Lower gastrointestinal bleeding resident survival guide: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{WikiDoc CMG}}; {{AE}} {{TS}} | {{WikiDoc CMG}}; {{AE}} {{TS}}; {{Rim}} | ||
== | ==Overview== | ||
Lower GI bleed refers to any bleeding originating from gastrointestinal tract distal to [[ligament of Treitz]].<ref name="pmid19881516">{{cite journal| author=Barnert J, Messmann H| title=Diagnosis and management of lower gastrointestinal bleeding. | journal=Nat Rev Gastroenterol Hepatol | year= 2009 | volume= 6 | issue= 11 | pages= 637-46 | pmid=19881516 | doi=10.1038/nrgastro.2009.167 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19881516 }} </ref><br> | Lower GI bleed refers to any bleeding originating from gastrointestinal tract distal to [[ligament of Treitz]].<ref name="pmid19881516">{{cite journal| author=Barnert J, Messmann H| title=Diagnosis and management of lower gastrointestinal bleeding. | journal=Nat Rev Gastroenterol Hepatol | year= 2009 | volume= 6 | issue= 11 | pages= 637-46 | pmid=19881516 | doi=10.1038/nrgastro.2009.167 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19881516 }} </ref><br> | ||
{|class="wikitable" | {|class="wikitable" | ||
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==Causes== | ==Causes== | ||
===Life Threatening Causes=== | ===Life Threatening Causes=== | ||
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Shown below is an algorithm summarizing the approach to initial assessment of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy.<ref name="pmid16246674">{{cite journal| author=Davila RE, Rajan E, Adler DG, Egan J, Hirota WK, Leighton JA et al.| title=ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. | journal=Gastrointest Endosc | year= 2005 | volume= 62 | issue= 5 | pages= 656-60 | pmid=16246674 | doi=10.1016/j.gie.2005.07.032 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16246674 }} </ref> | Shown below is an algorithm summarizing the approach to initial assessment of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy.<ref name="pmid16246674">{{cite journal| author=Davila RE, Rajan E, Adler DG, Egan J, Hirota WK, Leighton JA et al.| title=ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. | journal=Gastrointest Endosc | year= 2005 | volume= 62 | issue= 5 | pages= 656-60 | pmid=16246674 | doi=10.1016/j.gie.2005.07.032 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16246674 }} </ref> | ||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{familytree | {{familytree | | | | | A01 | | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterize the symptoms:'''<br> | ||
❑ Frank blood per rectum <br>❑ Dark or maroon colored stools <br> ❑ [[Abdominal pain]]<br> ❑ [[Fatigue]]<br>❑ [[Diarrhea]]<br>❑ [[Constipation]]<br>❑ Fever<br> | ❑ Frank blood per rectum <br>❑ Dark or maroon colored stools <br> ❑ [[Abdominal pain]]<br> ❑ [[Fatigue]]<br>❑ [[Diarrhea]]<br>❑ [[Constipation]]<br>❑ Fever<br> | ||
❑ [[Tenesmus]]<br>❑ [[Palpitations]]<br> ❑ [[Lightheadedness]]<br> | ❑ [[Tenesmus]]<br>❑ [[Palpitations]]<br> ❑ [[Lightheadedness]]<br> | ||
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'''Obtain the medical history:'''<br> | '''Obtain the medical history:'''<br> | ||
❑ Previous GI bleed<br>❑ Use of NSAIDs, [[aspirin]] or [[anticoagulants]]<br>❑ History of radiation<br>❑ History of liver disease<br>❑ History of [[IBD]]<br>❑ Recent [[polypectomy]]<br>❑ Family history of [[colorectal cancer]]</div>}} | ❑ Previous GI bleed<br>❑ Use of NSAIDs, [[aspirin]] or [[anticoagulants]]<br>❑ History of radiation<br>❑ History of liver disease<br>❑ History of [[IBD]]<br>❑ Recent [[polypectomy]]<br>❑ Family history of [[colorectal cancer]]</div>}} | ||
{{familytree | {{familytree | | | | | |!| | }} | ||
{{familytree | {{familytree | | | | | B01 | | B01=<div style="float: left; text-align: left; width: 24em; padding:1em;">'''Examine the patient:'''<br> | ||
