Lower Gastrointestinal Bleeding

Lower Gastrointestinal Bleeding free pdf ebook was written by Randolph Steinhagen, MD on May 09, 2006 consist of 3 page(s). The pdf file is provided by www.mssurg.net and available on pdfpedia since September 10, 2011.

lower gastrointestinal bleeding • definition: hemorrhage into the lumen of the bowel..of ngt if positive results, i.e. gross blood or coffee grounds,..aspirate clear, cannot r/o duodenal source for bleeding, clinical decision egd...

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Lower Gastrointestinal Bleeding pdf




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: Randolph Steinhagen, MD
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Lower 
Gastrointestinal Bleeding - page 1
LOWER GASTROINTESTINAL BLEEDING Definition: hemorrhage into the lumen of the bowel from a source distal to the ligament of Treitz Diagnosis o History/Physical - nature/duration of bleeding, stool color/frequency, intravascular volume status, abdominal/rectal exam o Placement of NGT If positive results, i.e. gross blood or coffee grounds, then EGD Copious amounts of bile suggestive of lower GI source If aspirate clear, cannot r/o duodenal source for bleeding, clinical decision EGD vs. colonoscopy Management o Initial hemodynamic stabilization o Localization of bleeding site Colonoscopy Diagnostic yield 53-97%, complication rate 0.5% Procedure of choice for evaluation, angiography reserved for patients with ongoing bleeding in whom endoscopy is not feasible Radionuclide scanning Highly sensitive, detects rates as low as 0.1 to 0.4 ml/min. but no therapeutic intervention capabilities Technetium-99m sulfur colloid vs RBC SC requires no preparation time but is rapidly absorbed RBC requires preparation but can be detected on images 24-48 hours Selective mesenteric angiography Bleeding rate must be 1.0 to 1.5 ml/min Positive test shows extravasation into lumen of bowel Diagnostic yield 27-67%, complication rate 2-4% Reserved for patients who cannot undergo colonoscopy Provocative Angiography Obscure bleeding persists despite negative endoscopy, mesenteric angiography, radionuclide scanning Short acting anticoagulant agents - heparin, tolazoline, TPA, urokinase - to localize bleeding point, then immediately to OR Success unclear o Site specific Therapeutic Intervention Endoscopic Thermal contact probes, laser photocoagulation, electrocauterization, injection of vasoconstrictors, application of metallic clips, injection sclerotherapy Diverticular hemorrhage difficult to treat due to high bleeding rate and location of bleeding within diverticula 170
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Lower 
Gastrointestinal Bleeding - page 2
Angiodysplasia typically can be treated, right colon risk of perforation (2%), in distal colon angiodysplasias from radiation can treat with thermal contact probes, lasers or non contact devices like argon plasma coagulator Angiography Intra-arterial injection of vasopressin Arteriolar vasoconstriction and bowel wall contraction, localize bleeding then position catheter Rate of 0.2 U/min can be increased to 0.4 U/min, angiogram after 20-30 minutes, infuse 6-12 hours, halve rate then continue 6-12 hours, if no recurrence then remove catheter Systemic side effects — MI, peripheral ischemia, hypertension, dysrhythmias, mesenteric thrombosis, intestinal infarction, death Success rate 60-100%, complications 10-20%, rebleeding rates as high as 50% Trans catheter embolization Alternative for patients with CAD, PVD - Selective placement in vessel with injection of embolizing agent - Small series have found highly successful 90-100% with low rebleeding rates. Surgical No absolute criteria, generally, patients who require more than 4 U of PRBC in 24 hours, bleeding has not stopped for 72 hours, rebleeding within 1 week of initial episode Directed segmental resection - rebleeding rates 0-14%, mortality 0-13% If cannot identify bleeding prior to surgery, intraoperative options for localization - colonoscopy, EGD, enteroscopy If still cannot identify bleeding, subtotal colectomy is procedure of choice, mortality 5-33% Common Causes of Lower GI Bleed o Diverticular Disease 17-40% of lower GI bleed, prevalence diverticulosis 37-45%, 17% patients with diverticulosis experience bleeding 80-85% diverticular bleeding stops spontaneously, risk of second bleeding episode 25%, 3 rd episode 50% surgery offered after second diverticular bleeding episode o Arteriovenous Malformation Vascular ectasias, angiomas, angiodysplasias chronic colonic wall muscle contraction, chronic partial obstruction of veins, vessels become dilated, precapillary sphincters become incompetent most common in cecum 171
Lower 
Gastrointestinal Bleeding - page 3
diagnosis during angiography (ectatic, slow emptying veins, vascular tufts, early filling veins) or colonoscopy (red, flat lesions about 2-10 mm in diameter, sometimes accompanied by a feeding vessel) only 2% of acute bleeding, usually slow, chronic. Stops spontaneously in 85-90%, recurs in 25-85% therefore requires definitive surgical or colonoscopic treatment. o Colitis 9-21% of lower GI bleed includes IBD, infectious colitis, radiation colitis, idiopathic ulcers 6-10% of patients with UC have lower GI bleeding severe enough to need emergency surgical resection 0.6-1.3% of patients with Crohn’s 50% of IBD patients with lower GI bleed will spontaneously resolve radiation therapy damages bowel mucosa, forming vascular telangiectasias that are prone to bleeding, 1-5% of cases of acute lower GI bleeding from radiation induced proctocolitis requires hospitalization. Initial treatment endoscopic treatment. Neoplasia From colorectal neoplasia 7-33% from erosions on luminal surface Bleeding most common complication after endoscopic polypectomy 0.2- 6%, both immediate and delayed Benign Anorectal Disease Hemorrhoids, ulcer/fissure disease, fistula-in-ano Patients with hemorrhoids should still undergo endoscopic evaluation to rulke out other pathologic conditions Portal hypertension, CHF, splenic vein thrombosis can cause colonic or anorectal varices Upper GI source Small bowel source o o o o Gita Pillai, MD February 23, 2006 172
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