia and crampy LLQ pain

Question 13

epidemiology of diverticulosis– how does age and ethnicity effect it?

Answer 13

age dependent– 70% chance of diverticulosis at 85 years
developedmore in western populations
white = sigmoid colon
asian = right colon

bleeding tends to arise from right colon, whereas abdominal pain usually arises from left/sigmoid colon. Diverticula at dif places manifest as different symptoms

Question 14

diverticulosis is caused by Pulsions which is:

Answer 14

herniation of submucosa/mucosa BUT NOT MUSCULARIS through naturally occurring defects in wall where vessles penetrate.

• causes abnormal motility: increased pressure in colonic lumen: protrusion because intral lumen pressure is high.
• decreased tensile strength from exaggerated aging changes in bowel wall. Vasa recta are then stretched over the dome of the diverticula. Any trauma can then cause rupture because the vessels are so stretched thin

Question 15

diverticulitis is often presented as_

Answer 15

appendicitis

Question 16

diverticula presence is often asymptomatic (70%) or may have painless diverticular bleeing (10%), but diverticulitiz (20%) can be painful, with 3/4 of it being uncomplicated and the other 25% being complicated causing ___ ___ __ or ___

Answer 16

abscess, perforation, fistula, or sepsis.

Question 17

how does sepsis occur in a pt with diverticulosis? What are the consequences?

Answer 17

stool blocks sac –> stasis –> sepsis. Consequence is actute diverticulitis (inflammation and pain in LLQ and increased WBC)

• simple would be self limited
• complicated may result in microperforation/LLQ appendicitis, perforation, fistula (ex/ to the bladder), or obstruction (from thick wall and narrowed lumen)

*for asians it can happen on the right hand side.

Question 18

how does segmental colitis occur in a pt with diverticulosis? How do you diagnose it and how do you treat it?

Answer 18

mucosal prolapse, fecal stasis, localized ischemia.

presentation: intermittident hematochezia, chornic bloody diarrhea or LLQ cramping

Dx via sigmoidoscopy
Rx via antibiotics 3 ASA, steroids

Question 19

management of diverticular disease

Answer 19

fiber!

• complications from bleeding: resuscitate and endoscope
  diverticulitis: antibiotics, possible surgery

Question 20

T/F Acute significant lower GI bleed often never stops and requires immediate intervention

Answer 20

false. 80% of lower GIBs stop spontaneously, but the prognosis is dependent on risk factors:
- hemodynamic instability
- ongoing bleeding
- older pt with comorbid illnesses or coagulopathies

Question 21

Managing significant heamtochezia
- may be hemodynamically unstable, ongoing bleeding, could have serious comorbid disease. Determine if stable or unstable.

• make sure to resuscitate with IV fluis, blood. Admit. Rule out upper GI source.

If stable and no uppger GI source, do urgent colonoscopy <24 hours. If unstable, they will be intolerant to colonscopy prep. Do a CT angiography, rbc scan. Consult with surgery/

Answer 21

If low risk they;lk have

• no or few high risk featyres
• hemodynamically stable
• • no ongoing bleeding
• no serious co morbid disease.
• this is urgent but not emergent. Do a colonoscopy soon

Question 22

when you’re managing a person with an LGIB, after doing resuscitation you have to do diagnostic studies like sigmoidoscopy or colonoscopy. What’re you looking for to determine cause?

Answer 22

on the imaging, look for “thumb printing” which could be indicative of ischemia. Do a CT of abdomen.

If colonscopy was not diagnostic and theres continued bleeding over >0.5ml/min, might need to do angiography or labelled RBC scan.

Question 23

when you’re managing a person with an LGIB, after doing resuscitation you have to do diagnostic studies like sigmoidoscopy or colonoscopy. What’re you looking for to determine cause?

Answer 23

on the imaging, look for “thumb printing” which could be indicative of ischemia. Do a CT of abdomen.

If colonscopy was not diagnostic and theres continued bleeding over >0.5ml/min, might need to do angiography or labelled RBC scan.

Question 24

ischemic colitis is common in people with low flow states including

Answer 24

cardiac co morbities, diabetes, hypotension/vasculitis. also in elderly.If younger, rule out the risk for thromboembloic event (atrial fib)

Question 25

PS, OE, Dx, and Rx for ischemic colitis

Answer 25

PS: abdominal pain and bloody diarrhea
OE: tenderness
Dx: X ray, endoscopy
Rx: supportive.

Question 26

occaisonal UPPER GI Bleeds may look like LGIB. How so

Answer 26

rectal bleeding
marked hypovolemia
NG emesis/coffee ground barf
elevated BUN

Question 27

overall management of acute lower GI bleeding

Answer 27

1. initial assessment and appropriate triage
2. resuscitate prn
3. localize bleeding site via colonscopy (make sure to clean them out before hand) and Ct angiography if lots of bleeding.
4. stop bleeding via therapeutic intervention in <24 hours.

Question 28

IBD diseases

Answer 28

crohns, ulcerative colitis