❑ '''[[Assess the hemodynamic status]]'''<ref name="pmid18387374">{{cite journal| author=Cappell MS, Friedel D| title=Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. | journal=Med Clin North Am | year= 2008 | volume= 92 | issue= 3 | pages= 491-509, xi | pmid=18387374 | doi=10.1016/j.mcna.2008.01.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18387374 }} </ref><br> | ❑ '''[[Assess the hemodynamic status]]'''<ref name="pmid18387374">{{cite journal| author=Cappell MS, Friedel D| title=Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. | journal=Med Clin North Am | year= 2008 | volume= 92 | issue= 3 | pages= 491-509, xi | pmid=18387374 | doi=10.1016/j.mcna.2008.01.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18387374 }} </ref><br> | ||
: ❑ [[Blood pressure]] | : ❑ [[Blood pressure]] | ||
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</table> | </table> | ||
❑ Perform a [[digital rectal examination]]<br>❑ Examine the stool for [[occult blood]]</div>|B02= [[Hematochezia]] PLUS<br> [[hemodynamic instability]]|B03=Nasogastric lavage<br>(to rule out upper GI bleed)}} | ❑ Perform a [[digital rectal examination]]<br>❑ Examine the stool for [[occult blood]]</div>|B02= [[Hematochezia]] PLUS<br> [[hemodynamic instability]]|B03=Nasogastric lavage<br>(to rule out upper GI bleed)}} | ||
{{familytree | {{familytree | | | | | |!| | | | | | }} | ||
{{familytree | {{familytree | | | | | C01 | | | | | C01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Order tests:'''<br> | ||
❑ [[Blood type]] and [[cross match]]<br> | ❑ [[Blood type]] and [[cross match]]<br> | ||
❑ [[CBC]]<br>❑ Coagulation profile <br>❑ [[Liver function tests]]<br>❑ [[Electrolytes]]<br>❑ [[BUN]]<br>❑ [[Creatinine]]<br>❑ [[EKG]] ( for elderly ) </div>|C02= Blood in NG lavage fluid|C03=Copious amount of bile with no trace of blood }} | ❑ [[CBC]]<br>❑ Coagulation profile <br>❑ [[Liver function tests]]<br>❑ [[Electrolytes]]<br>❑ [[BUN]]<br>❑ [[Creatinine]]<br>❑ [[EKG]] (for elderly ) </div>|C02= Blood in NG lavage fluid|C03=Copious amount of bile with no trace of blood }} | ||
{{familytree | {{familytree | | | | | |!| | | | | | }} | ||
{{familytree | {{familytree | | | | | D01 | | | | |D01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> | ||
'''Initiate initial supportive measures:'''<br> | '''Initiate initial supportive measures:'''<br> | ||
❑ Establish intravenous access<br> | ❑ Establish intravenous access<br> | ||
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: ❑ 500 ml of [[NS]] over 30 minutes. | : ❑ 500 ml of [[NS]] over 30 minutes. | ||
❑ Administer [[supplemental oxygen]]<br> | ❑ Administer [[supplemental oxygen]]<br> | ||
❑ Cardiac monitoring</div>|D02=❑ Proceed with [[EGD]] after initial assessment|D03=❑ Proceed with colonoscopy after initial | ❑ Cardiac monitoring</div>|D02=❑ Proceed with [[EGD]] after initial assessment|D03=❑ Proceed with colonoscopy after initial assessment}} | ||
{{familytree | {{familytree | | | | | |!| | | | | | | }} | ||
{{familytree | {{familytree | | | | | E01 | | | | | |E01='''Risk stratification of patients'''}} | ||
{{familytree | {{familytree | |,|-|-|-|+|-|-|-|.| | | }} | ||
{{familytree | {{familytree | F01 | | F02 | | F03 | |F01=<div style="float: left; text-align: left; width: 20em; padding:1em;">❑ Young patient<br>❑ Scant bleeding<br>❑ No [[anemia]]<br>❑ Suspected [[anorectal bleeding]]</div>|F02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> ❑ Severe active bleeding<br> ❑ Hemodynamic instability<br> ❑ Need for > 2 units of [[blood transfusion]]<br>❑ Presence of other significant comorbidities</div>|F03=<div style="float: left; text-align: left; width: 20em; padding:1em;"> ❑ Bleeding stopped<br> | ||
❑ | ❑ Hemodynamic stability</div>}} | ||
{{familytree | {{familytree | |!| | | |!| | | |!| | | }} | ||
{{familytree | {{familytree | G01 | | G02 | | G03 | |G01=❑ Outpatient treatment|G02=❑ Admit to [[ICU]]|G03=❑ Admit to hospital ward}} | ||
{{familytree | {{familytree | | | | | | | | | | | | | }} | ||
{{familytree/end}} | {{familytree/end}} | ||
