Meckel's diverticulum medical therapy: Difference between revisions
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{{Meckel's diverticulum}} | {{Meckel's diverticulum}} | ||
{{CMG}} | {{CMG}} {{AE}} {{Cherry}} | ||
==Overview== | |||
Initially, the medical management of a [[symptomatic]] case of Meckel's diverticulum is directed toward management of clinical manifestations of complications. Intravenous lines for [[fluid]] and electrolyte therapy, nasogastric [[decompression]] for patients with symptoms and signs of [[Bowel obstruction|intestinal obstruction]], [[Proton pump inhibitor|proton-pump inhibitors]] and [[Aluminium hydroxide|Aluminum hydroxide]] for patients with [[gastrointestinal bleeding]] are preferred. The process of initial [[Cardiopulmonary resuscitation|resuscitation]] in patients with [[lower gastrointestinal bleeding]] due to Meckel's diverticulum) is similar to the steps followed in any case of [[Lower gastrointestinal bleeding|lower GI bleeding]]. | |||
==Medical Therapy== | |||
* Initial medical management of symptomatic Meckel's diverticulum is directed toward management of clinical manifestations of complicated cases of Meckel's diverticulum associated with:<ref name="pmid17152574">{{cite journal |vauthors=Dumper J, Mackenzie S, Mitchell P, Sutherland F, Quan ML, Mew D |title=Complications of Meckel's diverticula in adults |journal=Can J Surg |volume=49 |issue=5 |pages=353–7 |year=2006 |pmid=17152574 |pmc=3207587 |doi= |url=}}</ref><ref name="pmid7944666">{{cite journal |vauthors=Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ |title=Surgical management of Meckel's diverticulum. An epidemiologic, population-based study |journal=Ann. Surg. |volume=220 |issue=4 |pages=564–8; discussion 568–9 |year=1994 |pmid=7944666 |pmc=1234434 |doi= |url=}}</ref><ref name="pmid29078157">{{cite journal |vauthors=Hong J, Park SB |title=A case of retroperitoneal abscess: A rare complication of Meckel's diverticulum |journal=Int J Surg Case Rep |volume=41 |issue= |pages=150–153 |year=2017 |pmid=29078157 |doi=10.1016/j.ijscr.2017.10.012 |url=}}</ref><ref name="pmid28698005">{{cite journal |vauthors=Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A |title=Meckel's diverticulum in the adult |journal=J Visc Surg |volume=154 |issue=4 |pages=253–259 |year=2017 |pmid=28698005 |doi=10.1016/j.jviscsurg.2017.06.006 |url=}}</ref><ref name="pmid28473039">{{cite journal |vauthors=Cotter TG, Buckley NS, Loftus CG |title=Approach to the Patient With Hematochezia |journal=Mayo Clin. Proc. |volume=92 |issue=5 |pages=797–804 |year=2017 |pmid=28473039 |doi=10.1016/j.mayocp.2016.12.021 |url=}}</ref><ref name="pmid28154669">{{cite journal |vauthors=Rosat A, Pérez E, Oaknin HH, Mendiz J, Hernández G, Barrera M |title=Spontaneous hemoperitoneum caused by meckel's diverticulum in an elder patient |journal=Pan Afr Med J |volume=24 |issue= |pages=314 |year=2016 |pmid=28154669 |pmc=5267917 |doi=10.11604/pamj.2016.24.314.10384 |url=}}</ref><ref name="pmid28051045">{{cite journal |vauthors=Rattan KN, Singh J, Dalal P, Rattan A |title=Meckel's diverticulum in children: Our 12-year experience |journal=Afr J Paediatr Surg |volume=13 |issue=4 |pages=170–174 |year=2016 |pmid=28051045 |pmc=5154221 |doi=10.4103/0189-6725.194671 |url=}}</ref><ref name="pmid27492813">{{cite journal |vauthors=Choi SY, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC |title=The many faces of Meckel's diverticulum and its complications |journal=J Med Imaging Radiat Oncol |volume=61 |issue=2 |pages=225–231 |year=2017 |pmid=27492813 |doi=10.1111/1754-9485.12505 |url=}}</ref><ref name="pmid27483571">{{cite journal |vauthors=Chabowski M, Szymanska-Chabowska A, Dorobisz