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Kristina Hester

on 29 January 2013

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ETIOLOGY Review Questions Review: Question #2 No Disclosures Kristina Hester, PGY-1
Emory University
Department of Emergency Medicine
January 29, 2013 Lower GI Bleeding OVERVIEW LGIB Definition: Bleeding distal to ligament of Treitz
Includes: jejunum, ileum, colon, rectum, anus; 20-30/100,000 people
15-20% of all GIB's
Risk increases with age
(esp >60, male) Incidence: Severity: 80-85% are self-limiting
Compared with UGIB, LGIB are:
Lower incidence of shock (19vs35)
Fewer transfusions (36 vs 64)
Higher Hgb level (81 vs 64) Case: Initial
Management A
B
C INFECTIOUS CAUSES Bacterial
Campylobacter
Clostridium difficile
ETEC
Salmonella
Shigella
Vibrio parahemolyticus
Yersinia. Viral
Cytomegalovirus
Herpes virus

Parasites
Cryptosporidium
E. histolytica -Outpouchings of mucosa through bowel associated with increased intraluminal pressure.
-Painless bleeding
-Most commonly found in sigmoid colon & descending colon DIVERTICULOSIS A congenital anomaly of the GI tract, due to incomplete obliteration of the vitelline duct, resulting in an ileal diverticulum
Occurs in 1% to 2% of the population MECKEL’S DIVERTICULUM Greater tendency to bleed if located in the right colon

Common in older patients, affecting about two-thirds of patients over 80 years of age CROHN’S DISEASE Colon or Rectum
Hematochezia (Bloody diarrhea)
Crypt abscesses
Cramps,Tenesmus, Colicky abdominal pain, Fever
Extra intestinal manifestations ULCERATIVE COLITIS INFLAMMATORY BOWEL DISEASE Can affect any part of GI tract
Transmural, skip lesions
Crampy abdominal pain, diarrhea, Fever
Ano-rectal disease
Melena in about 50% of cases with colon involvement
Extra intestinal manifestations Young patients, below 50 years Anorectal disease e.g. hemorrhoids, anal fissures
Infectious colitis: due to shigella, E.coli
Inflammatory bowel disease Older patients, above 50 years Diverticulosis
Angiodysplasia
Neoplasms
Ischemic Colitis Painful bleeding Anal fissure, ischemic colitis and IBD Painless bleeding HEMORRHOIDS Proctoscopy
Anoscopy
Sigmoidoscopy Assess airway
Clear any secretions
Intubate if needed O2 sat
Supplemental O2
Respiratory Rate HR, BP
Pulses
Is pt in shock Signs/Sx's of Shock Cold, clammy skin
Weak pulses
Agitation
Drowsiness/Confusion
Tachycardia
Hypotension
Poor UOP CBC (H/H, PLT)
CMP (BUN/Cr)
Coags (PT, PTT, Fibrinogen)
Type and screen/cross
VBG, CE's, Lactic acid* BUN sig elevated points to possible UGIB *** If INR >1.5 give FFP
If PTT elevated may give Protamine sulfate Goal Hgb >10 in acutely bleeding symptomatic pt
Transfuse PLT if <50 2 lg bore IV's
IVF Boluses
PRBC's if heavy bleeding; (Class III or IV)
send Labs
Foley Resuscitation Exam: -Sick vs Not sick
-Vitals
-Cardiac
-Abdominal
-Skin
-Digital Rectal* Pertinent Hx: -Onset/Duration of bleeding
-Quanity, color, consistency
-Previous episodes
-Meds
-Comorbidities, coagulopathy
-Lightheaded, SOB, CP
-Recent Surgeries? Vascular?
-Recent procedures, colonoscopy?
-Wt loss, Cancer, Prev radiation?
-Fever, diarrhea/constipation
-Pain? MEDS -NSAIDs, Aspirin
-Anticoagulants
-Chemo agents
-Corticosteroids Make sure to ask about: -CAD
-CHF
-Liver Disease
-Alcohol abuse
-Diabetes
-Smoking Comorbidities If Severe bleeding consult GI/Surgery early! Localization: -Rectal BRBPR?
-Hemoccult +?
-NG tube (assess for possible UGIB)
-Colonoscopy- preferred initial diagnostic
study in LGIB Barnert, J. & Messmann, H. (2009) Diagnosis and management of lower gastrointestinal bleeding. Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2009.167 Sources of Hematochezia Barnert, J. & Messmann, H. (2009) Diagnosis and management of lower gastrointestinal bleeding
Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2009.167 Colon Cancer Usually painless hematochezia or Occult blood +
Sx's vary depending on location of lesion
i.e wt loss, decreased caliber of stools, obstruction Bleeding is usually occult and results from mucosal defects on the surface of the lesion.
Rarely severe; generally painless and intermittent 11-15% of Hematochezia is from UGIB DIAGNOSIS: Painless bleeding (Internal) vs painful (External-if thrombosed)
Common with increased intra-abdominal pressure, obesity, pregnancy, anal intercourse
Tx: High fiber, sitz bath, topical steroids, band ligation References: Barnert, J. & Messmann, H. (2009) Diagnosis and management of lower gastrointestinal bleedingNat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2009.167
Uptodate.com: GI bleed
Westhoff, John. "Gastrointestinal Bleeding: an evidenced based approach to risk stratification." EM Practice. 6.
Agabegi, Steven. Step-Up to Medicine. 2nd. Baltimore, MD: LW&W, 2008. Print. Special Thanks to: Dr. Tamara Espinoza
Dr. Ashleigh Fay Aortoenteric Fistula Diagnosis: Neg stool studies
Colonoscopy with BX Treatment: Systemic corticosteroids for acute exacerbations
Sulfasalazine
Immunosuppressants
Metronidazole or cipro- (Crohn's only).
Surgical: (Colectomy often curative in UC) Rare, but lethal cause of GIB
Direct communication between aorta and lumen of GI tract
Usually pt with hx of vascular graft
Pt presents with GI bleed
Can quickly progress to hemorrhagic shock and death ABC's
Stabilize, resuscitate pt
Consult early (If needed)
EGD 1st if possible UGIB
Diagnostics
Disposition Question #1 Appears anxious/diaphoretic.
BP 79/58, pulse 122, O2 100% 67 yo F presents via EMS s/p hematemesis x 2 this AM. Pt also notes hematochezia x 24 hrs EMS reports that she takes OTC meds for Osteoarthritis
No other sig PMHx
On PE: Epigastrum is TTP Hematemesis and Hematochezia...

