Sandbox spinalcord

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Lower gastrointestinal bleeding, commonly abbreviated LGIB, refers to any form of bleeding in the lower gastrointestinal tract.

Causes

• Coagulopathy - specifically a bleeding diathesis
• Colitis
  • ischaemic colitis
  • ulcerative colitis
  • infectious colitis
    • E. coli O157:H7
    • Shigella
    • C. difficile
    • Campylobacter jejuni
• Hemorrhoids
• Angiodysplasia
• Neoplasm - cancer
• Diverticular disease - diverticulosis, diverticulitis

Diagnosis

The following suggest an LGIB:

• Melena and a negative oesophagogastroduodenoscopy
• Hematochezia
• Fecal occult blood

The following may suggest an LGIB:

• Anemia

Related Chapter

• Fecal occult blood
• Blood in stool
• Rectal bleeding
• Upper gastrointestinal bleeding

Blood in stools

Abdominal pain

Yes

No

Fever

Rectal pain

Yes

No

H/O of constipation

H/O of constipation

No

Yes

No

Yes

Weightloss

Diverticulosis

Hemodynamic status

Diverticulitis

No

Yes

Stable

Unstable

Polyps

Colon cancer

No

Yes

Weight Loss

Anal fissure External Hemmrhoids

Yes

No

Rectal cancer Colon cancer

Angiodysplasia Polyps

Management

Hepatic adenoma

Management of hepatic adenoma depends upon:

• Symptoms
• Size
• Number
• Location
• Certainty of the diagnosis

Asymptomatic woman on OCPs with a small adenoma

The European Association for Study of the Liver recommends

• Discontinuation of contraceptive medication
• Close observation of the lesion with repeated imaging and alpha fetoprotein.
  • Contrast-enhanced magnetic resonance imaging at a six month interval to determine if there is regression of a large adenoma to less than 5 cm.
• Patients with hepatic adenomas that do not resolve or that enlarge after six months of observation should undergo treatment.

Symptomatic patients and those with large adenomas

• Surgical resection is recommended for all symptomatic patients with hepatic adenoma and those with large lesions (>5 cm).
• Surgical options include :
  • Enucleation
  • Resection
  • Liver transplantation

• Nonsurgical interventions include
  • Transarterial embolization
  • Radiofrequency ablation

Hepatic Hemangioma

• Asymptomatic patients
  • Patients with lesions <1.5 cm, are reassured and observed.
  • Follow-up imaging in patients with hemangiomas ≤5 cm in size is usually not recommended.
  • Patients with rapid growth of a hemangioma or with lesions >5 cm it is recommended to repeat imaging in 6 to 12 months.
  • It is recommended not perform additional imaging if there is no change in the size of the lesion.  
• Symptomatic patients
  • Patients who have pain or symptoms suggestive of extrinsic compression of adjacent structures should be considered for surgical options.
  • Surgical options include 
    • Liver resection
    • Enucleation
    • Hepatic artery ligation
    • Liver transplantation
  • Non-surgical techniques include
    • Hepatic artery embolization
    • Radiotherapy
    • Interferon alfa-2a 

Focal nodular hyperplasia

• Due to their benign nature of focal nodular hyperplasia, there is

• Follow-up studies at three and six months will often be sufficient to confirm the stability of the lesion and its benign nature, after which no long-term follow-up is required routinely.
• Surgery should be reserved for symptomatic FNH lesion.