T, Janczak D, Jelen M, Janczak D |title=A massive bleeding from a gastrointestinal stromal tumor of a Meckel's diverticulum |journal=Srp Arh Celok Lek |volume=144 |issue=3-4 |pages=219–21 |year=2016 |pmid=27483571 |doi= |url=}}</ref><ref name="pmid26932405">{{cite journal |vauthors=Srisajjakul S, Prapaisilp P, Bangchokdee S |title=Many faces of Meckel's diverticulum and its complications |journal=Jpn J Radiol |volume=34 |issue=5 |pages=313–20 |year=2016 |pmid=26932405 |doi=10.1007/s11604-016-0530-x |url=}}</ref><ref name="pmid26884080">{{cite journal |vauthors=Alfa-Wali M, Wardle S, Nizar S, Bloom IT |title=Atypical presentation of a Meckel's diverticulum |journal=BMJ Case Rep |volume=2016 |issue= |pages= |year=2016 |pmid=26884080 |doi=10.1136/bcr-2016-214464 |url=}}</ref> | |||
**[[Bleeding|Hemorrhage]] | |||
**[[Perforation]] of the [[Intestine|bowel]] | |||
**[[Diverticulitis]] | |||
**[[Small intestine|Small bowel]] [[obstruction]] | |||
**[[Ulcer|Ulceration]] | |||
**[[Intussusception]] | |||
** [[Peritonitis]] | |||
* In order to manage complications, treatment administered is as follows: | |||
* Intravenous lines for: | |||
** [[Fluid]] therapy | |||
** Electrolyte therapy | |||
* Nasogastric [[decompression]] for patients with symptoms and signs of [[Bowel obstruction|intestinal obstruction]] | |||
* For patients with [[gastrointestinal bleeding]]: | |||
** [[Proton pump inhibitor|Proton-pump inhibitor]] therapy | |||
** [[Aluminium hydroxide|Aluminum hydroxide]] | |||
==Initial Resuscitation in patients with lower gastrointestinal bleed due to Meckel's diverticula== | |||
The process of initial [[Cardiopulmonary resuscitation|resuscitation]] in patients with [[lower gastrointestinal bleeding]] due to any [[pathology]] (including Meckel's diverticulum) is similar and includes the steps enlisted below. | |||
===Initial Evaluation=== | |||
*In patients with [[Acute (medicine)|acute]] [[lower gastrointestinal bleeding]] who are unstable, rapid assessment and [[Cardiopulmonary resuscitation|resuscitation]] should be initiated even before diagnostic evaluation.<ref name="pmid26925883">{{cite journal |vauthors=Strate LL, Gralnek IM |title=ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding |journal=Am. J. Gastroenterol. |volume=111 |issue=4 |pages=459–74 |year=2016 |pmid=26925883 |pmc=5099081 |doi=10.1038/ajg.2016.41 |url=}}</ref><ref name="pmid19881516">{{cite journal |vauthors=Barnert J, Messmann H |title=Diagnosis and management of lower gastrointestinal bleeding |journal=Nat Rev Gastroenterol Hepatol |volume=6 |issue=11 |pages=637–46 |year=2009 |pmid=19881516 |doi=10.1038/nrgastro.2009.167 |url=}}</ref><ref name="pmid18346685">{{cite journal |vauthors=Barnert J, Messmann H |title=Management of lower gastrointestinal tract bleeding |journal=Best Pract Res Clin Gastroenterol |volume=22 |issue=2 |pages=295–312 |year=2008 |pmid=18346685 |doi=10.1016/j.bpg.2007.10.024 |url=}}</ref><ref name="pmid26925883">{{cite journal |vauthors=Strate LL, Gralnek IM |title=ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding |journal=Am. J. Gastroenterol. |volume=111 |issue=4 |pages=459–74 |year=2016 |pmid=26925883 |pmc=5099081 |doi=10.1038/ajg.2016.41 |url=}}</ref><ref name="pmid24294124">{{cite journal |vauthors=Raphaeli T, Menon R |title=Current treatment of lower gastrointestinal hemorrhage |journal=Clin Colon Rectal Surg |volume=25 |issue=4 |pages=219–27 |year=2012 |pmid=24294124 |pmc=3577609 |doi=10.1055/s-0032-1329393 |url=}}</ref><ref name="pmid23737154">{{cite journal |vauthors=Ghassemi KA, Jensen DM |title=Lower GI bleeding: epidemiology and management |journal=Curr Gastroenterol Rep |volume=15 |issue=7 |pages=333 |year=2013 |pmid=23737154 |pmc=3857214 |doi=10.1007/s11894-013-0333-5 |url=}}</ref><ref name="pmid21603524">{{cite journal |vauthors=Beck DE, Margolin DA, Whitlow CB, Hammond KL |title=Evaluation and management of gastrointestinal bleeding |journal=Ochsner J |volume=7 |issue=3 |pages=107–13 |year=2007 |pmid=21603524 |pmc=3096402 |doi= |url=}}</ref><ref name="pmid23018607">{{cite journal |vauthors=Triadafilopoulos G |title=Management of lower gastrointestinal bleeding in older adults |journal=Drugs Aging |volume=29 |issue=9 |pages=707–15 |year=2012 |pmid=23018607 |doi=10.1007/s40266-012-0008-1 |url=}}</ref> | |||
*The initial steps in the management of a patient with [[lower gastrointestinal bleeding]] are to assess the severity of [[bleeding]], and then institute [[fluid]] and other measures of resuscitation as needed. | |||
*Once [[Hemodynamics|hemodynamic]] stability is achieved, nasogastric lavage should be performed to rule out an [[Upper gastrointestinal bleeding|upper GI]] source. | |||
*Equilibration between the [[Blood vessel|intravascular]] and extravascular volumes cannot be achieved until 24 to 72 hours after [[bleeding]] has occurred. | |||
===Role of Nasogastric tube (NGT)=== | |||
*[[Gastric lavage|Nasogastric tube (NGT) lavage]] is recommended in all [[Patient|patients]] with [[lower gastrointestinal bleeding]], once the [[patient]] is stabilized. | |||
*A carefully placed [[Nasogastric intubation|nasogastric tube (NGT)]] with irrigation and [[Aspiration (medicine)|aspiration]] of [[bile]] is necessary to ensure sampling of [[Duodenum|duodenal]] contents. | |||
*If there is a bloody [[Nasogastric intubation|NGT]] aspirate, then an [[esophagogastroduodenoscopy]] ([[Esophagogastroduodenoscopy|EGD]]) is warranted (11 to 15% of cases of “negative” [[Nasogastric intubation|NGT]] aspirates are due to [[Upper gastrointestinal bleeding|upper GI bleeding]]). | |||
*Obtaining clear fluid favors a [[Lower gastrointestinal bleeding|lower GI]] source of [[bleeding]]. | |||
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable" | |||
! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + | Workup and Initial Management | |||
|- | |||
| style="background:#DCDCDC; + " |'''Initial Evaluation''' | |||
| | |||
* Airway, Breathing, Circulation | |||
|- | |||
| style="background:#DCDCDC; + " |'''Supportive Therapy''' | |||
| | |||
* Ensure patent and protected airway | |||
* [[Intubation|Intubate]] if needed | |||
* Consider [[mechanical ventilation]] | |||
* 2 large-bore, peripheral intravenous lines | |||
* Can consider [[Central venous catheter|large-bore central venous catheter]] or [[Intraosseous infusion|intraosseous]] line if rapid transfusion is needed | |||
|- | |||
| style="background:#DCDCDC; + " |'''Blood transfusion''' | |||
| | |||
* Resuscitate with 1:1:1 of packed [[Red blood cell|red blood cells]] (PRBCs) to [[fresh frozen plasma]] ([[Fresh frozen plasma|FFP]]) to [[Platelet|platelets]] | |||
* Consider massive [[Blood transfusion|transfusion]] protocol | |||
* Target [[hemoglobin]]=7 mg/dL | |||
* Consider [[Sengstaken-Blakemore tube]] for control of immediately life-threatening [[Upper gastrointestinal bleeding|upper GI bleeding]] | |||
|} | |||
== | ===Assessment of severity of bleeding=== | ||
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable" | |||
! colspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" + | Bleeding severity | |||
! colspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" + | Vital signs | |||
! colspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" + | Blood loss | |||
|- | |||
| style="background:#DCDCDC; + " |Minor | |||
|Normal | |||
|<10% | |||
|- | |||
| style="background:#DCDCDC; + " |Moderate | |||
