Difference between revisions of "Gastrointestinal bleeding"

 
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==Background==
+
*Adults
*Loss of blood from the GI tract distal to the ligament of Treitz
+
**[[Upper GI Bleeding]]
*Upper GI bleeds are most common source for blood detected in the lower GI system
+
**[[Lower GI Bleeding]]
*80% of lower GI bleeding will resolve spontaneously
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*[[GI Bleeding (Peds)]]
*Cause of bleeding found in <50% of cases
 
 
 
==False Positive Guaiac==
 
#Red meat
 
#Red jello
 
#Fruit and vegetables
 
##(Melon, broccoli, radish
 
#Iron (causes GI bleed by irritation)
 
 
 
==Diagnosis==
 
===History===
 
*Type of blood
 
**Hematochezia
 
***Bright red or maroon-colored bleeding that comes from the rectum
 
***Usually represents lower GI bleeding
 
***May represent UGIB if bleeding is brisk
 
****Usually accompanied by hematemesis and hemodynamic instability
 
**Melena
 
***Usually represents bleeding from upper GI source
 
***May represent bleeding from lower GI source due to slow bleeding
 
*Medications
 
**Salicylates, NSAIDs, warfarin
 
 
 
===Physical Exam===
 
#Consider anoscopy if source of bleeding cannot be identified on external exam
 
 
 
==Workup==
 
#Labs
 
##CBC
 
###Chemistry
 
###BUN may be elevated if bleeding occurs from site high in GI tract
 
##Coags
 
##LFTs
 
##Type and screen
 
#ECG (if concern for silent ischemia inn pts likely to have CAD)
 
#Imaging
 
##CTA
 
###Requires brisk bleeding rate (0.5 cc/min) for detectio
 
##Proctoscopy (22cm from anal verge)
 
##Sigmoidoscopy (60cm from anal verge)
 
 
 
==DDX==
 
#Upper GI bleed
 
#Diverticular disease
 
##Painless bleeding
 
##Up to 90% of episodes resolve spontaneously
 
##Can result in massive hemorrhage
 
#Vascular ectasia
 
##Angiodysplasia, AVM
 
#Inflammatory bowel disease
 
#Colitis
 
##Infectious
 
##Ischemic
 
###90% of cases occur in age >70yo
 
###Colon is predisposed to ischemia due to poor vascular ciculation, high bacterial count
 
###Causes: aneurysmal rupture, vasculitis, hypercoagulable, CV insult, IBS, slow motility
 
###Most cases resolve on own; 20% of cases requires surgical intervention
 
#[[Mesenteric Ischemia]]
 
##Medical emergency that often leads to bowel necrosis
 
##Causes: thrombosis/embolism of SMA, mesenteric vein thrombosis, low arterial flow
 
##Associated w/ A fib, CHF, MI, age >60yo
 
##CT only 64% Sn, angiography is imaging study of choice
 
#Meckel Diverticulum
 
#Malignancy / polyps
 
#Hemorrhoids
 
##Massive hemorrhage is unusual
 
#Rectal ulcer
 
#Foreign body
 
#Rectal ulcer (HIV, syphilis, STIs)
 
#Anal fissure
 
 
 
==Treatment==
 
#IVF
 
#Correct coagulopathy
 
#Blood
 
##Give if continued active bleeding and failure to improve perfusion after 2L NS
 
#?NGT
 
##Hematochezia unexpectedly originates from upper GI source 10-15% of cases
 
#Sigmoidoscopy/colonoscopy
 
#Surgery if endoscopy fails or not available
 
 
 
==Disposition==
 
Discharge:
 
**Bleeding from hemorrhoids, anal fissures, or known IBD (hemodynamically stable)
 
**No gross blood on rectal exam (hemodynamically stable)
 
 
 
==Source ==
 
*Tintinalli
 
  
 
[[Category:GI]]
 
[[Category:GI]]
 +
[[Category:Symptoms]]

Latest revision as of 23:10, 28 November 2019