Lower gastrointestinal bleeding resident survival guide: Difference between revisions
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== | ==Initial Assessment== | ||
Shown below is an algorithm summarizing the approach to <nowiki>[[Lower GI bleed]]</nowiki>. | Shown below is an algorithm summarizing the approach to <nowiki>[[Lower GI bleed]]</nowiki>. | ||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
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❑ '''Assess hemodynamic status'''<br> | ❑ '''Assess hemodynamic status'''<br> | ||
❑ Digital rectal examination<br> | ❑ Digital rectal examination<br> | ||
❑ Stool examination for [[occult blood]]</div>|B02= [[Hematochezia]] PLUS<br> [[hemodynamic instability]]|B03=Nasogastric lavage<br>(to rule out | ❑ Stool examination for [[occult blood]]</div>|B02= [[Hematochezia]] PLUS<br> [[hemodynamic instability]]|B03=Nasogastric lavage<br>(to rule out upper GI bleed)}} | ||
{{familytree | | | | | | |!| | | | | | | | | | | | }} | {{familytree | | | | | | |!| | | | | | |,|-|^|-|.| }} | ||
{{familytree | | | | | | C01 | | | | | | | | {{familytree | | | | | | C01 | | | | | C02 | | C03 | C01=<div style="float: left; text-align: left; height: 12em; width: 20em; padding:1em;"> '''Order tests'''<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 patients</div>}} | ❑ [[CBC]]<br>❑ [[Coagulation profile]]<br>❑ [[Liver function tests]]<br>❑ [[Electrolytes]]<br>❑ [[BUN]]<br>❑ [[Creatinine]]<br>❑ [[EKG]] for elderly patients</div>|C02= Blood in NG lavage fluid|C03=Copious amount of bile with no trace of blood }} | ||
{{familytree | | | | | | |!| | | | | | | | | | | | }} | {{familytree | | | | | | |!| | | | | | |!| | | |!| }} | ||
{{familytree | | | | | | D01 | | | | | | | | {{familytree | | | | | | D01 | | | | | D02 | | D03|D01= <div style="float: left; text-align: left; height: 12em; width: 20em; padding:1em;"> | ||
'''Initiate initial supportive measures'''<br> | '''Initiate initial supportive measures'''<br> | ||
---- | ---- | ||
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❑ <u>Fluid resuscitation</u><br> | ❑ <u>Fluid resuscitation</u><br> | ||
❑ Supplemental oxygen<br> | ❑ Supplemental oxygen<br> | ||
❑ Cardiac monitoring</div>}} | ❑ Cardiac monitoring</div>|D02=❑ Proceed with [[EGD]] after initial assessment|D03=❑ Proceed with colonoscopy after initial assesment}} | ||
{{familytree | | | | | | |!| | | | | | | | | | | | }} | {{familytree | | | | | | |!| | | | | | | | | | | | }} | ||
{{familytree | | | | | | E01 | | | | | | | | | | |E01='''Risk stratification of patients'''}} | {{familytree | | | | | | E01 | | | | | | | | | | |E01='''Risk stratification of patients'''}} | ||
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{{familytree | | | | | | | | | | | | | | | | | }} | {{familytree | | | | | | | | | | | | | | | | | }} | ||
{{familytree/end}} | {{familytree/end}} | ||
==Endoscopic | ==Approach to Endoscopic Management== | ||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{familytree| | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Assess | {{familytree| | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Assess hemodynamic status''' }} | ||
{{familytree| | | | | | |,|-|-|-|-|^ | {{familytree| | | | | | |,|-|-|-|-|-|^|-|-|-|-|.| | | | | | | | | | | | | | | | }} | ||
{{familytree| | | | | | |!| | | | | | | | | | |!| | | | | | | | }} | {{familytree| | | | | | |!| | | | | | | | | | |!| | | | | | | | }} | ||
{{familytree| | | | | | B02 | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; height: 1em; width: 10em; padding:1em;">Stable patient</div>|B02=<div style="float: left; text-align: left; height: 1em; width: 10em; padding:1em;"> Unstable patient</div>}} | {{familytree| | | | | | B02 | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; height: 1em; width: 10em; padding:1em;">Stable patient</div>|B02=<div style="float: left; text-align: left; height: 1em; width: 10em; padding:1em;"> Unstable patient</div>}} | ||
{{familytree| | | | | | |!| | | | | | |,|-|-|-|^|-|-|.| | | | | | | | | | | | }} | {{familytree| | | | | | |!| | | | | | |,|-|-|-|^|-|-|.| | | | | | | | | | | | }} | ||