<span style="font-size:85%">'''GI''': Gastrointestinal; '''NSAIDs''': Non steroid anti-inflammatory drugs; '''IBD''': Inflammatory bowel disease; '''BUN''': Blood urea nitrogen; '''CBC''': Complete blood count; '''EKG''': Electrocardiogram; '''NS''': Normal saline; '''ICU''': Intensive care unit</span> | <span style="font-size:85%">'''GI''': Gastrointestinal; '''NSAIDs''': Non steroid anti-inflammatory drugs; '''IBD''': Inflammatory bowel disease; '''BUN''': Blood urea nitrogen; '''CBC''': Complete blood count; '''EKG''': Electrocardiogram; '''NS''': Normal saline; '''ICU''': Intensive care unit</span> | ||
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Shown below is an algorithm summarizing the approach to endoscopic management of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy.<ref name="Davila-2005">{{Cite journal | last1 = Davila | first1 = RE. | last2 = Rajan | first2 = E. | last3 = Adler | first3 = DG. | last4 = Egan | first4 = J. | last5 = Hirota | first5 = WK. | last6 = Leighton | first6 = JA. | last7 = Qureshi | first7 = W. | last8 = Zuckerman | first8 = MJ. | last9 = Fanelli | first9 = R. | title = ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. | journal = Gastrointest Endosc | volume = 62 | issue = 5 | pages = 656-60 | month = Nov | year = 2005 | doi = 10.1016/j.gie.2005.07.032 | PMID = 16246674 }}</ref> | Shown below is an algorithm summarizing the approach to endoscopic management of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy.<ref name="Davila-2005">{{Cite journal | last1 = Davila | first1 = RE. | last2 = Rajan | first2 = E. | last3 = Adler | first3 = DG. | last4 = Egan | first4 = J. | last5 = Hirota | first5 = WK. | last6 = Leighton | first6 = JA. | last7 = Qureshi | first7 = W. | last8 = Zuckerman | first8 = MJ. | last9 = Fanelli | first9 = R. | title = ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. | journal = Gastrointest Endosc | volume = 62 | issue = 5 | pages = 656-60 | month = Nov | year = 2005 | doi = 10.1016/j.gie.2005.07.032 | PMID = 16246674 }}</ref> | ||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{familytree| | | | | | | | | A01 | {{familytree| | | | | | | | | A01 | | A01=<div style="float: left; text-align: left; width:10em; padding:1em;"> ❑ '''Assess the hemodynamic status'''</div>}} | ||
{{familytree| | | | |,|-|-|-|-|+|-|-|-|-|-|-|. | {{familytree| | | | |,|-|-|-|-|+|-|-|-|-|-|-|.| | | }} | ||
{{familytree| | | | Z03 | | | Z02 | | | | | Z01 | {{familytree| | | | Z03 | | | Z02 | | | | | Z01 | |Z01=<div style="float: left; text-align: left; width:10em; padding:1em;">'''Intermittent scant bleeding'''</div>|Z02=<div style="float: left; text-align: left; width:10em; padding:1em;">'''Moderate to severe bleeding'''</div>|Z03=<div style="float: left; text-align: left; width:10 em; padding:1em;">'''Massive bleeding'''</div>}} | ||
{{familytree| | | | |!| | | | |!| | | |,|-|-|^|-|. | {{familytree| | | | |!| | | | |!| | | |,|-|-|^|-|.| | | }} | ||
{{familytree| | | | C04 | | | C03 | | C02 | | | C01 | {{familytree| | | | C04 | | | C03 | | C02 | | | C01 | | C01=<div style="float: left; text-align: left; width: 10em; padding:1em;">❑ Age < 40 years<br>❑ Hemodynamically stable patient<br>❑ Suspected anorectal source of bleeding</div>|C02=<div style="float: left; text-align: left; width:10em; padding:1em;">❑ Age > 50 years<br>❑ Presence of [[anemia]]</div>|C03=<div style="float: left; text-align: left; width:10em; padding:1em;">❑ Colonoscopy <br> ❑ Endoscopic therapy </div>|C04=<div style="float: left; text-align: left; width:10em; padding:1em;">❑ Assess hemodynamic stability </div>}} | ||
{{familytree| | |,|-|^|-|.| | | | | | |!| | | | |! | {{familytree| | |,|-|^|-|.| | | | | | |!| | | | |!| | | }} | ||