Parasitic Infection		Mode of infection		Epidemiology	Clinical manifestations	Diagnosis	Treatment
Disease	Parasite		Incidence	Geographic distrubution
Ascariasis	Ascaris lumbricoides	Ingestion of Ascaris eggs secreted in the feces of humans or pigs. Ingesting uncooked pig or chicken liver with the larvae.	Ascariasis affects at least 1 billion people worldwide and about 4 million people in the United States.	Asia Africa South America	Abdominal discomfort Anorexia Nausea and vomiting Diarrhea Intestinal obstruction	Stool microscopy Peripheral eosinophilia Barium swallow	Albendazole Mebendazole Ivermectin
Necatoriasis	Necator americanus	Skin contact	Approximately 800 million people are infected with hookworms worldwide.	Brazil Texas Africa China Southwest Pacific islands India Southeast Asia	Acute Nausea and vomiting Diarrhea Epigastric pain Increased flatulence  Chronic Bloody stools Anemia LBW in pregnant women	Stool microscopy Peripheral eosinophilia	Albendazole Mebendazole Pyrantel pamoate
Giardiasis	Giardia lamblia	Ingestion of raw or undercooked food contaminated with cysts.	Approximately, 15,223 cases were reported in the United States in 2012.	Worldwide infection Among mountains hikers	Asymptomatic Acute Diarrhea Malaise Steatorrhea Abdominal cramps Bloating Nausea Weight loss. Chronic Lose stools Malabsorption Steatorrhea Weight loss Fatigue	Antigen detection assays  Fluorescein-tagged monoclonal antibodies Immunochromatographic assays Enzyme-linked immunosorbent assays  Nucleic acid amplificationassays (NAAT) Stool microscopy	Tinidazole Nitazoxanide
Fasciolosis	Fasciola Hepaticum			Central and South America Asia (China, Vietnam, Taiwan, Korea, and Thailand) Europe (Portugal, France, Spain, and Turkey) Africa The Middle East.	Acute liver phase Fever Anorexia Nausea and vomiting Myalgia Cough Right upper quadrant pain Hematomas of the liver Jaundice Hepatomegaly. Chronic biliary phase Asymptomatic Common bile duct obstruction Pancreatitis	Microscopy Stools Bile Duodenal aspiration Peripheral eosinophilia may disappear. Serology Indirect hemagglutination Complement fixation Enzyme-linked immunosorbent assay	Triclabendazole Bithionol Nitazoxanide
Schistosomiasis	S. mansoni S. japonicum S. haematobium	Infection can occur by: Penetration of the human skin by cercaria Handling of contaminated soil Consumption of contaminated water or food sources (e.g, unwashed garden vegetables)	Approximately 200 million people are infected annually with 200,000 deaths per year.	Sub-Saharan Africa.	Acute schistosomiasis syndrome  Fever and chills Urticaria Angioedema Myalgias Arthralgias Dry cough Diarrhea Abdominal pain Headache. Chronic schistosomias Intestinal schistosomiasis Hepatosplenic schistosomiasis Pulmonary schistosomiasis Genitourinary schistosomiasis	Stool microscopy Serologic tests include: Indirect hemagglutination Complement fixation Enzyme-linked immunosorbent assay PCR	Praziquantel Oxamniquine
Strongyloidiasis	Strongyloidis Stercoralis	Infection is contracted via direct contact with contaminated soil during agricultural, domestic, and recreational activities	Approximately 30–100 million infected persons worldwide	Tropical and subtropical regions	Hyperinfection syndrome Fever Nausea and vomiting Anorexia Diarrhea Abdominal pain Dyspnea Wheezing Hemoptysis Cough	Aspiration of duodenojejunal fluid is sometimes used to detect  Stool microscopy PCR, ELISA	Ivermectin Albendazole
Amoebiais	E. Histolytica	Transmitted by the fecal-oral route through contaminated drinking water or food. Direct contact with infected individuals.	Annual incidence of amoebiasis is approximately 50 million cases.	India Africa Mexico Parts of Central and South America	Asymptomatic Mild diarrhea to severe dysentery. Fulminant amebic colitis. Weight loss Amebic dysentery	Stool microscopy Antigen testing PCR	Metronidazole Tinidazole  Paromomycin  Diloxanide furoate  Iodoquinol
Taeniasis	Taenia saginata (beef tapeworm) Taenia solium, ( pork tapeworm).	Consumption of undercooked beef	Approximately 50 million human have cysticercosis.	Europe Parts of Asia.	Most human carriers are asymptomatic. Symptoms may include Nausea Anorexia Epigastric pain	Stool microscopy Peripheral eosinophilia ELISA PCR	Albendazole
Trichuriasis	Trichuris trichiura	Ingestion of embryonatedeggs from contaminated drinking water and food.		Endemic in tropical and subtropical countries.  Southern United States Incidence and prevalence rates are highest in children living in Sub-Saharan Africa Asia Latin America Caribbean	Asymptomatic Loose stool which may contain mucus and blood Nocturnal stooling Rectal prolapse	Stool microscopy Proctoscopy Demonstrates adult worms protruding from the bowel mucosa. Eosinophilia Polymerase chain reaction	Mebendazole 500 mg PO q24h X 3 day (or) 100 mg PO q12h x 2 days Albendazole 400 mg POq24h
Hymenolepiasis	Hymenolepis nana	Ingestion of infected eggs		Most common in temperate zones South Europe Russia India US Latin America.	Asymptomatic Heavy infections with >1000 worms can occur Crampy abdominal pain Diarrhea Anorexia Fatigue Pruritus ani	Stool microscopy FLOTAC method	Praziquantel Prompt family screening or empiric treatment