LGIB


Hematemesis: (Vomiting of blood)
  • UGIB proximal to ligament of Treitz

Hematochezia (fresh blood thorugh anus)

  • Maroon: transverse and right colon
  • Bright red: anus, rectum, sigmoid
  • 10% due to rapid UGIB

Melena (Dark sticky feaces containing partly digested blood)

  • Usually due to UGIB
  • Iron and bismuth ingestion causes black, heme-negative stool

Etiology

HEMORRHOIDS

Diagnosis

  • External hemorrhoids by visualization or on digital exam as swollen pads of tissue
  • Internal hemorrhoids dx w/anoscopy
  • Hemorrhoid bleed dx w/ active bleeding seen or a clot is overlying hemorrhoid

Pathophysiology

  • Hemorrhoids are submucosal plexus of veins lining lower rectum, that can be seen endoscopically
  • Hemorrhoids incr in size w/ incr venous pressure to plexus (pregnancy, prolonged sitting, cirrhosis, etc), thrombose and cause pain

Treatment

  1. See Hemorrhoids
DIVERTICULOSIS

Diagnosis

  • Most asymptomatic
  • Common abd pain or change of bowel pattern
  • Bleeding (overt, massive 5%) spontaneously, bright red or maroon stool, & stops abruptly in most cases, 25% recurrent, 50% after second episode
  • Demonstrated endoscopically, or w/ massive bleed, consider angiography or nuclear bleeding scan
  • 15% of pts w/ hematochezia have an upper GI source

Pathophysiology:

  • From out pouching of mucosa through muscularis layers, to site of blood vessels
  • Most diverticula involve sigmoid, but bleeding can occur anywhere there are diverticula, 10% diverticula throughout colon

Treatment:

  1. See also Diverticular Disease
  2. 75-95% subside spontaneously or w/ conservative management
  3. Uncontrolled
    • Endoscopy w/ heater probe, laser or electrocautery
    • Intraarterial vasopressin on angiography
  4. Uncontrolled bleeding may require surgery
ANGIODYSPLASIA OF THE COLON

Diagnosis

  • Bright red or maroon stools
  • Brief bleeding episodes
  • 10% may have only occult loss
  • Cecum and ascending colon common sites
  • 1/2 of lower GI bleed in pts >50
  • Endoscope & mesenteric angiography to diagnose

Pathophysiology

  • Involves dilated & tortuous submucosal vessels w/ in colonic walls
  • Unknown etiology: ?aged bowel; 50% assoc w/ valvular dz(calcified aortic stenosis)

Treatment

  1. Endoscope & mesenteric angiography to cauterize (50% effective), or embolize
ISCHEMIC COLITIS

Diagnosis

  • Sudden onset abdominal pain, bleeding
  • Pain precedes bleed; despite severe pain, abd soft
  • Consider any patient w/ H/O MI, arrhythmia, or hypotension
  • Usually left colon

Pathophysiology

  • Interruption of blood flow to a distal segment
  • Occlusive (thrombosis, emboli) resulting in ischemia, or nonocclusive (as low flow states) splenic flexure & sigmoid more susceptible

Treatment

  1. Bleeding usually self-limited
  2. Treat predisposing factors
  3. Bowel rest
  4. NGT
  5. Uncontrolled, continuous hemorrhage requires angiogram
  6. Continued pain: see Mesenteric Ischemia
NEOPLASMS
  • Small Bowel
    • Uncommon & asympt, occ w/occult or overt bleed
    • Dx difficult; X-ray, CT, arteriography are limited
  • Large Bowel
    • Benign/malignant tumors can produce blood loss, usually episodic to overt bleed, usually painless
    • Dx by colonoscopy is standard
  •  Treatment
    • Most small bowel tumors require surgery
    • Benign colon polyps may be removed at colonoscopy
MECKEL'S DIVERTICULUM
Diagnosis
  • Usually <2 yo
  • 50% of lower intestinal bleeding in children
  • Painless maroon stool
  • Dx by clinical suspicion, mesenteric angiography (for ongoing blood loss), (barium studies rarely helpful)

Pathophysiology

  • Incomplete closure of vitelline duct, produces blind pouch attached to ileum
  • Bleed results from peptic ulceration of mucosa

Treatment

  1. Surgical resection
  2. See Meckel diverticulum in
Colitis
  • Inflammatory bowel disease
  • Infections-Salmonella, E.Coli O 157:H7, Shigella. Campylobacter
  • Radiation colitis

 

Symptoms

  • Hematochezia, Abdominal pain, Weight loss, Change in bowel pattern, Hypovolemia or signs of shock

