Undifferentiated lower gastrointestinal bleeding - Revision history

Danbot: Add MedicationDose entry (vitamin K) with SMW annotations

2026-03-20T18:55:58Z

Add MedicationDose entry (vitamin K) with SMW annotations

← Older revision		Revision as of 18:55, 20 March 2026
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	**Non-actionable unless abdominal pain present		**Non-actionable unless abdominal pain present



			==Medication Dosing==
			{{MedicationDose
			\| drug = Vitamin K
			\| dose = 10mg
			\| route = IV
			\| context = Coagulopathy reversal for active GI bleeding
			\| indication = Undifferentiated lower gastrointestinal bleeding
			\| population = Adult
			}}

	==Disposition==		==Disposition==

Ostermayer: Prepared the page for translation

2026-01-05T00:02:27Z

Prepared the page for translation

Show changes

Patricklin at 04:17, 24 July 2024

2024-07-24T04:17:37Z

Show changes

Rossdonaldson1: /* Evaluation */

2024-02-07T21:15:15Z

Evaluation

← Older revision		Revision as of 21:15, 7 February 2024
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	==Evaluation==		==Evaluation==
			[[File:Fecal Occult Blood Test.jpg\|thumb\|Fecal Occult Blood Test showing positive (A) and positive control (B).]]
	*Digital rectal exam for guaiac or assessment of anorectal structural abnormalities		*Digital rectal exam for guaiac or assessment of anorectal structural abnormalities
	*Consider chart review to search for prior colonoscopy/endoscopy results		*Consider chart review to search for prior colonoscopy/endoscopy results

Rossdonaldson1: /* Background */

2024-02-07T19:35:47Z

Background

← Older revision		Revision as of 19:35, 7 February 2024
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	==Background==		==Background==
			[[File:Figure 34 01 10f.png\|thumb\|Gasterointestinal anatomy.]]
	[[File:Layers of the GI Tract english.png\|thumb\|Layers of the Alimentary Canal. The wall of the alimentary canal has four basic tissue layers: the mucosa, submucosa, muscularis, and serosa.]]		[[File:Layers of the GI Tract english.png\|thumb\|Layers of the Alimentary Canal. The wall of the alimentary canal has four basic tissue layers: the mucosa, submucosa, muscularis, and serosa.]]
	*Loss of blood from the gastrointestinal tract distal to the ligament of Treitz		*Loss of blood from the gastrointestinal tract distal to the ligament of Treitz

Rossdonaldson1: Rossdonaldson1 moved page Lower gastrointestinal bleeding to Undifferentiated lower gastrointestinal bleeding

2024-02-07T19:25:40Z

Rossdonaldson1 moved page Lower gastrointestinal bleeding to Undifferentiated lower gastrointestinal bleeding

← Older revision	Revision as of 19:25, 7 February 2024
(No difference)

Rossdonaldson1: /* Background */

2024-02-07T19:24:26Z

Background

← Older revision		Revision as of 19:24, 7 February 2024
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	==Background==		==Background==
			[[File:Layers of the GI Tract english.png\|thumb\|Layers of the Alimentary Canal. The wall of the alimentary canal has four basic tissue layers: the mucosa, submucosa, muscularis, and serosa.]]
	*Loss of blood from the gastrointestinal tract distal to the ligament of Treitz		*Loss of blood from the gastrointestinal tract distal to the ligament of Treitz
	**Majority of cases originate distally to ileocecal valve, rather than small intestines<ref> Farrell JJ, Friedman LS. Review article: the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2005 Jun 1;21(11):1281-98. doi: 10.1111/j.1365-2036.2005.02485.x. PMID: 15932359.</ref>		**Majority of cases originate distally to ileocecal valve, rather than small intestines<ref> Farrell JJ, Friedman LS. Review article: the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2005 Jun 1;21(11):1281-98. doi: 10.1111/j.1365-2036.2005.02485.x. PMID: 15932359.</ref>

Rossdonaldson1: /* Management */

2024-01-24T22:40:26Z

Management

← Older revision		Revision as of 22:40, 24 January 2024
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	**Calculate risk score to determine disposition		**Calculate risk score to determine disposition
	***Oakland score		***Oakland score
	***Glasgow-Blatchford ~~score~~		***[[Glasgow-Blatchford Bleeding Score]]

	===Major Bleed and Supratherapeutic INR===		===Major Bleed and Supratherapeutic INR===