{{familytree| | D04 | | D02 | | | | | D04 | | | D01 | {{familytree| | D04 | | D02 | | | | | D04 | | | D01 | |D01=<div style="float: left; text-align: left; width:10em; padding:1em;">❑ Perform digital rectal examination<br>❑ [[Sigmoidoscopy]]</div>|D02=<div style="float: left; text-align: left; width:10em; padding:1em;">❑ Colonoscopy <br> ❑ Endoscopic therapy </div>|D03=Moderately stable |D04=<div style="float: left; text-align: left; width:10em; padding:1em;">❑ Colonoscopy <br> ❑ Endoscopic therapy </div>}} | ||
{{familytree| | |!| | | |!| | | | | | | | | | | |! | {{familytree| | |!| | | |!| | | | | | | | | | | |!| | | }} | ||
{{familytree| | E04 | | E03 | | | | | | | | | | E01 | {{familytree| | E04 | | E03 | | | | | | | | | | E01 | |E01='''Anorectal source of bleeding confirmed'''|E02=❑ '''Anorectal source of bleeding not confirmed'''|E03=<div style="float: left; text-align: left; width:10em; padding:1em;">❑ [[EGD]] to rule out [[Upper gastrointestinal bleeding resident survival guide| upper GI bleed]]</div>|E04=<div style="float: left; text-align: left; width:10em; padding:1em;">❑ Emergent [[angiography]] with [[angiotherapy]]<br>❑ Request a surgical consult </div>}} | ||
{{familytree| | |!| | | |!| | | | | | | | | | | |! | {{familytree| | |!| | | |!| | | | | | | | | | | |!| | | }} | ||
{{familytree| | F03 | | F04 |-| F05 | | F06 |-|-|( | {{familytree| | F03 | | F04 |-| F05 | | F06 |-|-|(| | |F03='''Bleeding not controlled?'''|F04= '''Lesion identified?'''|F05=No|F06=No}} | ||
{{familytree| | |!| | | |!| | | |!| | | |!| | | |! | {{familytree| | |!| | | |!| | | |!| | | |!| | | |!| | |}} | ||
{{familytree| | G01 | | G02 | | G03 | | G04 | | Z01 | {{familytree| | G01 | | G02 | | G03 | | G04 | | Z01 | | |G01=❑ Surgery|G02=Yes|G03=<div style="float: left; text-align: left; width:10em; padding:1em;">❑ Colonoscopy <br> ❑ Endoscopic therapy </div>| G04= <div style="float: left; text-align: left; width:10em; padding:1em;">❑ Colonoscopy <br> ❑ Endoscopic therapy </div>|Z01=Yes}} | ||
{{familytree| | | | | | |!| | | | | | | | | | | |!| | | |}} | {{familytree| | | | | | |!| | | | | | | | | | | |!| | | |}} | ||
{{familytree| | | | | | H01 | | | | | | | | | | F01 | | |H01= Treat as [[Upper gastrointestinal bleeding resident survival guide| upper GI bleed]]|F01= Treat accordingly}} | {{familytree| | | | | | H01 | | | | | | | | | | F01 | | |H01= ❑ Treat as [[Upper gastrointestinal bleeding resident survival guide| upper GI bleed]]|F01= ❑ Treat accordingly}} | ||
{{familytree/end}} | {{familytree/end}} | ||
<span style="font-size:85%">'''GI''': Gastrointestinal; '''EGD''': Esophagogastroduodenoscopy</span> | <span style="font-size:85%">'''GI''': Gastrointestinal; '''EGD''': Esophagogastroduodenoscopy</span> | ||
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Shown below is an algorithm summarizing the endoscopic management of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy and American College of Gastroenterology.<ref name="Davila-2005">{{Cite journal | last1 = Davila | first1 = RE. | last2 = Rajan | first2 = E. | last3 = Adler | first3 = DG. | last4 = Egan | first4 = J. | last5 = Hirota | first5 = WK. | last6 = Leighton | first6 = JA. | last7 = Qureshi | first7 = W. | last8 = Zuckerman | first8 = MJ. | last9 = Fanelli | first9 = R. | title = ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. | journal = Gastrointest Endosc | volume = 62 | issue = 5 | pages = 656-60 | month = Nov | year = 2005 | doi = 10.1016/j.gie.2005.07.032 | PMID = 16246674 }}</ref><ref name="pmid9707037">{{cite journal| author=Zuccaro G| title=Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. | journal=Am J Gastroenterol | year= 1998 | volume= 93 | issue= 8 | pages= 1202-8 | pmid=9707037 | doi=10.1111/j.1572-0241.1998.00395.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9707037 }} </ref> | Shown below is an algorithm summarizing the endoscopic management of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy and American College of Gastroenterology.