|Postural hypotension | |||
|10-20% | |||
|- | |||
| style="background:#DCDCDC; + " |Severe | |||
|Shock | |||
|>25% | |||
|} | |||
===Fluid resuscitation=== | |||
*Two large caliber (16-gauge) peripheral catheters or a [[Central venous catheter|central venous line]] should be inserted in patients who are [[hemodynamically unstable]]. | |||
*The rate of fluid resuscitation is proportional to the severity of [[bleeding]] with the goal of restoring and maintaining the patient’s [[blood pressure]]. | |||
*Infusion of 500 mL of [[normal saline]] or lactated [[Ringer's lactate|Ringer's solution]] over 30 minutes is the preferred treatment for patients with [[Bleeding|active bleeding]] before [[Blood type|blood type matching]] and blood [[transfusion]]. | |||
*Intensive monitoring with a [[pulmonary artery catheter]] is recommended to monitor the response of initial resuscitation efforts and any complications of [[fluid]] overload. | |||
*If the [[blood pressure]] fails to respond to initial [[Cardiopulmonary resuscitation|resuscitation]], the rate of [[fluid]] administration should be increased and urgent intervention (eg, [[Angiogram|angiography]]) should be considered. | |||
===Blood transfusion=== | |||
*Patients with severe [[bleeding]] need to be transfused.<ref name="pmid24063362">{{cite journal |vauthors=Al-Jaghbeer M, Yende S |title=Blood transfusion for upper gastrointestinal bleeding: is less more again? |journal=Crit Care |volume=17 |issue=5 |pages=325 |year=2013 |pmid=24063362 |pmc=4056793 |doi=10.1186/cc13020 |url=}}</ref><ref name="pmid23281973">{{cite journal |vauthors=Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C |title=Transfusion strategies for acute upper gastrointestinal bleeding |journal=N. Engl. J. Med. |volume=368 |issue=1 |pages=11–21 |year=2013 |pmid=23281973 |doi=10.1056/NEJMoa1211801 |url=}}</ref> | |||
*[[Fresh frozen plasma|Fresh frozen plasma,]] [[platelets]], or both should be given to patients with [[coagulopathy]] who are actively [[bleeding]] and to those who have received more than 10 units of packed [[erythrocytes]]. | |||
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable" | |||
! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Indications for transfusion | |||
|- | |||
! colspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" + |Age | |||
! colspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" + |Target Hematocrit | |||
|- | |||
| style="background:#DCDCDC; + "|Elderly patient ( >45) | |||
|30% | |||
|- | |||
| style="background:#DCDCDC; + "|Younger patient (<45) | |||
|25% | |||
|- | |||
| style="background:#DCDCDC; + "|Patients with [[portal hypertension]] | |||
|28% | |||
|} | |||
===Triage and consultations === | |||
*Visible [[rectal]] [[bleeding]] warrants an immediate evaluation in all cases. The timing and setting of the evaluation depends upon the severity of [[bleeding]] and the [[patient]] [[Comorbidity|comorbidities]]. | |||
*A [[gastroenterology]] consultation should be obtained early in the [[hospital]] course of [[Patient|patients]] with acute [[Lower gastrointestinal bleeding|lower GI bleeding]]. | |||
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable" | |||
! colspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" + |Evaluation setting | |||
! colspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" + |Patient catagories | |||
|- | |||
| style="background:#DCDCDC; + "|ICU | |||
|Patients with high-risk features | |||
|- | |||
| style="background:#DCDCDC; + "|Outpatient | |||
|Patients with low-risk features<sup>†</sup> | |||
|- | |||
| style="background:#DCDCDC; + "|Regular Ward | |||
|Most other patients can be admitted to a regular medical ward<sup>♦</sup> | |||
