Updated: 12/15/2021

Lower GI Bleed

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  • Snapshot
    • A 40-year-old man presents to the emergency room soon after arriving back from a vacation on a cruise ship. He reports feeling unwell and losing his appetite in the past few days. He has had several episodes of nausea and vomiting, but today had an episode of bloody diarrhea. He is otherwise healthy and is concerned about the amount of blood. He has also had subjective fevers. (Infectious colitis)
  • Introduction
    • Overview
      • lower gastrointestinal bleed results from bleeding from the colon or rectum
  • Epidemiology
    • Elderly patients with comorbidities
    • Incidence
      • very common
    • Risk factors
      • diverticulosis
      • angiodysplasia
      • ischemic colitis
      • neoplasm
      • inflammatory bowel disease
      • infection
        • Salmonella
        • Shigella
      • hemorrhoids
      • anal fissure
  • etiology
    • Pathogenesis
      • mechanism
        • depends on the etiology
  • Presentation
    • Symptoms
      • common symptoms
        • rectal bleeding
          • hematochezia
            • bright red (originating from left side of colon)
            • maroon blood (originating from right side of colon)
          • has the potential to be fatal and cause massive hemorrhagic shock
          • fecal occult blood test is positive
        • a fever may indicate infectious etiology
        • painless bleeding may indicate angiodysplasia or diverticular bleeding
        • abdominal pain may indicate ischemic colitis
    • Physical exam
      • inspection
        • dehydration
  • Imaging
    • Radionuclide scan
      • indications
        • often performed before angiography as it is not invasive and a negative result negates a need for further invasive procedures
        • high sensitivity
    • Angiography
      • indications
        • hemodynamically unstable patients
        • if colonoscopy does not reveal a bleeding site in hemodynamically stable patients
        • can also be therapeutic
  • Studies
    • Serum labs
      • complete blood count
      • serum electrolytes
      • coagulation studies
    • Invasive studies
      • colonoscopy/anoscopy/sigmoidoscopy
        • indication
          • first-line for patients who are hemodynamically stable
          • patients require bowel preparation
          • can also be used therapeutically for hemostasis
          • in patients > 50 years of age, must rule out malignancy with colonoscopy
  • Differential
    • Upper gastrointestinal bleed
      • key distinguishing factor
        • source of bleeding from stomach or small intestine
        • may also present as bright red blood if there is rapid hemorrhage
  • Treatment
    • Medical
      • resuscitation
        • modalities
          • large-bore intravenous access
          • crystalloid fluid replacement
          • blood transfusions if needed
    • Surgical
      • colonoscopy/anoscopy/sigmoidoscopy
        • indication
          • both diagnostic and therapeutic
          • colonoscopy specifically for all patients over 40 to rule out malignancy
        • modalities
          • hemostasis via
            • coagulation i.e., electrocoagulation
            • clip placement
      • angiography
        • indication
          • both diagnostic and therapeutic
          • used when colonoscopy is unrevealing or contraindicated
          • hemodynamically unstable patients
        • modalities
          • embolization
          • vasopressin drip
      • surgical exploration
        • indication
          • hemodynamically unstable patients refractory to resuscitation
          • persistent or recurrent bleeding
  • Complications
    • Death
    • Shock
  • Prognosis
    • Can be inconsequential or life-threatening

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(M2.GI.17.80) A 72-year-old male with a past medical history significant for aortic stenosis and hypertension presents to the emergency department complaining of weakness for the past 3 weeks. He states that, apart from feeling weaker, he also has noted lightheadedness, pallor, and blood-streaked stools. The patient's vital signs are stable, and he is in no acute distress. Laboratory workup reveals that the patient is anemic. Fecal occult blood test is positive for bleeding. EGD was performed and did not reveal upper GI bleeding. Suspecting a lower GI bleed, a colonoscopy is performed after prepping the patient, and it is unremarkable. What would be an appropriate next step for localizing a lower GI bleed in this patient?

QID: 106153

Nasogastric tube lavage

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Technetium-99 labelled erythrocyte scintigraphy

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(3/4)

Ultrasound of the abdomen

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CT of the abdomen

25%

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Flexible sigmoidoscopy

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M 6 B

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(M2.OMB.82) A 66-year-old man presents to the clinic with a 6-week history of bloody stools. He describes the blood as bright red wisps that float on the surface of the stool. He has no pain with bowel movements but notes on occasion he may strain. He does not endorse fatigue, fever, constipation, diarrhea, nausea, vomiting, abdominal pain, weight loss, or dyspnea. His last colonoscopy was 3 years prior to presentation and was benign. He has a medical history significant for hypertension that is well-controlled with lisinopril. He had an uncomplicated appendectomy when he was 23 years old. He has no family history of gastrointestinal malignancy. His temperature is 98.6°F (37.0°C), blood pressure is 140/90 mmHg, pulse is 76/min, and respirations are 16/min. On physical exam, the patient's abdomen is soft, non-distended, and non-tender with normal bowel sounds and without organomegaly or masses. The anus is patent without fissures, hemorrhoids, or skin tags. Which of the following is the most appropriate next step in management?

QID: 216275

Colonoscopy

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Computerized tomography scan of abdomen and pelvis

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Increase fiber in diet

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Observation

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Sigmoidoscopy

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M 6 E

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(M3.GI.12.2) A 71-year-old woman is brought to the emergency department following a syncopal episode. Earlier in the day, the patient had multiple bowel movements that filled the toilet bowl with copious amounts of bright red blood. Minutes later, she felt dizzy and lightheaded and collapsed into her daughter's arms. The patient has a medical history of diabetes mellitus and hypertension. Her temperature is 99.0°F (37.2°C), blood pressure is 155/94 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 99% on room air. The patient's exam is notable for fecal occult blood positivity on rectal exam; however, the patient is no longer having bloody bowel movements. The patient's lungs are clear to auscultation and her abdomen is soft and nontender. Labs are ordered as seen below.

Hemoglobin: 7.1 g/dL
Hematocrit: 25%
Leukocyte count: 5,300/mm^3 with normal differential
Platelet count: 182,500/mm^3

Two large bore IV's are placed and the patient is given normal saline. What is the best next step in management?

QID: 102631

Colonoscopy

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CT abdomen

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Fresh frozen plasma

17%

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Packed red blood cells

17%

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Type and screen

33%

(2/6)

M 11 E

Select Answer to see Preferred Response

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