<ref name="Davila-2005">{{Cite journal | last1 = Davila | first1 = RE. | last2 = Rajan | first2 = E. | last3 = Adler | first3 = DG. | last4 = Egan | first4 = J. | last5 = Hirota | first5 = WK. | last6 = Leighton | first6 = JA. | last7 = Qureshi | first7 = W. | last8 = Zuckerman | first8 = MJ. | last9 = Fanelli | first9 = R. | title = ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. | journal = Gastrointest Endosc | volume = 62 | issue = 5 | pages = 656-60 | month = Nov | year = 2005 | doi = 10.1016/j.gie.2005.07.032 | PMID = 16246674 }}</ref><ref name="pmid9707037">{{cite journal| author=Zuccaro G| title=Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. | journal=Am J Gastroenterol | year= 1998 | volume= 93 | issue= 8 | pages= 1202-8 | pmid=9707037 | doi=10.1111/j.1572-0241.1998.00395.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9707037 }} </ref> | ||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{familytree | {{familytree | | | | | | | | H03 | | |H03='''Colonoscopic therapy'''<br><div style="float: left; text-align: left; height: em; width: 17em; padding:1em;"> | ||
❑ Schedule the procedure within 12-48 hours<br> | ❑ Schedule the procedure within 12-48 hours<br> | ||
❑ Prepare the patient for endoscopy<br> | ❑ Prepare the patient for endoscopy<br> | ||
: ❑ Administer 4-6 L of [[polyethylene glycol]] (PEG) at a rate of 1 L every 30 min in acute cases. | : ❑ Administer 4-6 L of [[polyethylene glycol]] (PEG) at a rate of 1 L every 30 min in acute cases. | ||
: ❑ Consider [[metoclopramide]] 10 mg IV.</div>}} | : ❑ Consider [[metoclopramide]] 10 mg IV.</div>}} | ||
{{familytree | {{familytree | | | | | | | | |!| | | | | |}} | ||
{{familytree | {{familytree | | | | |,|-|-|-|^|-|-|-|.| |}} | ||
{{familytree | {{familytree | | | | I02 | | | | | | I01 |I01=<div style="float: left; text-align: left; height: em; width: 17em; padding:1em;">'''Lesion identified'''</div>|I02=<div style="float: left; text-align: left; height: em; width: 17em; padding:1em;">'''Lesion not identified'''</div>}} | ||
{{familytree | {{familytree | | | | |!| | | | | | | |!| | |}} | ||
{{familytree | {{familytree | | | | J01 | | | | | | J02 |J02=<div style="float: left; text-align: left; height: em; width: 17em; padding:1em;">'''Proceed with endotherapy'''<br> | ||
❑ Thermal contact modalities<br> | ❑ Thermal contact modalities<br> | ||
: ❑ | : ❑ Heat probe<br> | ||
: ❑ Bipolar/multipolar coagulation<br> | : ❑ Bipolar/multipolar coagulation<br> | ||
❑ Epinephrine injection<br> | ❑ Epinephrine injection<br> | ||
Line 118: | Line 117: | ||
❑ Argon plasma coagulation | ❑ Argon plasma coagulation | ||
</div>|J01=❑ Assess if bleeding is persistent}} | </div>|J01=❑ Assess if bleeding is persistent}} | ||
{{familytree | {{familytree | | |,|-|^|-|.| | | |,|-|^|-|.| | |}} | ||
{{familytree | {{familytree | | |!| | | |!| | | |!| | | |!| | |}} | ||
{{familytree | {{familytree | | Z01 | | Z02 | | Z03 | | Z04 | |Z01='''Persistent bleeding'''|Z02='''Ceased bleeding'''|Z03='''Persistent bleeding''' | Z04= '''Ceased bleeding'''}} | ||
{{familytree | {{familytree | | |!| | | |!| | | |!| | | |!| | |}} | ||
{{familytree | {{familytree | | K01 | | K03 | | K04 | | K05 | |K01=❑ Proceed with [[EGD]]|K03=❑ Proceed with arteriography (+/- consider nuclear scan first)|K04=❑ Consider surgery| K05= ❑ No additional therapy is required}} | ||
{{familytree | {{familytree | |,|^|-|.| | | | | | | | | | | | |}} | ||
{{familytree | L03 | | L04 | | | | | | | | | | | |L03='''Lesion identified'''|L04='''Lesion not identified'''}} | |||
{{familytree | |!| | | |!| | | | | | | | | | | | |}} | |||
{{familytree | {{familytree | M01 | | M02 | | | | | | | | | | | |M01=❑ Treat as [[Upper gastrointestinal bleeding resident survival guide|upper GI bleed]]|M02=<div style="float: left; text-align: left; height: em; width: 15em; padding:1em;">❑ Proceed with small bowel studies:<br> | ||
{{familytree | |||
{{familytree | |||
: ❑ Capsule enteroscopy<br> | : ❑ Capsule enteroscopy<br> | ||
: ❑ Double balloon enteroscopy</div> | : ❑ Double balloon enteroscopy</div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