Patricklin at 14:59, 10 January 2024

2024-01-10T14:59:27Z

← Older revision		Revision as of 14:59, 10 January 2024
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	==Background==		==Background==
	*Loss of blood from the gastrointestinal tract distal to the ligament of Treitz		*Loss of blood from the gastrointestinal tract distal to the ligament of Treitz
	*~~Upper GI bleeds are most common source for blood detected in~~ the lower ~~GI system~~		**Majority of cases originate distally to ileocecal valve, rather than small intestines<ref> Farrell JJ, Friedman LS. Review article: the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2005 Jun 1;21(11):1281-98. doi: 10.1111/j.1365-2036.2005.02485.x. PMID: 15932359.</ref>
	*~~80%~~ of lower GI ~~bleeding will resolve spontaneously{{Citation needed\|reason=Reliable source needed\|date=May 2016}}~~		*[[Diverticulosis]] cause majority, other conditions include [[colitis]], polyps, [[colorectal cancer]], [[hemorrhoids]], [[anal fissures]], [[inflammatory bowel disease]]
			**Consider recent procedures such as abdominal surgeries or colonoscopies/polypectomies
			**Must consider upper GI bleed (especially rapid transit) as a source, as a significant number of lower GI bleeds have a concurrent upper GI bleed, brisk or not<ref>Amin SK, Antunes C. Lower Gastrointestinal Bleeding. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448126</ref>
	*Cause of bleeding found in <50% of cases{{Citation needed\|reason=Reliable source needed\|date=May 2016}}		*Cause of bleeding found in <50% of cases{{Citation needed\|reason=Reliable source needed\|date=May 2016}}
	**[[Diverticulosis]] cause majority, ~~other conditions include [[colitis]], polyps, [[colorectal cancer]], [[hemorrhoids]], [[anal fissures]]~~		*80% of lower GI bleeding will resolve spontaneously<ref> Farrell JJ, Friedman LS. Review article: the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2005 Jun 1;21(11):1281-98. doi: 10.1111/j.1365-2036.2005.02485.x. PMID: 15932359.</ref>
	*Hematochezia originates from briskly bleeding ~~upper GI source in~~ 10-~~15% of cases{{Citation needed\|reason=Reliable source needed\|date=May 2016}}~~

	===Medication Risk Factors===		===Medication Risk Factors===
	*[[Salicylates]]		*Obtain a thorough medication history to assess for new antiplatelets or anticoagulants
	*[[NSAIDs]]		**[[Salicylates]]
	*[[Warfarin]]		**[[NSAIDs]]
			**[[Warfarin]] and [[Clopidogrel]]
			**[[Apixaban]] and [[Rivaroxaban]]

	==Clinical Features==		==Clinical Features==
	===Type of blood===		===Type of blood===
	*Hematochezia		*Hematochezia
	**Bright red or maroon-colored bleeding that comes from the rectum
	**Usually represents lower GI bleeding		**Usually represents lower GI bleeding
			**Left colonic bleeding tends to be bright red, whereas right colonic is usually maroon and mixed with stool<ref>Frost J, Sheldon F, Kurup A, Disney BR, Latif S, Ishaq S. An approach to acute lower gastrointestinal bleeding. Frontline Gastroenterol. 2017 Jul;8(3):174-182. doi: 10.1136/flgastro-2015-100606. Epub 2015 Jun 29. PMID: 28839906; PMCID: PMC5558275.</ref>
	**May represent upper GI source if bleeding is brisk		**May represent upper GI source if bleeding is brisk
	***Usually accompanied by hematemesis and hemodynamic instability		***Usually accompanied by hematemesis and hemodynamic instability
	*Melena		*Melena
	**Usually represents bleeding from upper GI source (see [[upper GI bleed]])		**Usually represents bleeding from upper GI source (see [[upper GI bleed]])
	**May represent slow bleeding from lower GI source		**May represent slow bleeding or slow stool transit from lower GI source

	==Differential Diagnosis==		==Differential Diagnosis==
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	==Evaluation==		==Evaluation==
			*Digital rectal exam for guaiac or assessment of anorectal structural abnormalities
			*Consider chart review to search for prior colonoscopy/endoscopy results

