2/3/2010

1

Abdullah Al-Abdali

R2 EM

Outline

Case discussion

Clinical approach to such cases

2/3/2010

2

82 years old female, presented with:

Bloody diarrhea with fresh blood

Abdominal pain

hematurea

primary survey

vital signs

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Sick looking

P: 110

BP:85/55

T:36.9

sat: 96% on RA

CRT ??

10

survey

A: patent

B: normal, RR 14, sPO2 96% in RA,

C: P 110, BP 85/55, T 36.9

D: GCS; (14/15), pupils reacting b/l, RBS 7.2

E: NAD

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Intervention ??

NS boluses

Blood ordered, 6U

Post resuscitation

P:92

BP:100/60

Sat:100% on 100% O2

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History

Investigation

Consultation

DDx

2nd survey

2nd survey

H&N ….. Normal

Chest ….. Reduce air entry in lower base

B/L

CVS …… S1+S2, ESM

Abdomen: slightly distended, Soft, tender

all over

PR: fresh blood in the glove, no mass felt

CNS :no obvious neurologic deficit.

ECG: sinus tachycardia

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History

HTN = not on medication currently

Dx 5 months back as leaking

descending Aortic aneurysm not fit for

any surgical intervention.

B/L pleural effusion under Ix, but she

sign LAMA.

DDx

aortoenteric fistula

Aortic Aneurysm leakage

Diverticulosis,

Angiodysplasia

Cancer

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Consultations

General surgery

Cardio-thoracic surgery

Cardiology

Acute medical admission

Gastroenterology

CBC:

HB: 5

Hct: 16%

Plt: 80.4

WBC: 62

ANC:47.1

U/E:

Na:140

K: 4

Urea: 13.7

creat:115

coagulation:

PT:13.8

APTT:34.2

LFT:

Normal

CT angio

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General surgery

For urgent CT angio.

To be seen by cardio-thoracic

Cardio-thoracic surgery

To stabilize the patient and to Do CT angio

(chest & abdomen)

To consult cardiologist for assessment

CT angio= Thoracic Aortic aneurism not

increased in size and no leakage from it.

SO, no cardiothoracic interference required

at present, and to be seen by general

medicine for further Management

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Cardiology

Bed side ECHO done:

Normal LV size

EF:40%

Normal LA size grade 2 MR

Mild AS

Dilated Descending AO

She is high risk for surgery and GA

Acute medical admission

d/w Gastro on call, advised admission

under acute medicine as pt need

stabilization

To start Omeprazol and octriotide

To f/u official CT report

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CT report

Impression:

Thoracic aneurysm

Possibility of subintimal intramural bleed

Active intraluminal bleed in short

segment of distal small bowel loop seen

at left lower abdomen.

B/L pleural effusion, more in L. side

Back to surgery

Surgically patient is high risk & needs

optimal localization via selective

mesenteric angio with possible

emboilization.

OGD done

Colonoscopy done

Selective angio done= no abnormal vascularity seen,

tiny bleeding into the lumen of small bowel at they Lt, para-lumbar

area.

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OT

There was blood inside the last 20-30

cm of ileum, there were multiple

ulcers seen with bleeding, Resection

done of about 20-30cm of ileum down

to about 10cm from ileo-caecal valve.

Clinical approach to lower GI bleeding

(LGIB) refers to blood loss of recent

onset originating from a site distal to

the ligament of Treitz.

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Etiology

Common causes of lower gastrointestinal bleeding

AnatomicalDiverticulosis,

VascularAngiodysplasia

Ischemic Radiation-induced telangiectasia

InflammatoryInfectious

Idiopathic inflammatory bowel disease

Neoplastic Polyp

Carcinoma

OthersHemorrhoid

Ulcer

Post biopsy or polypectomy

Diverticulosis — 33 %

Cancers/polyps — 19 %

Colitis/ulcers (including inflammatory bowel disease,

infectious, ischemic, and radiation colitis, vasculitis, and

inflammation of unknown cause) — 18 %

Unknown — 16 %

Angiodysplasia — 8 %

Miscellaneous (postpolypectomy, aortocolonic

fistula, stercoral ulcer, anastomotic bleeding) — 8 %

Anorectal (hemorrhoids, fissures, and idiopathic rectal

ulcers) — 4 %

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Clinical approach

Patients should be categorized as:

low risk

high risk

Low risk:

(eg, a young otherwise

healthy patient with

self-limited rectal

bleeding that is most

likely due to an

internal haemorrhoid)

may be evaluated in

the outpatient setting.

High risk*:

including those with:

-hemodynamic instability,

-serious comorbid diseases,

-persistent bleeding,

-the need for multiple blood

transfusions

-evidence of an acute Abdomen

Resuscitation

All patients with:

hemodynamic instability (shock,

orthostatic hypotension),

evidence of severe bleeding (eg, a

decrease in hematocrit of at least 6 %,

or transfusion requirement greater than

two units of packed red blood cells)

continuous active bleeding

should be admitted to an intensive care unit

for resuscitation and close observation

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General surgery and gastroenterology

should be involved earlier in

management.

Investigations In patients with bleeding suspected to be coming from a

lower GI source, colonoscopy is suggested (grade 2B).

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Take home message:

Visible rectal bleeding occurring in adults warrants an evaluation in

all cases. Patients should be categorized as either low or high risk

for complications based upon their clinical presentation and

hemodynamic status.

Patients with hemodynamic instability, with evidence of severe

bleeding or continuous active bleeding should be admitted to an

intensive care unit for resuscitation and close observation.

follow guidelines that have been issued by the American College of

Gastroenterology and approved by the American gastroenterological

Association and the American Society for Gastrointestinal

Endoscopy for evaluation of the patient with presumed lower

gastrointestinal bleeding.

THANK YOU