{{familytree| | | | | | Z03 | | | | | Z02 | | | | | Z01 | | | | | | | | | | | | |Z01=<div style="float: left; text-align: left; height: 1em; width: 13em; padding:1em;">Intermittent scant bleeding</div>|Z02=<div style="float: left; text-align: left; height: 1em; width: 13em; padding:1em;">Moderate to severe bleeding</div>|Z03=<div style="float: left; text-align: left; height: 1em; width: 13em; padding:1em;">Massive bleeding</div>}} | {{familytree| | | | | | Z03 | | | | | Z02 | | | | | Z01 | | | | | | | | | | | | |Z01=<div style="float: left; text-align: left; height: 1em; width: 13em; padding:1em;">'''Intermittent scant bleeding'''</div>|Z02=<div style="float: left; text-align: left; height: 1em; width: 13em; padding:1em;">'''Moderate to severe bleeding'''</div>|Z03=<div style="float: left; text-align: left; height: 1em; width: 13em; padding:1em;">'''Massive bleeding'''</div>}} | ||
{{familytree| | | | | | |!| | | | | | |!| | | |,|-|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | }} | {{familytree| | | | | | |!| | | | | | |!| | | |,|-|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | }} | ||
{{familytree| | | | |,| C04 |.| | | | |!| | | C02 | | | C01 | | | | | | | | | | | | | | | | C01=❑ Age < 40 years<br>❑ Healthy stable patient<br>❑ Anorectal source of bleeding highly suspected|C02=❑ Age > 50 years<br>❑ Anemic patient|C03=[[Colonoscopy]]|C04= Assess if endoscopy can be done according to hemodynamic status}} | {{familytree| | | | |,| C04 |.| | | | |!| | | C02 | | | C01 | | | | | | | | | | | | | | | | C01=❑ Age < 40 years<br>❑ Healthy stable patient<br>❑ Anorectal source of bleeding highly suspected|C02=❑ Age > 50 years<br>❑ Anemic patient|C03=❑ [[Colonoscopy]]|C04=❑ Assess if endoscopy can be done according to hemodynamic status}} | ||
{{familytree| | | | |!| | | |!| | | | |!| | | |!| | | | |!| | | | | | | | | | | }} | {{familytree| | | | |!| | | |!| | | | |!| | | |!| | | | |!| | | | | | | | | | | }} | ||
{{familytree| | | | D04 | | D03 | | | |`| D02 |'| | | | D01 | | | | | | | | | |D01=❑ | {{familytree| | | | D04 | | D03 | | | |`| D02 |'| | | | D01 | | | | | | | | | |D01=❑ Perform igital rectal examination<br>❑ [[Sigmoidoscopy]]|D02=❑ Colonoscopy|D03=Yes|D04=No (highly unstable patient)}} | ||
{{familytree| | | | |!| | | |!| | | | | | |!| | | | |,|-|^|-|.| | | | | | | | | | | | | }} | {{familytree| | | | |!| | | |!| | | | | | |!| | | | |,|-|^|-|.| | | | | | | | | | | | | }} | ||
{{familytree| | | | E04 | | E03 | | | | | |!| | | | E02 | | E01 | | | | | | | | | | | | |E01=❑ '''Anorectal source of bleeding confirmed?'''|E02=❑ '''Anorectal source of bleeding not confirmed?'''|E03=[[EGD]] to rule out [[upper GI bleed]]|E04=❑ Emergent [[angiography]] with angiotherapy<br>❑ Request a surgical consult}} | {{familytree| | | | E04 | | E03 | | | | | |!| | | | E02 | | E01 | | | | | | | | | | | | |E01=❑ '''Anorectal source of bleeding confirmed?'''|E02=❑ '''Anorectal source of bleeding not confirmed?'''|E03=❑ [[EGD]] to rule out [[Upper gastrointestinal bleeding resident survival guide| upper GI bleed]]|E04=❑ Emergent [[angiography]] with [[angiotherapy]]<br>❑ Request a surgical consult}} | ||
{{familytree| | | | |!| | | |!| | | | | | |!| | | | |!| | | |!| | | | | | | | | | | | | | | | | }} | {{familytree| | | | |!| | | |!| | | | | | |!| | | | |!| | | |!| | | | | | | | | | | | | | | | | }} | ||
{{familytree| | | | F03 | | F04 |-| F05 | |!| | | | F02 | | F01 | | | | | | | | | | | | | | | |F01= Treat accordingly|F02=Colonoscopy|F03=Bleeding not controlled?|F04= Lesion identified?|F05=No}} | {{familytree| | | | F03 | | F04 |-| F05 | |!| | | | F02 | | F01 | | | | | | | | | | | | | | | |F01= Treat accordingly|F02=[[Colonoscopy]]|F03=Bleeding not controlled?|F04= '''Lesion identified?'''|F05=No}} | ||
{{familytree| | | | |!| | | |!| | | |!| | |!| | | | |!| }} | {{familytree| | | | |!| | | |!| | | |!| | |!| | | | |!| }} | ||
{{familytree| | | | G01 | | G02 | | G03 |-|+|-|-|-|-|'|G01=Surgery|G02=Yes|G03=Colonoscopy}} | {{familytree| | | | G01 | | G02 | | G03 |-|+|-|-|-|-|'|G01=Surgery|G02=Yes|G03=Colonoscopy}} | ||
{{familytree| | | | | | | | |!| | | | | | |!| | | | | | |}} | {{familytree| | | | | | | | |!| | | | | | |!| | | | | | |}} | ||
{{familytree| | | | | | | | H01 | | | | | H02 | | | |H01= Treat as upper GI bleed|H02=<div style="float: left; text-align: left; height: em; width: 13em; padding:1em;">Colonoscopic therapy<br> | {{familytree| | | | | | | | H01 | | | | | H02 | | | |H01= Treat as [[Upper gastrointestinal bleeding resident survival guide| upper GI bleed]]|H02=<div style="float: left; text-align: left; height: em; width: 13em; padding:1em;">'''Colonoscopic therapy'''<br> | ||
---- | |||
❑ Recommended within 12-48 hours<br> | ❑ Recommended within 12-48 hours<br> | ||
