Flashcards in Bernadino: Lower GI Bleeds Deck (40):
What is the most common source of lower GI bleeds?
Colonic Source> upper GI source*most deadly> sml bowel source
What are colonic sources of lower GI bleeding?
Diverticular hemorrhage – 30-50%
Angiodysplasia – 20-30%
Where are most diverticula in the colon?
sigmoid and left colon 65%
Who does acute colonic diverticulitis MC effect?
5-10% > age 40
80% > age 85 higher rates w/ increasing age
What are sxs of acute colonic diverticulitis?
Most pts are asymptomatic.
What complications are associated w/ acute colonic diverticulitis?
fistulize to adjacent organs
How do you dx acute colonic diverticulitis?
NOT endoscopy or barium enema
How do you tx mild diverticulitis w/out peritoneal signs?
Out pt tx for nonelderly pt w/out comorbidities:
10 days of oral antibiotics (metronidazole and ciprofloxacin)(Amox/Clavulanate)
How do you tx severe pain caused by diverticulitis in elderly/comorbidities/immunocomp pts?
What accounts for 50% of acute lower GI bleeding?
Acute diverticular hemorrhage (self limited in 80%)--transfuse and assume it will stop
It recurs in 1/3
Risk of rebleeding after a 2nd bleed is >50%
**How do you treat diverticular hemorrhage that is persistent?
Fluids/blood/make sure you're not missing upper GI bleed--> elevated BUN indicates upper GI bleed
Colonoscopy if persistent – epinephrine, clip, cautery, band
Embolizatoin is standard of care if colonoscopy fails
What is angioectasia (angiodysplasia)?
Tortuous, dilated submucosal capillaries / veins lacking smooth muscle> weak> rupture
Most common in the right colon--cecum (can be anywhere)
80% will rebleed without endotherapy
How does angioectasia usually present?
Overt hemorrhage or anemia.
Present in less than 1% of screening colonoscopies
Increased frequency with age* up there w/ diverticula
What are comorbidities for angioectasia?
Aortic stenosis (Heyde's syndrome> break up multimer that protects a cofactor, exposing it to degradation in the blood stream)
Chronic renal failure (faulty platelets/faulty vessels)
Advanced age: Common cause of hematochezia in patients older than 65
**How do you tx angiodysplasia?
colonoscopy w/ ablation**
- argon plasma, cautery, hemoclip
surgery- subtotal colectomy
What are inflammatory causes of colitis?
NSAIDS (ileum and R colon)
What are infectious causes of colitis?
**How do you tx infectious colitis?
Tx: IV hydration and antibiotics
*What causes non-occlusive ischemic colitis?
*What causes occlusive ischemic colitis?
mesenteric vein thrombosis
vascular procedure, vasculitis
vasospastic, hypercoagulable state
How does ischemic colitis usually present?
Acute-severe abdominal pain followed by self limited hematochezia (sudden passing of blood, acute pain= ischemia--L side; R side is MUCH more severe)
*IMA Right sided ischemia (transverse colon to splenic flexure is the watershed area)
*usually w/out complications
How do you dx ischemic colitis?
Hx: sudden, passed bloody stool, got better in 2 days in the hospital
CT: thickened colon wall
Colonoscopy: confluent, mucosal ulceration friability, usually splenic flexure.
How do you treat ischemic colitis?
- correct underlying cuase
-elective colonoscopy in 6-8 wks to rule out other cuases
**How are neoplasms location dependent?
Right colon – anemia (leaking slowly, don't see blood)
Left colon – obstruction (crampy pain)
**A pt presents w/ occult, slow bleeding and anemia, and NO hematochezia.
Tx: surgical resection
A pt presents w/ tenesmus, diarrhea and pain, but no bleeding following radiation.
Acute radiation proctitis (vessels get thing> bleed)
A pt presents w/ anemia and hematochezia (bright red blood) years after radiation.
Chronic radiation proctopathy (seen more often; maybe on coumadin to make it worse; looks like AVMs throughout the colon)
**How do you tx radiation proctitis?
What is an anal fissure?
Acute (and recurrent) or CHRONIC tear in the anal canal that is usually POSTERIOR (watershed located here)
High sphincter pressure> decreases perfusion> causes perfusion to occur> bright blood> pain passing stool (chronic constipation, straining, diabetic)
Tx: bulk stool to decrease strain, topical nitrates improve flow
What is a hemorrhoid?
Dilated blexus of submucosal middle and superior hemorrhoidal veins
pain (not usually)
-advanced age, pregnant, chronic constipation, prolonged sitting/straining
How do you tx hemorrhoids?
stool softening and bulking fiber
**A pt presents w/ bright blood, straining, pelvic fullness and constipation.
Solitary rectal ulcer
RECTAL PROLAPSE (more common in women related to estrogen)
puborectalis spasm/weak pelvic floor
pt >40, F
How do you tx a solitary retal ulcer?**
topical mesalmine or steroids
What is diverticulosis
presence of diverticula, low fiber> generates a lot of pressure> bulge where wall is weak
What is diverticulitis?
Complication of having diverticulosis
90 y/o F w/ episodes of hematochezia (bright blood)
76 y/o M is dizzy after passing bright red stool w/ clots and showing hemodynamic compromise. Acute onset of bleeding.
Diff: upper GI bleed (hx, elevated BUN), diverticular hemorrhage, AVM (aortic stenosis)
Work-up: ICU d/t hemodynamic compromise, upper endoscopy to exclude GI bleed
Dx: Colonic bleed
84 y/o w/ RENAL FAILURE and copious rectal bleeding.
AVM** (elderly, renal> hi risk of AVM)
68 y/o M w/ CAD and intermittent abdominal pain w/ a hix of severe lower abdominal pain followed by an hour later by passage of bright red blood per rectum.
acute colonic ischemia
Acute MS- sick, often acidotic (dead sml bowel), suggestion of atherosclerotic disease at SMA take off, air in wall of small bowel (fine walking/talking) (thrombotic event or low flow state)
Tx: hydrate bowel and surgery
Chronic mesenteric ischemia: M, elderly, smoker post prandial periumbilical pain, weight loss
*less overlap in sml bowel (SMA) so it is often more severe