<span style="font-size:85%">'''GI''': Gastrointestinal; '''EGD''': Esophagogastroduodenoscopy</span> | <span style="font-size:85%">'''GI''': Gastrointestinal; '''EGD''': Esophagogastroduodenoscopy</span> | ||
==Do's== | ==Do's== | ||
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* Consider abdominal X-ray or CT prior to colonoscopy in cases of suspected colitis or aortoenteric fistula. | * Consider abdominal X-ray or CT prior to colonoscopy in cases of suspected colitis or aortoenteric fistula. | ||
* Use band ligation to control bleeding from internal [[hemorrhoids]] and [[rectal varices]]. | * Use band ligation to control bleeding from internal [[hemorrhoids]] and [[rectal varices]]. | ||
* Epinephrine injections: | |||
** Inject 1-3 ml of 1:10,000 diluted epinephrine solution at 1 or more sites in and around the bleeding lesion.<br> | |||
** Inject 1-3 mm away from the lesion in cases of non bleeding visible vessels.<ref name="Davila-2005">{{Cite journal | last1 = Davila | first1 = RE. | last2 = Rajan | first2 = E. | last3 = Adler | first3 = DG. | last4 = Egan | first4 = J. | last5 = Hirota | first5 = WK. | last6 = Leighton | first6 = JA. | last7 = Qureshi | first7 = W. | last8 = Zuckerman | first8 = MJ. | last9 = Fanelli | first9 = R. | title = ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. | journal = Gastrointest Endosc | volume = 62 | issue = 5 | pages = 656-60 | month = Nov | year = 2005 | doi = 10.1016/j.gie.2005.07.032 | PMID = 16246674 }}</ref><ref name="pmid9707037">{{cite journal| author=Zuccaro G| title=Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. | journal=Am J Gastroenterol | year= 1998 | volume= 93 | issue= 8 | pages= 1202-8 | pmid=9707037 | doi=10.1111/j.1572-0241.1998.00395.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9707037 }} </ref><ref name="pmid20370741">{{cite journal| author=Palamidessi N, Sinert R, Falzon L, Zehtabchi S| title=Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis. | journal=Acad Emerg Med | year= 2010 | volume= 17 | issue= 2 | pages= 126-32 | pmid=20370741 | doi=10.1111/j.1553-2712.2009.00609.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20370741 }} </ref> | |||
==Dont's== | ==Dont's== | ||
* Do not use sclerosants and dessicating agents in colon to achieve hemostasis. | * Do not use sclerosants and dessicating agents in colon to achieve hemostasis. | ||
* Due to low sensitivity and poor negative likelihood ratio, nasogastric lavage cannot rule out upper GI bleed effectively in cases of hematochezia.<ref name="pmid20370741">{{cite journal| author=Palamidessi N, Sinert R, Falzon L, Zehtabchi S| title=Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis. | journal=Acad Emerg Med | year= 2010 | volume= 17 | issue= 2 | pages= 126-32 | pmid=20370741 | doi=10.1111/j.1553-2712.2009.00609.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20370741 }} </ref> | * Due to low sensitivity and poor negative likelihood ratio, nasogastric lavage cannot rule out upper GI bleed effectively in cases of hematochezia.<ref name="pmid20370741">{{cite journal| author=Palamidessi N, Sinert R, Falzon L, Zehtabchi S| title=Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis. | journal=Acad Emerg Med | year= 2010 | volume= 17 | issue= 2 | pages= 126-32 | pmid=20370741 | doi=10.1111/j.1553-2712.2009.00609.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20370741 }} </ref> | ||
==References== | ==References== | ||
{{Reflist|2}} | |||
[[Category:Help]] | [[Category:Help]] |
Latest revision as of 00:19, 13 March 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]; Rim Halaby, M.D. [3]
Overview
Lower GI bleed refers to any bleeding originating from gastrointestinal tract distal to ligament of Treitz.[1]
Acute GI bleed | Bleeding occurring for less than 3 days.[1] |
Chronic GI bleed | Slow and intermittent bleeding occurring over a duration of several days.[1] |
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Severe gastrointestinal bleeding is a life-threatening condition and must be treated as such irrespective of the causes.
