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Flashcards in Bernadino: Lower GI Bleeds Deck (40):
1

What is the most common source of lower GI bleeds?

Colonic Source> upper GI source*most deadly> sml bowel source

2

What are colonic sources of lower GI bleeding?

Diverticular hemorrhage – 30-50%
Angiodysplasia – 20-30%
Ischemia
Postpolypectomy
Neoplasm
IBD
Infection
Radiation colitis
Anorectal disorders

3

Where are most diverticula in the colon?

sigmoid and left colon 65%

4

Who does acute colonic diverticulitis MC effect?

5-10% > age 40
80% > age 85 higher rates w/ increasing age

5

What are sxs of acute colonic diverticulitis?

Most pts are asymptomatic.

pain
diarrhea
fever
abdominal tenderness

*rarely hemorrhage

6

What complications are associated w/ acute colonic diverticulitis?

abscess
rupture
fistulize to adjacent organs

7

How do you dx acute colonic diverticulitis?

CT

NOT endoscopy or barium enema

8

How do you tx mild diverticulitis w/out peritoneal signs?

Out pt tx for nonelderly pt w/out comorbidities:

oral hydration
liquid diet
10 days of oral antibiotics (metronidazole and ciprofloxacin)(Amox/Clavulanate)

9

How do you tx severe pain caused by diverticulitis in elderly/comorbidities/immunocomp pts?

hospitalize
IV antibiotics
NPO
CT scan

10

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%

11

**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

12

What is angioectasia (angiodysplasia)?

Tortuous, dilated submucosal capillaries / veins lacking smooth muscle> weak> rupture

Most common in the right colon--cecum (can be anywhere)

*unexplained anemia

80% will rebleed without endotherapy

13

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

14

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


15

**How do you tx angiodysplasia?

colonoscopy w/ ablation**
- argon plasma, cautery, hemoclip

surgery- subtotal colectomy

16

What are inflammatory causes of colitis?

Crohns
UC
NSAIDS (ileum and R colon)

17

What are infectious causes of colitis?

salmonella
shigella
campylobacter
e. coli

18

**How do you tx infectious colitis?

Usually self-limited

Hospitalize if:
-elderly
-immunocomp
-dehydrated
Tx: IV hydration and antibiotics

19

*What causes non-occlusive ischemic colitis?

hypoperfusion
drugs
heart disease
exercise
idiopathic

20

*What causes occlusive ischemic colitis?

embolic
A Fib
mesenteric vein thrombosis
vascular procedure, vasculitis
vasospastic, hypercoagulable state

21

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

22

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.

Biopsy

23

How do you treat ischemic colitis?

Improve perfusion
- correct underlying cuase
-elective colonoscopy in 6-8 wks to rule out other cuases

24

**How are neoplasms location dependent?

Right colon – anemia (leaking slowly, don't see blood)
Left colon – obstruction (crampy pain)

25

**A pt presents w/ occult, slow bleeding and anemia, and NO hematochezia.

Dx?

Neoplasm

Tx: surgical resection

26

A pt presents w/ tenesmus, diarrhea and pain, but no bleeding following radiation.

Dx?

Acute radiation proctitis (vessels get thing> bleed)

27

A pt presents w/ anemia and hematochezia (bright red blood) years after radiation.

Dx?

Chronic radiation proctopathy (seen more often; maybe on coumadin to make it worse; looks like AVMs throughout the colon)

28

**How do you tx radiation proctitis?

Endoscopic ablation**

29

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

30

What is a hemorrhoid?

Dilated blexus of submucosal middle and superior hemorrhoidal veins

Pt 45-60

Presents w/:
bleeding
pruritis
pain (not usually)

-advanced age, pregnant, chronic constipation, prolonged sitting/straining

31

How do you tx hemorrhoids?

Branding**
stool softening and bulking fiber

32

**A pt presents w/ bright blood, straining, pelvic fullness and constipation.

Dx?

Solitary rectal ulcer

Caused by:
RECTAL PROLAPSE (more common in women related to estrogen)
puborectalis spasm/weak pelvic floor
constipation
pt >40, F

ulcer/erythema/nodularity

33

How do you tx a solitary retal ulcer?**

Stool bulking
softeners
biofeedback
topical mesalmine or steroids
surgery

34

What is diverticulosis

presence of diverticula, low fiber> generates a lot of pressure> bulge where wall is weak

35

What is diverticulitis?

Complication of having diverticulosis

36

90 y/o F w/ episodes of hematochezia (bright blood)

diverticular hemmorhage

angioectasia

37

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

38

84 y/o w/ RENAL FAILURE and copious rectal bleeding.

AVM** (elderly, renal> hi risk of AVM)

39

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

Diff:
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

tx: stenting

40

15 y/o M presents to ER w/ first ever episode of severe rectal bleeding. He is dizzy and his Hb is 10.3. He has no pain but has cramps just before a BM.

Crohns
UC
Polyps
Meckel's Diverticulum (Techneetian-sp scan)