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LOWER GI BLEEDNG

LOWER GI BLEEDNG. CLINICAL PRESENTATION. A 68 yrs old presents to the ER with BRBPR. He has several episodes, beginning on the evening before presentation. He describes the bleeding as profuse and filling the toilet, he felt light headed and almost passed out while sitting on the toilet.

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LOWER GI BLEEDNG

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  1. LOWER GI BLEEDNG

  2. CLINICAL PRESENTATION • A 68 yrs old presents to the ER with BRBPR. He has several episodes, beginning on the evening before presentation. • He describes the bleeding as profuse and filling the toilet, he felt light headed and almost passed out while sitting on the toilet. • PMHx: htn • Meds: amlodipine • P.Ex: B.P. =86/42mm hg, pulse = 134/min, pt. is orthostatic. Abdominal examination reveals slight abdominal distention with hyperactive bowel sounds. Rectal exam shows gross blood

  3. Wbc-10 • Hct-28 % • Plt-180 • Lytes – wnl • Coagulation profile wnl • LFTs wnl

  4. Estimation of blood loss

  5. RESUSCITATION • High-risk patients (eg, those who are elderly or who have severe co morbid illnesses such as coronary disease or cirrhosis) should receive packed red blood cell transfusions to maintain the hematocrit above 30 percent. • Patients who are elderly or have known cardiovascular disease are at increased risk for a myocardial infarction and should thus be monitored appropriately; consideration should be given to ruling out a myocardial infarction. • Young and otherwise healthy patients should be transfused to maintain their hematocrit above 20 percent. • Patients with active bleeding and a coagulopathy (prolonged prothrombin time with INR >1.5) or low platelet count (<50,000/microL) should also be transfused with fresh frozen plasma and platelets, respectively.

  6. Lower GI bleeding • Next step

  7. Risk stratification

  8. Risk stratification • Strate and colleagues retrospectively collected data on 24 clinical variables available in the first 4 hours of evaluation in 252 consecutive patients. Seven independent predictors of severity in acute LGIB • hypotension • tachycardia, • syncope, • nontender abdominal exam, • bleeding within 4 hours of presentation, • aspirin use, and • more than two comorbid diseases

  9. Risk stratification • Based on these factors, patients could be stratified into three risk groups: • Patients with more than three risk factors had an 84% risk of severe bleeding, • One to three risk factors a 43% risk, and • No risk factors a 9% risk.

  10. Risk stratification • In another study clinical predictors in the first hour of evaluation in patients with severe LGIB included • initial hematocrit of no more than 35%, • presence of abnormal vital signs 1 hour after initial medical evaluation, and • gross blood on initial rectal examination.

  11. Next step

  12. localization • An upper gastrointestinal source of bleeding is detected in 10% to 15% of patients presenting with severe hematochezia . • Patients with hemodynamic compromise and hematochezia should have a nasogastric tube placed. If bile is present, an upper source is unlikely. If the aspirate is nondiagnostic (no blood or bile), or if there is a strong suspicion of an upper bleeding source (i.e., history of previous peptic ulcer disease or frequent NSAID use), then an upper endoscopy should be performed before examining the colon . • An upper endoscopy should be performed if no source of bleeding is identified during colonoscopy.

  13. LOCALIZATION • The duration, frequency, and color of blood passed per rectum may help discern the severity and location of bleeding. • Characteristically, melena or black, tarry stool, indicates bleeding from an upper gastrointestinal or small bowel source, • Maroon color suggests rt. Sided lesion • whereas bright red blood per rectum signifies bleeding from the left colon or rectum. However, patient and physician reports of stool color are often inaccurate and inconsistent • In addition, even with objectively defined bright red bleeding, significant proximal lesions can be found on colonoscopy

  14. LOCALIZATION • past medical history may also help to elucidate a specific bleeding source. • antecedent constipation or diarrhea (hemorrhoids, colitis), • the presence of diverticulosis (diverticular bleeding), • receipt of radiation therapy (radiation enteritis), • recent polypectomy (postpolypectomy bleeding), and • vascular disease/hypotension (ischemic colitis). • A family history of colon cancer increases the likelihood of a colorectal neoplasm and generally calls for a complete colonic examination in patients with hematochezia. • Nonetheless, even after a detailed history, physicians cannot reliably predict which patients with hematochezia will have significant pathology and a history of bleeding from one source does not eliminate the possibility of bleeding from a different source.

