Gastrointestinal bleeding: Difference between revisions

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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
*[[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]]

Revision as of 23:10, 28 November 2019