	===Workup===		===Workup===
	*CBC		*CBC
	*~~Chemistries~~		**Consider q3-12hr serial Hgb, depending on suspected severity of bleed
	**BUN may be elevated if bleeding occurs from site high in GI tract		**Initial Hgb may be normal if bleeding is acute
			*CMP
			**BUN may be elevated if bleeding occurs from site high in GI tract, due to heme digestion to nitrogenous substances reflected in BUN<ref>Patel, Sneha MD; Peraza, Jellyana MD; Hasani, Aliaskar MD; Luther, Sanjana MD; Chugh, Rishika MD; Tokayer, Aaron MD, FACG. 611 Finding the Ideal BUN to Creatinine Ratio in an Upper GI Bleed. The American Journal of Gastroenterology 114():p S355, October 2019. \| DOI: 10.14309/01.ajg.0000591980.77707.20</ref>
	*Coags		*Coags
	*[[LFTs]]		*Type and screen/cross
	*Type and screen
	*Consider:		*Consider:
	**[[ECG]] (if concern for silent ischemia in patients likely to have CAD)		**[[ECG]] (if concern for silent ischemia in patients likely to have CAD)
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	==Management==		==Management==
			*NPO, if there is foreseeable endoscopy or surgery
			*Fluid resuscitation for all

	''Categorize as stable versus unstable using [[shock index]]: <1 stable; >1 unstable or suspect active bleeding''		''Categorize as stable versus unstable using [[shock index]]: <1 stable; >1 unstable or suspect active bleeding''
	*Unstable		*Unstable
	**~~Resuscitate,~~ CT ~~angiogram, if CTA does not identify source of bleeding, upper endoscopy if hemodynamic instability~~ <ref> Oakland K, Chadwick G, East JE, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019;67:776-789. </ref>		**CT angiography is preferred for hemodynamically unstable patients due to speed<ref> Oakland K, Chadwick G, East JE, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019;67:776-789. </ref>
	**Consider transfusing [[pRBCs]]/[[platelets]] for unstable patients or with very low hemoglobin (<7). with cardiovascular disease use trigger of 8 and target of 10 hemoglobin.		**Consider transfusing [[pRBCs]]/[[platelets]] for unstable patients or with very low hemoglobin (<7). with cardiovascular disease use trigger of 8 and target of 10 hemoglobin.
	**~~Emergent~~ sigmoidoscopy/colonoscopy (next 24 hours)		***Base decision to transfuse on individual clinical factors. Active bleeding and tachycardia may call for transfusion despite normal Hgb
	**~~Surgery~~ if endoscopy fails or not available		**Consider withholding and DOACs; consult with a specialist or the physician who prescribed the medication especially if high-risk cardiac pathology is present
	*Stable		**Consult GI for emergent sigmoidoscopy/colonoscopy (next 24 hours); upper endoscopy may be needed if CTA does not reveal source of GI bleeding
			**Consult interventional radiology for embolization if an extravasating lesion is identified on CTA<ref>Sengupta, Neil, Feuerstein, Joseph, Jairath, Vipul, et al. Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Am J Gastroenterol. 2023;118(2):208-231. doi:10.14309/ajg.0000000000002130.</ref>
			**Consult surgery if endoscopy fails or not available
			*Stable
	**Calculate risk score to determine disposition		**Calculate risk score to determine disposition
	***Oakland score		***Oakland score
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	==Disposition==		==Disposition==
	===Discharge===		===Discharge===
			*Oakland score can help determine if outpatient management is feasible<ref>Oakland K, Jairath V, Uberoi R, Guy R, Ayaru L, Mortensen N, Murphy MF, Collins GS. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. Lancet Gastroenterol Hepatol. 2017 Sep;2(9):635-643. doi: 10.1016/S2468-1253(17)30150-4. Epub 2017 Jun 23. PMID: 28651935.</ref>
	*Bleeding from [[hemorrhoids]], [[anal fissures]], or known [[IBD]] (hemodynamically stable)		*Bleeding from [[hemorrhoids]], [[anal fissures]], or known [[IBD]] (hemodynamically stable)
	*No gross blood on rectal exam (hemodynamically stable)		*No gross blood on rectal exam (hemodynamically stable)

Rossdonaldson1: /* See Also */

2022-03-12T14:06:52Z

← Older revision		Revision as of 14:06, 12 March 2022
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	==See Also==		==See Also==
	*[[Upper GI ~~Bleeding]]~~		{{GI bleeding pages}}

	==References==		==References==