Is this Upper or Lower GI Bleed??? 64 yom, pmhx sig for HTN, Diverticulosis, remote AAA repair, presents with 2 day hx of black stools, abd discomfort, low-grade fever. +Diaphoresis, BP 72/46, P 138, RR 24; PE- midline abd scar, abd diffusely ttp. Rectal: BRBPR. 2 lg bore IV's in and IVF boluses are running. What is next step in mgmt? A. Vascular surgery consult
B. Abd/pelvic CT and start IV ABX
C. NG lavage and upper endoscopy consult
D. Start PPI and Octreotide What is the most common cause of SBO in children? A. Adhesions
B. Hernia
C. Intussusception
D. Midgut volvulus Intussusception -Telescoping of a proximal section of bowel into more distal bowel
-Presents as colicky abd pain, possibly vomiting
-May have palpable abdominal mass in RUQ
-Late phase can have bloody diarrhea
-Causes ischemia partial SBO Question #3 24 yom with hemophelia presents with BRBPR. He is 80 kg. How much factor needs to be given? A. 400 U
B. 800 U
C. 1600 U
D. 4000 U D. 4000
80 x 0.5 x 100 Diagnosis:
-Thorough hx
-High clinical suspicion
-CT scan

TX: Surgery What if patient is not stable enough for Colonoscopy? Is the patient still bleeding? If Yes, CTA vs Tagged RBC scan CTA Tagged RBC Requires bleeding rate of >/= 1ml/min
Use if massive bleeding, or unable to localize on colonoscopy
Has both diagnostic and therapeutic modalities Requires bleeding rate of only 0.1-0.5 ml/min
Use if continued bleeding unable to be localized on colonoscopy
More sensitive than CTA, not as specific
Diagnostic only In the Hemodynamically unstable Pt...
EGD First!
-Massive upper GI bleed may present with hematochezia
-Must always have this on your differential! Still no source? -Capsule endoscopy (evaluates small bowel)
-Surgery (Ex-lap) Finally, Back to our case... Other causes not covered:

Anal Fissure
Ischemic colitis
AVM Internal hemorrhoids, diverticulosis Pt is hemodynamically unstable.
It is a UGIB until proven otherwise.

Remember...
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