❑ Prep colon for endoscopy<br> | ❑ Prep colon for endoscopy<br> | ||
: ❑ Administer 4-6 L of polyethylene glycol(PEG) at a rate of 1 L every 30 min </div>}} | : ❑ Administer 4-6 L of polyethylene glycol (PEG) at a rate of 1 L every 30 min </div>}} | ||
{{familytree| | | | | | | | | | | | |,|-|-|^|-|-|.| | }} | {{familytree| | | | | | | | | | | | |,|-|-|^|-|-|.| | }} | ||
{{familytree| | | | | | | | | | | | I01 | | | | I02 |I01=Lesion identified|I02=Lesion not identified}} | {{familytree| | | | | | | | | | | | I01 | | | | I02 |I01=Lesion identified|I02=Lesion not identified}} |
Revision as of 06:35, 30 January 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]
Definition
Lower GI bleed refers to any bleeding originating from gastrointestinal tract distal to ligament of Treitz.
- Acute GI bleed: Defined as bleeding occurring for less than 3 days.
- Chronic GI bleed: Defined as slow and intermittent bleeding occurring over a duration of several days.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Any severe GI bleed can be life threatening and should be managed appropriately irrespective of the cause.
Common Causes
- Anal fissure
- Angiodysplasia
- Colitis
- Colon cancer
- Diverticulosis
- Hemorrhoids
- Inflammatory bowel disease
- Radiation enteritis
- Rectal varices
Initial Assessment
Shown below is an algorithm summarizing the approach to [[Lower GI bleed]].
Characterize the symptoms ❑ Frank blood per rectum (bleeding from left colon) Obtain past 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 hemodynamic status | Hematochezia PLUS hemodynamic instability | Nasogastric lavage (to rule out upper GI bleed) | |||||||||||||||||||||||||||||||||||
Order tests ❑ Blood type and cross match ❑ CBC ❑ Coagulation profile ❑ Liver function tests ❑ Electrolytes ❑ BUN ❑ Creatinine ❑ EKG for elderly patients | Blood in NG lavage fluid | Copious amount of bile with no trace of blood | |||||||||||||||||||||||||||||||||||
Initiate initial supportive measures ❑ Intravenous access | ❑ Proceed with EGD after initial assessment | ❑ Proceed with colonoscopy after initial assesment | |||||||||||||||||||||||||||||||||||
Risk stratification of patients | |||||||||||||||||||||||||||||||||||||
❑ Young patient ❑ Scant bleeding ❑ No anemia ❑ Suspected bleeding from anorectal region | ❑ Severe active bleeding ❑ Unstable hemodynamically ❑ Need for > 2 units of blood transfusion ❑ Presence of other significant comorbidities | ❑ Bleeding stopped ❑ Patient is hemodynamically stable | |||||||||||||||||||||||||||||||||||
Outpatient treatment | Admit to ICU | Admit to hospital ward | |||||||||||||||||||||||||||||||||||
Approach to Endoscopic Management
Assess hemodynamic status | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Unstable patient | Stable patient | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Massive bleeding | Moderate to severe bleeding | Intermittent scant bleeding | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Assess if endoscopy can be done according to hemodynamic status | ❑ Age > 50 years ❑ Anemic patient | ❑ Age < 40 years ❑ Healthy stable patient ❑ Anorectal source of bleeding highly suspected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No (highly unstable patient) | Yes | ❑ Colonoscopy | ❑ Perform igital rectal examination ❑ Sigmoidoscopy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Emergent angiography with angiotherapy ❑ Request a surgical consult | ❑ EGD to rule out upper GI bleed | ❑ Anorectal source of bleeding not confirmed? | ❑ Anorectal source of bleeding confirmed? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Bleeding not controlled? | Lesion identified? | No | Colonoscopy | Treat accordingly | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Surgery | Yes | Colonoscopy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Treat as upper GI bleed | Colonoscopic therapy ❑ Recommended within 12-48 hours
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Lesion identified | Lesion not identified | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Endotherapy ❑ Thermal contact modalities
❑ Epinephrine injection | ❑ Consider EGD ❑ Small bowel studies | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Lesion identified? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Angiography | Treat accordingly | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||