3.3.10 Kwan Obscure GI Bleed

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GI bleed

Transcript of 3.3.10 Kwan Obscure GI Bleed

  • Finding Sources of Obscure Lower GI BleedingWilliam Kwan

  • Causes of HematocheziaCOLONIC BLEEDING (95%)SMALL BOWEL BLEEDING (5%)Diverticular disease30-40AngiodysplasiasIschemia5-10 Erosions or ulcers (K, NSAIDs)Anorectal disease5-15Crohn's diseaseNeoplasia5-10RadiationInfectious colitis3-8Meckel's diverticulumPostpolypectomy3-7NeoplasiaIBD3-4Aortoenteric fistulaAngiodysplasia3 Radiation colitis/proctitis1-3 Other1-5 Unknown10-25

  • Causes of HematocheziaDiverticulosisBleeding occurs in only 3-5%Left-sided source more common when diagnosed by colonoscopyRight-sided source more common when diagnosed by angiographyAngiodysplasiaMost common in cecum and ascending colonWhen in the small bowel, presents as iron deficiency anemia and rarely as hematochezia

  • Causes of HematocheziaHemorrhoidsIschemic colitisNeoplasmsNSAID-induced injury in terminal ileum and proximal colonIBD10-15% of hematochezia caused by upper GI bleed

  • HistoryNSAIDs & ASA strongly associated with lower GI bleeding just as with upper GI bleedingStercoral ulcers caused by severe constipationRecent polypectomyHypovolemia preceding bleed suggests ischemic colitis

  • Going Hunting

  • Going HuntingBleeding source not found in 25%KUB to look for perforation or obstructionNG aspirateColonoscopyNo agreement over whether prep is needed because of increased risk of perforation with unpreped colonRadionuclide imagingCan detect slow bleeds at 0.1-0.5ml/minMore sensitive but less specific than angiography

  • Going HuntingAngiographyRequires bleeding of at least 1ml/minVery specific but not very sensitiveMay cause bowel infarction, renal failureSmall bowel evaluationPush enteroscopy can allow evaluation of the first 60cm of jejunumVideo capsule to evaluate the remainderMeckel scan

  • Strategy with Lower GI bleedingIf persistently unstable and major bleeding, proceed to surgeryIf colonic source, subtotal colectomy with ileorectal anastomosisIf small bowel source, resectionIf no identified source, intraoperative enteroscopy followed by resectionIf stable and major bleedingTagged red cell scan If positive, follow with angiographyIf negative, capsule endoscopy, enteroclysis, enteroscopy

  • Strategy with Lower GI bleedingIf stable and minor bleedingColonoscopyIf negative, capsule endoscopy, enteroclysis, enteroscopyIf all studies negativeColonoscopy if rebleeding

  • Dont ForgetIn addition to basic labs (CBC, Chemistries, Coags), obtaining type and crossTwo large bore peripheral IVsRectal exam as up to 40% of rectal cancers can be detected this way

  • ReferencesBounds, BC and PB Kelsey. Lower Gastrointestinal Bleeding. Gastrointestinal Endoscopy Clinics of North America. 2007: 17, 273-88.Townsend: Sabiston Textbook of Surgery. 18th ed.