|- | |||
| colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + | | |||
* '''†''': Low-risk features include a young, otherwise healthy patient with minor, self-limited rectal bleeding suspected to be from an anal source) | |||
* ♦: Requires continuous electrocardiogram monitoring and pulse oximetry. | |||
|} | |||
===Risk stratification=== | |||
*[[Symptom|Clinical features]] can predict the risk of complications in [[Patient|patients]] with presumed [[Acute (medicine)|acute]] [[Lower gastrointestinal bleeding|lower GI bleeding]]. These features may also be used to categorize [[Patient|patients]] as either low or high risk. | |||
*The presence of more number of high-risk [[Features (pattern recognition)|features]] directly correlate with the likelihood of a poor outcome. | |||
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable" | |||
! colspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" + |High-risk features | |||
|- | |||
| | |||
*[[Shock|Hemodynamic instability]] ([[hypotension]], [[tachycardia]], [[Orthostatic hypotension|orthostasis]], [[syncope]]) | |||
*Persistent [[bleeding]] | |||
*Significant [[Comorbidity|comorbidities]] | |||
*Advanced age | |||
*[[Bleeding]] that occurs in a patient who is hospitalized for another reason | |||
*A prior history of [[bleeding]] from [[diverticulosis]] or [[angiodysplasia]] | |||
*Current [[aspirin]] use | |||
*Prolonged [[prothrombin time]] | |||
*A non-[[Tenderness (medicine)|tender]] [[abdomen]] | |||
*[[Anemia]] | |||
*An elevated [[blood urea nitrogen]] level | |||
*An abnormal [[Neutrophil|white blood cell count]] | |||
|} | |||
==Medical Therapy== | ==Medical Therapy== | ||
Pharmacotherapy is only used as an [[adjuvant therapy]] for [[Patient|patients]] with [[Lower gastrointestinal bleeding|lower GI bleed]] due to Meckel's diverticulum. [[Epinephrine]] is used alone or in conjunction with other surgical techniques. Local injection of [[epinephrine]] stops bleeding by both pressure [[tamponade]] and the v[[Vasoconstrictor|asoconstrictor effect]]. In patients with re-[[bleeding]], [[surgery]] should be considered.<ref name="pmid16718798">{{cite journal |vauthors=Liou TC, Lin SC, Wang HY, Chang WH |title=Optimal injection volume of epinephrine for endoscopic treatment of peptic ulcer bleeding |journal=World J. Gastroenterol. |volume=12 |issue=19 |pages=3108–13 |year=2006 |pmid=16718798 |pmc=4124392 |doi= |url=}}</ref><ref name="pmid23737154">{{cite journal |vauthors=Ghassemi KA, Jensen DM |title=Lower GI bleeding: epidemiology and management |journal=Curr Gastroenterol Rep |volume=15 |issue=7 |pages=333 |year=2013 |pmid=23737154 |pmc=3857214 |doi=10.1007/s11894-013-0333-5 |url=}}</ref><ref name="pmid21603524">{{cite journal |vauthors=Beck DE, Margolin DA, Whitlow CB, Hammond KL |title=Evaluation and management of gastrointestinal bleeding |journal=Ochsner J |volume=7 |issue=3 |pages=107–13 |year=2007 |pmid=21603524 |pmc=3096402 |doi= |url=}}</ref><ref name="pmid23018607">{{cite journal |vauthors=Triadafilopoulos G |title=Management of lower gastrointestinal bleeding in older adults |journal=Drugs Aging |volume=29 |issue=9 |pages=707–15 |year=2012 |pmid=23018607 |doi=10.1007/s40266-012-0008-1 |url=}}</ref> | |||
===Dosage=== | |||
:*Preferred regimen (1): Local injection of 1:10,000 to 20,000 solution (Intra-arterial [[epinephrine]] infusions begin at a rate of 0.2 U/min. If the [[bleeding]] persists, the rate of the [[Intravenous therapy|infusion]] is increased to 0.4-0.6 U/min). | |||
:*Note:- The [[bleeding]] stops in about 91% of [[Patient|patients]] receiving intra-[[Artery|arterial]] [[epinephrine]] but recurs in up to 50% of [[Patient|patients]] when the [[Intravenous therapy|infusion]] is stopped. | |||
