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Updated: Dec 15 2021

Lower GI Bleed

  • 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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