  15. LOCALIZATION • Multiple factors make the identification of a precise bleeding source in LGIB challenging. • The diversity of potential sources, • The length of bowel involved, • The need for colon cleansing, and • The intermittent nature of bleeding. • In up to 40% of patients with LGIB, more than one potential bleeding source will be noted and • Stigmata of recent bleeding in LGIB are infrequently identified • As a result, no definitive source will be found in a large percentage of patients

  16. Clinical scenarios • Pt. continued to bleed with hypotension and tachycardia. Patient requires 2 units of PRBCs • Pt. stopped bleeding. Vitals normalizes

  17. Options to diagnose and control the bleeding • RBC scan, requires 0.5-1 ml/min bleeding • Mesenteric angiography, requires 1-1.5 ml/min bleeding • Colonoscopy • Surgery • Meckels scan

  18. Scenario one- Pt. continues to bleed and is unstable.

  19. Rbc scan vs colonoscopy

  20. COLONOSCOPY • Colonoscopy is undoubtedly the best test for confirming the source of LGIB and for excluding ominous diagnoses, such as malignancy. • The diagnostic yield of colonoscopy ranges from 45% to 95% • Perform after golytely prep(w/in 12-24h) • Identifies lesion in 75 % or more • Can provide endoscopic therapy • Early colonoscopy associated with reduced stay • Complications 0.5-1 % • most patients undergoing radiographic evaluation for LGIB regardless of findings and interventions will subsequently require a colonoscopy to establish the cause of bleeding.

  21. URGENT COLONOSCOPY • Jensen et al Reduced rate of rebleeding and emergency surgery from diverticular bleed when compared to historical controls • Green et al 100 randomized to urgent (w/in 8hrs) colonoscopy to standard care Definitive source more common in urgent group No difference in multiple clinical outcomes • Issue is still not resolved

  22. CLINICAL SCENARIO • Patient continues to bleed • RBC scan is positive on the left side? How much true this information is?? • What to do next? surgery, ?angio with embolization?

  23. RADIONUCLIDE SCAN • radionuclide scanning has variable accuracy, cannot confirm the source of bleeding, and may delay other diagnostic and therapeutic procedures. • Correct localization rate is 41-100% • Accuracy appears to be best when the scan becomes positive within a short period of time • In one study, 42% of patients underwent an incorrect surgical procedure based on scintigraphy results. In addition, several studies have found that regardless of accuracy, scintigraphy did not affect surgical management • Predictors of positive response -hemodynamic instability= 62% vs. 21% ->2units transfused within 24 hrs= 64% vs. 32%

  24. CLINICAL SCENARIO • Patient underwent angiogram with embolization • Vitals improved • What are the chances that pt. will rebleed? • Colonoscopy?

  25. MESENTERIC ANGIOGRAM • Selective embolization initially controls hemorrhage in up to 100% of patients, but rebleeding rates are 15% to 40% • Advantages: -Precise localization -Can provide therapy with intra-arterial vasopressin or coil embolization -Procedure of choice in briskly bleeding pts -Minor complication rate of 9% and a 0% major complication rate

  26. Disadvantages: -Invasive -Less sensitive in detecting venous bleeding -Can cause ischemia, contrast reactions, arterial injury

  27. Pt. under went colonoscopy for definitive diagnosis. • In how many patients there will be more than one potential diagnosis? • In how many patients there will be no diagnosis found?

  28. ETIOLOGY

  29. DIAGNOSTIC DIFFICULTIES • When compared with EGD for upper GI bleeding, the diagnostic modalities for lower GI bleeding are not as sensitive or specific in making an accurate diagnosis. • Diagnostic evaluation is further complicated by the observation that, in up to 40% of patients with lower GI bleeding, more than one potential source of hemorrhage is identified. • If more than one source is identified, it is critical to confirm the responsible lesion before initiating aggressive therapy. • This approach may occasionally require a period of observation with several episodes of bleeding before a definitive diagnosis can be made. • In fact, in up to 25% of patients with lower GI hemorrhage, the bleeding source is never accurately identified.

  30. CLINICAL SCENARIO • COLONOSCOPY SHOWED old and BRB in mid colon tics seen throughout • Dx= probably diverticular beed • Pt was d/c home

  31. CLINICAL SCENARIO • 2 wks later readmitted with rebleed and syncope • Hct 32--- 24 • Urgent tagged RBC scan – neg • Deep mid AC diverticulum with clot that could not be removed • What is the next step

  32. SURGERY • Surgery usually is employed for hemorrhage in two settings: massive or recurrent bleeding. • It is required in 15% to 25% of patients who have diverticular bleeding and is recommended for patients with a high transfusion requirement (generally more than four units within a 24-hour period or greater than 10 units total) • Recurrent bleeding from diverticula occurs in 20% to 40% of patients and generally is considered an indication for surgery • In patients with serious comorbid medical conditions and without exsanguinating hemorrhage, this decision should be made carefully. • Great effort should be made to accurately localize the site of bleeding preoperatively so that segmental rather than subtotal colectomy can be performed Operative mortality is 10% even with accurate localization and up to 57% with blind subtotal colectomy.

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