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Flashcards in Lower GI Bleed - Bernadino Deck (24)
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1
Q

What are the causes of lower GI bleeding?

A
  • Upper GI Source – 10%
  • Small Bowel Source – 5%
  • Colonic Source – 85%
    • Diverticular hemorrhage (30-50%)
    • Angiodysplasia (20-30%)
    • Neoplasm
    • IBD
    • Ischemia
    • Infection
    • Radiation colitis
    • Anorectal disorders
    • Post polypectomy
2
Q

What are the clinical features of Acute Diverticulitis?

Sx

Complications

Dx

A
  • Diverticulosis affects 5-10% > age 40 and 80% > age 85.
  • Symptoms of diverticulitis or hemorrhage occur in about 20%.
  • Symptoms:
    • Pain, diarrhea, fever & abdominal tenderness
    • Hemorrhage is rare
  • Complications: abscess, rupture or fistulize to adjacent organs
  • Diagnosis is made by CT, not endoscopy or barium enema
3
Q

What is the treatment for Diverticulitis?

A
  • Mild diverticulitis without peritoneal signs:
    • oral hydration, liquid diet, 10 days of oral antibiotics (metronidazole and ciprofloxacin)(Amox/Clavulanate)
  • Severe pain; elderly, comorbidities, no PO intake:
    • hospitalize, IV antibiotics, NPO, CT scan
  • Peritonitis; sepsis; perforation
    • surgical intervention
4
Q

How often does Acute Diverticular Hemorrhage occur?

A
  • Accounts for 50% of acute lower GI bleeding
  • Massive bleeding occurs in 5% of patients with diverticulosis
  • Hemorrhage is self-limited in 80%
  • Bleeding recurs in 1/3
  • Risk of rebleeding after a 2nd bleed is > 50%
5
Q

What is the treatment for Diverticular Hemorrhage?

A
  • Resuscitation
  • Reverse anticoagulation
  • Transfuse
  • Consider / Exclude upper GI bleed
    • History, NG, BUN
  • Observation (80% self-limited)
  • Colonoscopy if persistent – epinephrine, clip, cautery, band
  • Bleeding scan, angiography and embolization
  • Surgery – attempt to localize with bleeding scan or colonoscopy
6
Q

What is Angioectasia/Angiodysplasia?

A
  • Angioectasia = Angiodysplasia
    • Tortuous, dilated submucosal capillaries / veins lacking smooth muscle.
    • Spider-like, peripherally expanding 5-10-mm.
    • Anywhere, most common in the right colon
    • Present as overt hemorrhage or anemia.
    • Present in less than 1% of screening colonoscopies
    • Increased frequency with age.
    • 80% will rebleed without endotherapy.
7
Q

What are the comorbidities associated with Angiodysplasia?

A
  • Aortic stenosis (Heyde’s syndrome)
  • Chronic renal failure
  • Advanced age:
    • Most common cause of hematochezia in patients older than 65
8
Q

What is the treatment for Angiodysplasia?

A
  • Colonoscopy with ablation
    • Argon plasma
    • Cautery
    • Hemoclip
  • Surgery – subtotal colectomy
9
Q

What is ischemic colitis?

A
  • Lack of blood flow
    • typically in watershed areas
10
Q

How does Ischemic Colitis present?

A
  • Non-occlusive: hypoperfusion, drugs, heart disease, exercise, idiopathic
  • Occlusive: embolic, A Fib, mesenteric vein thrombosis, vascular procedure, vasculitis, vasospastic, hypercoagulable state
  • Classic: Usually acute, severe abdominal pain → followed by self-limited hematochezia.
  • May have mild – moderate, focal tenderness, fever, WBC, ileus
  • Usually without complication: rarely stricture or perforate
11
Q

How do you diagnose Ischemic Colitis?

A
  • History
  • CT: Thickened colon wall
  • Colonoscopy: confluent, mucosal ulceration friability, usually splenic flexure.
  • Biopsy
12
Q

What is the treatment of Ischemic Colitis?

A
  • Management: Improve perfusion (volume)
    • Correct underlying cause.
    • If self-limited, early colonoscopy not indicated (high risk)
    • Elective colonoscopy in 6-8 weeks – rule out other cause, stricture
    • If peritonitis, sepsis - Surgery
13
Q

What symptoms are typical in Lower GI bleeds caused by Neoplasm?

A
  • Location-dependent symptoms
    • Right colon – anemia
    • Left colon – obstruction
  • Occult, slow bleeding or anemia
  • Rarely hematochezia
  • Cause in <10% of hematochezia in age > 50
14
Q

What is Radiation Proctitis? How does it present?

A
  • Acute radiation proctitis – during radiation Rx
    • tenesmus, diarrhea, pain, rarely bleeding
  • Chronic radiation proctopathy – delayed mos-yrs
    • Anemia, hematochezia
15
Q

What is the treatment for Radiation Proctitis?

A
  • Endoscopic ablation
  • Formaldehyde, SCFA, steroids
16
Q

What are the three Ano-Rectal Disorders that cause Lower GI bleeds?

A
  1. Fissure
  2. Hemorrhoids
  3. Solitary rectal ulcer
17
Q

Where are most Anal Fissures?

A

Usually posterior, less often anterior

18
Q

What are the common comorbidities associated with Anal Fissure?

A
  • Chronic constipation
  • diabetes
  • Crohn’s
19
Q

What is the treatment for Anal Fissures?

A
  • Stool softening and bulking (fiber)
  • Topical nitrates, calcium channel blocker (NTG, diltiazem, nifedipine)
  • Botulinum toxin
  • Lateral sphincterotomy – risk of incontinence
  • Sphicter dilation – mixed efficacy
20
Q

What are Hemorrhoids?

A

Dilated plexus of submucosal middle and superior hemorrhoidal veins

21
Q

What is the clinical presentation of Hemorrhoids?

A
  • Symptoms: Bleeding, pruritis, pain ( if thrombosis)
  • Peak age range (45-60), rare < 20 yo
  • Associated with:
    • advancing age, diarrhea, pregnancy, prolonged sitting, straining, and chronic constipation
22
Q

What is the treatment for Hemorrhoids?

A
  • Stool softening and bulking (fiber)
  • Banding, surgical hemmorrhoidectomy
23
Q

What is the clinical presentation of Solitary Rectal Ulcers?

A
  • Varying appearance
    • erythema
    • nodularity
    • ulcer
  • Etiology: rectal prolapse, puborectalis spasm, constipation, 4th decade
  • Symptoms: bright blood, straining, pelvic fullness, constipation
24
Q

What is the treatment for Solitary Rectal Ulcers?

A
  • Stool bulking, softeners, biofeedback
  • Topical mesalamine or steroids
  • Surgery