Common Causes
- Anal fissure
- Angiodysplasia
- Colitis
- Colon cancer
- Diverticulosis
- Hemorrhoids
- Inflammatory bowel disease
- Radiation enteritis
- Rectal varices
Management
Initial Management
Shown below is an algorithm summarizing the approach to initial assessment of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy.[2]
Characterize the symptoms: ❑ Frank blood per rectum Obtain the medical history: ❑ Use of NSAIDs, aspirin or anticoagulants ❑ History of radiation ❑ History of liver disease ❑ History of IBD ❑ Recent polypectomy ❑ Family history of colorectal cancer | |||||||||||||||||||||||||
Examine the patient: ❑ Assess the hemodynamic status[3]
❑ Examine the stool for occult blood | |||||||||||||||||||||||||
Order tests: ❑ Blood type and cross match ❑ Coagulation profile ❑ Liver function tests ❑ Electrolytes ❑ BUN ❑ Creatinine ❑ EKG (for elderly ) | |||||||||||||||||||||||||
Initiate initial supportive measures:
❑ Administer supplemental oxygen | |||||||||||||||||||||||||
Risk stratification of patients | |||||||||||||||||||||||||
❑ Severe active bleeding ❑ Hemodynamic instability ❑ Need for > 2 units of blood transfusion ❑ Presence of other significant comorbidities | ❑ Bleeding stopped ❑ Hemodynamic stability | ||||||||||||||||||||||||
❑ Outpatient treatment | ❑ Admit to ICU | ❑ Admit to hospital ward | |||||||||||||||||||||||
GI: Gastrointestinal; NSAIDs: Non steroid anti-inflammatory drugs; IBD: Inflammatory bowel disease; BUN: Blood urea nitrogen; CBC: Complete blood count; EKG: Electrocardiogram; NS: Normal saline; ICU: Intensive care unit
Approach to Endoscopic Management
Shown below is an algorithm summarizing the approach to endoscopic management of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy.[4]
❑ Assess the hemodynamic status | |||||||||||||||||||||||||||||||||||||||||||||
Massive bleeding | Moderate to severe bleeding | Intermittent scant bleeding | |||||||||||||||||||||||||||||||||||||||||||
❑ Assess hemodynamic stability | ❑ Colonoscopy ❑ Endoscopic therapy | ❑ Age > 50 years ❑ Presence of anemia | ❑ Age < 40 years ❑ Hemodynamically stable patient ❑ Suspected anorectal source of bleeding | ||||||||||||||||||||||||||||||||||||||||||
❑ Colonoscopy ❑ Endoscopic therapy | ❑ Colonoscopy ❑ Endoscopic therapy | ❑ Colonoscopy ❑ Endoscopic therapy | ❑ Perform digital rectal examination ❑ Sigmoidoscopy | ||||||||||||||||||||||||||||||||||||||||||
❑ EGD to rule out upper GI bleed | Anorectal source of bleeding confirmed | ||||||||||||||||||||||||||||||||||||||||||||
Bleeding not controlled? | Lesion identified? | No | No | ||||||||||||||||||||||||||||||||||||||||||
❑ Surgery | Yes | ❑ Colonoscopy ❑ Endoscopic therapy | ❑ Colonoscopy ❑ Endoscopic therapy | Yes | |||||||||||||||||||||||||||||||||||||||||
❑ Treat as upper GI bleed | ❑ Treat accordingly | ||||||||||||||||||||||||||||||||||||||||||||
GI: Gastrointestinal; EGD: Esophagogastroduodenoscopy
Endoscopic Management
Shown below is an algorithm summarizing the endoscopic management of lower GI bleed according to the guidelines issued by American Society of Gastrointestinal Endoscopy and American College of Gastroenterology.[4][5]
Colonoscopic therapy ❑ Schedule the procedure within 12-48 hours
| |||||||||||||||||||||||||||||||||||||
Lesion not identified | Lesion identified | ||||||||||||||||||||||||||||||||||||