Diagnosis

  • Rectal exam for presence of blood and anoscopy as indicated.
  • Angiography can localize site of bleeding if rate >0.5 mL/min.
  • Tagged red blood scan can localize the site of bleeding if rate >0.1 mL/min; not as good at localizing site of bleeding as angiography.
  • Colonoscopy (after bowel prep if patient is stable)
  • CBC, coagulation profile, type, and cross-match

Treatment

  • NPO
  • 2 large bore IVs
  • STOP all meds causing bleeding (ASA, Plavix, warfarin etc.)
  • +/- NG tube:
    • Recommended in most patients with significant GI bleeding regardless of source (to r/o upper GI bleed)
    • * Negative aspirate does not rule out upper GI source
       
  • Fluid and blood resuscitation:
    • Treat coagulopathy with FFP +/- Vitamin K (until PTT normalizes in cirrhotic pt)
    • Vitamin K if INR is high:
      • 5-9: 1 - 2.5 mg PO
      • >9: 5-10 mg PO
      • Any bleed: 10mg by slow IV infusion
    • Treat thrombocytopenia
    • Replace coagulation factors as needed.
    • Platelet transfusion if < 50K
    • PRBC:
      • If patient has ongoing bleeding -OR-
      • Symptomatic after 2 L of IV Bolus
         
  • PPI: reduce rebleeding and the need for subsequent surgery
    • Esomeprazole 80 mg IV bolus, followed by 8 mg/hr -OR-
    • Pantoprazole 80 mg IV bolus, followed by 8 mg/hr
      • Continue PO BID x 4-8 weeks for peptic ulcer disease
      • Assess for H.pylori infection & treat if present.
         
  • Vasopressin after angiography may be beneficial.
  • Definitive treatment includes selective embolization, endoscopic coagulation, and surgical resection.

Disposition

  • Most GI bleeds should be admitted.
    • Consider ICU ADMIT -- if Active Bleed, low Hgb, VS unstable
       
  • Low-risk patients (hemorrhoids, fissures, and proctitis) may be safely discharged if they have adequate follow-up care.
    • LOW RISK LGIB MANAGEMENT
      • Low Risk Criteria: consider discharge home with close follow-up
      • No comorbid disease
      • Normal vitals
      • Negative or trace positive stool guaiac
      • Negative GI aspirate (if done)
      • Normal H/H
      • Good home support
      • Patient understanding and agreement
      • Follow-up arranged within 24 hours

Admit Orders: GI Bleed

1. Admit to:

2. Diagnosis: Upper/lower GI bleed

3. Condition:

4. Vital Signs: q30min. Call physician if BP >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C; urine output <15 mL/hr for 4h.

5. Activity: Bed rest

6. Nursing: Place nasogastric tube, then lavage with 2 L of room temperature normal saline, then connect to low intermittent suction. Repeat lavage q1h. Inputs and outputs.

7. Diet: NPO

8. IV Fluids: Two 16 gauge IV lines. 1-2 L NS wide open; transfuse 2-6 units PRBC to run as fast as possible, then repeat CBC.

9. Special Medications:

-Oxygen 2 L by NC.

-Pantoprazole (Protonix) 80 mg IV over 15min, then 8 mg/hr IV infusion 80 mg IV q12h OR


Esophageal Variceal Bleeds:

-Somatostatin (Octreotide) 50 mcg IV bolus, followed by 50 mcg/h IV infusion (1200 mcg in 250 mL of D5W at 11 mL/h).
 

Vasopressin/Nitroglycerine Paste Therapy:

-Vasopressin (Pitressin) 20 U IV over 20-30 minutes, then 0.2-0.3 U/min [100 U in 250 mL of D5W (0.4 U/mL)] for 30 min, followed by increases of 0.2 U/min until bleeding stops or max of 0.9 U/min. If bleeding stops, taper over 24-48h AND

-Nitroglycerine paste 1 inch q6h OR nitroglycerin IV at 10-30 mcg/min continuous infusion (50 mg in 250 mL of D5W).

-Norfloxacin (Noroxin) 400 mg twice daily OR

-Ciprofloxacin (Cipro) 400 mg IV q12h.

-Thiamine 100 mg PO/IV qd.
 

10. Extras: Portable CXR, upright abdomen, ECG. Surgery and GI consults.

Upper GI Bleeds: Esophagogastroduodenoscopy with coagulation or sclerotherapy; Linton-Nachlas tube for esophageal varices.

Lower GI Bleeds: Sigmoidoscopy/colonoscopy (after a GoLytely purge 6-8 L over 4-6h), technetium 99m RBC scan, angiography with embolization.


11. Labs:
 Repeat hematocrit q2h; CBC with platelets q12-24h. Repeat INR in 6 hours. chem 7&12, ALT, AST, alkaline phosphatase, INR/PTT, type and cross for 3-6 U PRBC and 2-4 U FFP.

 





Source: Tintinalle ED 7th