Undifferentiated lower gastrointestinal bleeding: Difference between revisions
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*80% of lower GI bleeding will resolve spontaneously{{Citation needed|reason=Reliable source needed|date=May 2016}} | *80% of lower GI bleeding will resolve spontaneously{{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}} | *Cause of bleeding found in <50% of cases{{Citation needed|reason=Reliable source needed|date=May 2016}} | ||
*Hematochezia unexpectedly originates from upper GI source 10-15% of cases{{Citation needed|reason=Reliable source needed|date=May 2016}} | |||
===Medication Risk Factors=== | ===Medication Risk Factors=== | ||
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**Requires brisk bleeding rate (0.5 cc/min) for detection{{Citation needed|reason=Reliable source needed|date=May 2016}} | **Requires brisk bleeding rate (0.5 cc/min) for detection{{Citation needed|reason=Reliable source needed|date=May 2016}} | ||
=== | ===Definitive studies=== | ||
*Consider: | *Consider: | ||
**Anoscopy if source of bleeding cannot be identified on external exam | **Anoscopy if source of bleeding cannot be identified on external exam | ||
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*Consider transfusing [[pRBCs]]/[[platelets]] for unstable patients or with very low hemoglobin (<7) | *Consider transfusing [[pRBCs]]/[[platelets]] for unstable patients or with very low hemoglobin (<7) | ||
*Consider NGT - high possibility for surgery to request | *Consider NGT - high possibility for surgery to request | ||
*Emergent Sigmoidoscopy/colonoscopy (next 24 hours) | *Emergent Sigmoidoscopy/colonoscopy (next 24 hours) | ||
*Surgery if endoscopy fails or not available | *Surgery if endoscopy fails or not available | ||
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===Major Bleed and Supratheraputic INR=== | ===Major Bleed and Supratheraputic INR=== | ||
*[[Coagulopathy (main)|Correct coagulopathy]] | *[[Coagulopathy (main)|Correct coagulopathy]] | ||
**Vitamin K 10mg IV (best bioavailability in critical patient) | **[[Vitamin K]] 10mg IV (best bioavailability in critical patient) | ||
**FFP | **[[FFP]] | ||
===Special situations=== | ===Special situations=== | ||
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==Disposition== | ==Disposition== | ||
===Discharge=== | ===Discharge=== | ||
*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) | ||
Revision as of 22:38, 30 September 2016
Background
- 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
- 80% of lower GI bleeding will resolve spontaneously[citation needed]
- Cause of bleeding found in <50% of cases[citation needed]
- Hematochezia unexpectedly originates from upper GI source 10-15% of cases[citation needed]
Medication Risk Factors
Clinical Features
Type of blood
- Hematochezia
- Bright red or maroon-colored bleeding that comes from the rectum
- Usually represents lower GI bleeding
- May represent upper GI source if bleeding is brisk
- Usually accompanied by hematemesis and hemodynamic instability
- Melena
- Usually represents bleeding from upper GI source
- May represent slow bleeding from lower GI source
Differential Diagnosis
Undifferentiated lower gastrointestinal bleeding
- Upper GI Bleeding
- Diverticular disease
- Vascular ectasia / angiodysplasia
- Inflammatory bowel disease
- Infectious colitis
- Mesenteric Ischemia / ischemic colitis
- Meckel's diverticulum
- Colorectal cancer / polyps
- Hemorrhoids
- Aortoenteric fistula
- Nearly 100% mortality if untreated
- Consider in patients with gastrointestinal bleeding and known abdominal aortic aneurysms or aortic grafts
- Rectal foreign body
- Rectal ulcer (HIV, Syphilis, STI)
- Anal fissure
Evaluation
Workup
- CBC
- Chemistries
- BUN may be elevated if bleeding occurs from site high in GI tract
- Coags
- LFTs
- Type and screen
- ECG (if concern for silent ischemia in patients likely to have CAD)
- CTA
- Requires brisk bleeding rate (0.5 cc/min) for detection[citation needed]
Definitive studies
- Consider:
- Anoscopy if source of bleeding cannot be identified on external exam
- Proctoscopy (22cm from anal verge)
- Sigmoidoscopy (60cm from anal verge)
False Positive Guaiac
- Red meat
- Red jello
- Fruit and vegetables
- Melon, broccoli, radish, beets
- Iron (causes GI bleed by irritation)
Management
- IVF
- Consider transfusing pRBCs/platelets for unstable patients or with very low hemoglobin (<7)
- Consider NGT - high possibility for surgery to request
- Emergent Sigmoidoscopy/colonoscopy (next 24 hours)
- Surgery if endoscopy fails or not available
Major Bleed and Supratheraputic INR
Special situations
- Marathon runners - 16% will have hematochezia within 24-48 hrs of race and 85% will be guaiac positive<[citation needed]
- Non-actionable unless abdominal pain present
Disposition
Discharge
- Bleeding from hemorrhoids, anal fissures, or known IBD (hemodynamically stable)
- No gross blood on rectal exam (hemodynamically stable)
Admission
- Melena
- Significant anemia
- Hemodynamic instability