===Major contraindications=== | |||
*[[Glaucoma|Closed-angle glaucoma]] | |||
*[[Labor]] | |||
*[[Shock]] | |||
*[[Sulphur]] hypersensitivity | |||
*[[Coronary heart disease|CAD]], [[Peripheral arterial disease|PAD]] | |||
===Complications=== | |||
During [[vasopressin]] [[Intravenous therapy|infusion]], [[Patient|patients]] must be monitored for: | |||
*[[Hemorrhage|Recurrent hemorrhage]] | |||
*[[Myocardial ischemia]] ([[Nitroglycerine|Nitroglycerine drip]] can be used to overcome cardiac complications) | |||
*[[Arrhythmias]] | |||
*[[Hypertension]] | |||
*[[Volume]] overload with [[hyponatremia]] | |||
==References== | ==References== |
Latest revision as of 00:02, 5 January 2018
Meckel's diverticulum Microchapters |
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Case Studies |
Meckel's diverticulum medical therapy On the Web |
American Roentgen Ray Society Images of Meckel's diverticulum medical therapy |
Risk calculators and risk factors for Meckel's diverticulum medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]
Overview
Initially, the medical management of a symptomatic case of Meckel's diverticulum is directed toward management of clinical manifestations of complications. Intravenous lines for fluid and electrolyte therapy, nasogastric decompression for patients with symptoms and signs of intestinal obstruction, proton-pump inhibitors and Aluminum hydroxide for patients with gastrointestinal bleeding are preferred. The process of initial resuscitation in patients with lower gastrointestinal bleeding due to Meckel's diverticulum) is similar to the steps followed in any case of lower GI bleeding.
Medical Therapy
- Initial medical management of symptomatic Meckel's diverticulum is directed toward management of clinical manifestations of complicated cases of Meckel's diverticulum associated with:[1][2][3][4][5][6][7][8][9][10][11]
- In order to manage complications, treatment administered is as follows:
- Intravenous lines for:
- Fluid therapy
- Electrolyte therapy
- Nasogastric decompression for patients with symptoms and signs of intestinal obstruction
- For patients with gastrointestinal bleeding:
Initial Resuscitation in patients with lower gastrointestinal bleed due to Meckel's diverticula
The process of initial resuscitation in patients with lower gastrointestinal bleeding due to any pathology (including Meckel's diverticulum) is similar and includes the steps enlisted below.
Initial Evaluation
- In patients with acute lower gastrointestinal bleeding who are unstable, rapid assessment and resuscitation should be initiated even before diagnostic evaluation.[12][13][14][12][15][16][17][18]
- The initial steps in the management of a patient with lower gastrointestinal bleeding are to assess the severity of bleeding, and then institute fluid and other measures of resuscitation as needed.
- Once hemodynamic stability is achieved, nasogastric lavage should be performed to rule out an upper GI source.
- Equilibration between the intravascular and extravascular volumes cannot be achieved until 24 to 72 hours after bleeding has occurred.
Role of Nasogastric tube (NGT)
- Nasogastric tube (NGT) lavage is recommended in all patients with lower gastrointestinal bleeding, once the patient is stabilized.
- A carefully placed nasogastric tube (NGT) with irrigation and aspiration of bile is necessary to ensure sampling of duodenal contents.
- If there is a bloody NGT aspirate, then an esophagogastroduodenoscopy (EGD) is warranted (11 to 15% of cases of “negative” NGT aspirates are due to upper GI bleeding).
- Obtaining clear fluid favors a lower GI source of bleeding.