❑ Assess if bleeding is persistent | Proceed with endotherapy ❑ Thermal contact modalities
❑ Epinephrine injection | ||||||||||||||||||||||||||||||||||||
Persistent bleeding | Ceased bleeding | Persistent bleeding | Ceased bleeding | ||||||||||||||||||||||||||||||||||
❑ Proceed with EGD | ❑ Proceed with arteriography (+/- consider nuclear scan first) | ❑ Consider surgery | ❑ No additional therapy is required | ||||||||||||||||||||||||||||||||||
Lesion identified | Lesion not identified | ||||||||||||||||||||||||||||||||||||
❑ Treat as upper GI bleed | ❑ Proceed with small bowel studies:
| ||||||||||||||||||||||||||||||||||||
GI: Gastrointestinal; EGD: Esophagogastroduodenoscopy
Do's
- Suspect bleeding from the left colon in case of frank blood per rectum versus bleeding from the right colon in case of dark or maroon colored stools.
- Perform colonoscopy in patients with positive fecal occult blood test.
- Consider plain abdominal radiographs or CT if colitis, obstruction or perforation are highly suspected.
- Proceed with upper endoscopy in patients presenting with melena.
- Transfuse blood to maintain a hemoglobin of > 7 g/dL. In high risk patients with advanced age and significant comorbidities maintain an Hb > 10 g/dL.
- Maintain an INR of < 2 with fresh frozen plasma in cases of coagulopathy. Consider platelet transfusion if platelet count is < 50,000.
- Administer vit K in patients taking warfarin. Fresh frozen plasma or prothrombin complex can also be given due to their quick onset of action.
- Request a cardiac consult for patients with mechanical cardiac valves and/or metallic coronary stents.
- Consider abdominal X-ray or CT prior to colonoscopy in cases of suspected colitis or aortoenteric fistula.
- Use band ligation to control bleeding from internal hemorrhoids and rectal varices.
- Epinephrine injections:
Dont's
- Do not use sclerosants and dessicating agents in colon to achieve hemostasis.
- Due to low sensitivity and poor negative likelihood ratio, nasogastric lavage cannot rule out upper GI bleed effectively in cases of hematochezia.[6]
References
- ↑ 1.0 1.1 1.2 Barnert J, Messmann H (2009). "Diagnosis and management of lower gastrointestinal bleeding". Nat Rev Gastroenterol Hepatol. 6 (11): 637–46. doi:10.1038/nrgastro.2009.167. PMID 19881516.
- ↑ Davila RE, Rajan E, Adler DG, Egan J, Hirota WK, Leighton JA; et al. (2005). "ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding". Gastrointest Endosc. 62 (5): 656–60. doi:10.1016/j.gie.2005.07.032. PMID 16246674.
- ↑ Cappell MS, Friedel D (2008). "Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy". Med Clin North Am. 92 (3): 491–509, xi. doi:10.1016/j.mcna.2008.01.005. PMID 18387374.
- ↑ 4.0 4.1 4.2 Davila, RE.; Rajan, E.; Adler, DG.; Egan, J.; Hirota, WK.; Leighton, JA.; Qureshi, W.; Zuckerman, MJ.; Fanelli, R. (2005). "ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding". Gastrointest Endosc. 62 (5): 656–60. doi:10.1016/j.gie.2005.07.032. PMID 16246674. Unknown parameter
|month=
ignored (help) - ↑ 5.0 5.1 Zuccaro G (1998). "Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee". Am J Gastroenterol. 93 (8): 1202–8. doi:10.1111/j.1572-0241.1998.00395.x. PMID 9707037.
- ↑ 6.0 6.1 Palamidessi N, Sinert R, Falzon L, Zehtabchi S (2010). "Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis". Acad Emerg Med. 17 (2): 126–32. doi:10.1111/j.1553-2712.2009.00609.x. PMID 20370741.