Workup and Initial Management | |
---|---|
Initial Evaluation |
|
Supportive Therapy |
|
Blood transfusion |
|
Assessment of severity of bleeding
Bleeding severity | Vital signs | Blood loss |
---|---|---|
Minor | Normal | <10% |
Moderate | Postural hypotension | 10-20% |
Severe | Shock | >25% |
Fluid resuscitation
- Two large caliber (16-gauge) peripheral catheters or a central venous line should be inserted in patients who are hemodynamically unstable.
- The rate of fluid resuscitation is proportional to the severity of bleeding with the goal of restoring and maintaining the patient’s blood pressure.
- Infusion of 500 mL of normal saline or lactated Ringer's solution over 30 minutes is the preferred treatment for patients with active bleeding before blood type matching and blood transfusion.
- Intensive monitoring with a pulmonary artery catheter is recommended to monitor the response of initial resuscitation efforts and any complications of fluid overload.
- If the blood pressure fails to respond to initial resuscitation, the rate of fluid administration should be increased and urgent intervention (eg, angiography) should be considered.
Blood transfusion
- Patients with severe bleeding need to be transfused.[19][20]
- Fresh frozen plasma, platelets, or both should be given to patients with coagulopathy who are actively bleeding and to those who have received more than 10 units of packed erythrocytes.
Indications for transfusion | |
---|---|
Age | Target Hematocrit |
Elderly patient ( >45) | 30% |
Younger patient (<45) | 25% |
Patients with portal hypertension | 28% |
Triage and consultations
- Visible rectal bleeding warrants an immediate evaluation in all cases. The timing and setting of the evaluation depends upon the severity of bleeding and the patient comorbidities.
- A gastroenterology consultation should be obtained early in the hospital course of patients with acute lower GI bleeding.
Evaluation setting | Patient catagories |
---|---|
ICU | Patients with high-risk features |
Outpatient | Patients with low-risk features† |
Regular Ward | Most other patients can be admitted to a regular medical ward♦ |
|
Risk stratification
- Clinical features can predict the risk of complications in patients with presumed acute lower GI bleeding. These features may also be used to categorize patients as either low or high risk.
- The presence of more number of high-risk features directly correlate with the likelihood of a poor outcome.
High-risk features |
---|
|
Medical Therapy
Pharmacotherapy is only used as an adjuvant therapy for patients with lower GI bleed due to Meckel's diverticulum. Epinephrine is used alone or in conjunction with other surgical techniques. Local injection of epinephrine stops bleeding by both pressure tamponade and the vasoconstrictor effect. In patients with re-bleeding, surgery should be considered.[21][16][17][18]
Dosage
- Preferred regimen (1): Local injection of 1:10,000 to 20,000 solution (Intra-arterial epinephrine infusions begin at a rate of 0.2 U/min. If the bleeding persists, the rate of the infusion is increased to 0.4-0.6 U/min).
- Note:- The bleeding stops in about 91% of patients receiving intra-arterial epinephrine but recurs in up to 50% of patients when the infusion is stopped.
Major contraindications
Complications
During vasopressin infusion, patients must be monitored for:
- Recurrent hemorrhage
- Myocardial ischemia (Nitroglycerine drip can be used to overcome cardiac complications)
- Arrhythmias
- Hypertension
- Volume overload with hyponatremia
References
- ↑ Dumper J, Mackenzie S, Mitchell P, Sutherland F, Quan ML, Mew D (2006). "Complications of Meckel's diverticula in adults". Can J Surg. 49 (5): 353–7. PMC 3207587. PMID 17152574.
- ↑ Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ (1994). "Surgical management of Meckel's diverticulum. An epidemiologic, population-based study". Ann. Surg. 220 (4): 564–8, discussion 568–9. PMC 1234434. PMID 7944666.
- ↑ Hong J, Park SB (2017). "A case of retroperitoneal abscess: A rare complication of Meckel's diverticulum". Int J Surg Case Rep. 41: 150–153. doi:10.1016/j.ijscr.2017.10.012. PMID 29078157.
- ↑ Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A (2017). "Meckel's diverticulum in the adult". J Visc Surg. 154 (4): 253–259. doi:10.1016/j.jviscsurg.2017.06.006. PMID 28698005.
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