Lower GI BleedingAdvance MLP Training

Gil,M PA-C

Less straight forward treatment and disposition pathway than Upper GI Bleeding

Typically patients present with hematochezia or maroon colored stool◦ Remember a brisk upper GI bleed can present

with hematochezia◦ In some cases bleeding in the ascending colon will

present as Melena 80-85% will stop spontaneously 2-4 % will result in death

Overview

More common◦ Angiodysplasia◦ Diverticular disease◦ Colonic carcinoma or polyp◦ Hemorrhoids or anal fissure

Less common◦ Massive upper GI bleeding◦ Inflammatory bowel disease◦ Ischaemic colitis◦ Meckel’s diverticulum◦ Small bowel disease, e.g. tumor, diverticula, intussusception◦ Hemobilia (bleeding from the gallbladder)◦ Solitary colonic ulcer

Etiology

Ask about previous GI Bleeding Recent colonoscopy or surgeries Known Inflammatory Bowel Disease Bleeding disorders NSAID, Anticoagulant or Antiplatelet use Ask about pain which may suggest colitis Hematochezia which suggests diverticular

bleeding 10-15% of patients who describe severe

hematochezia will have an upper GI source Change in bowel habits suggesting cancer

History

Hemodynamic instability (hypotension, tachycardia, orthostasis, syncope)

Persistent bleeding Significant comorbid illnesses Advanced age A prior history of bleeding from diverticulosis or

angiodysplasia Current aspirin use Prolonged prothrombin time A non-tender abdomen Anemia An elevated blood urea nitrogen level An abnormal white blood cell count

High Risk Features

Rectal Exam◦ Look for any hemorrhoids at the source of bleeding◦ Appreciate color and character of stool

Bright red blood vs maroon colored stool Streaks of blood mixed with stool Gross blood without stool

Anoscopy◦ Some physicians will perform anoscopy at the bedside,

discuss this with your attending if you suspect an internal hemorrhoid as the source of bleeding

Abdominal exam◦ Tenderness◦ Distention, Ascites, Stigmata of liver failure?

Physical Exam

Mimics for hematochezia◦ Partially chewed/digested red grapes◦ Red food ie beets◦ Vaginal bleeding◦ Gross Hematuria◦ Buttock lesions

Ingestions that may cause a false positive occult blood test◦ Red meat◦ Turnips◦ Horseradish◦ Vitamin C

Mimics for GI Bleeding

CBC BMP Hepatic Function Tests Coags HemOccult testing

The only ED imaging the may be useful is a CT Scan Abd Pelvis with IV Only, this is only indicated in patients WITH abdominal pain

Never give PO Contrast to a patient with a suspected lower GI bleed, this will obscure any colonoscopy performed within the near future

Lab Testing

Imaging

Fluids◦ 500ml to 1 L NS

Type and Screen Blood Transfusion if indicated

◦ If pt is unstable, hypotensive, and you believe cause is acute blood loss start “Massive Transfusion Protocol”

◦ If pt is stable await CBC and type/screen◦ Obtaining blood can take HOURS if you believe pt

needs blood NOW consider starting O- Reverse any anticoagulation (Next slide)

Treatment

Dabigatran – Praxbind is now available, dosing per pharmacy, unsure if this is stocked in all our hospitals

Rivaroxaban, Apixaban, Edoxaban – administration of 4 factor PCCC at 50 units/kg◦ There is no research to support the use of PCCs

however there is currently no alternative◦ TXA can be given in addition ◦ FFP is not indicated

Reversing Anticoagulation

Coumadin Reversal Guidlelines

Most common cause of OVERT lower GI bleeding in adults

Most will stop without intervention◦ 14-38% will rebleed

About 7% of patients with Diverticulosis will have a diverticular bleed

The ascending colon is most commonly responsible 50-90% of the time

Diagnosis is made by Colonoscopy or Nuch Tech Scan

Diverticular Bleeding

Dilated submucosal veins in the anus◦ Internal – above the dentate line◦ External – below the dentate line

Hematochezia results from rupture of an internal hemorrhoid, almost always painless

Blood typically coats stool at end of defecation Significant GI Bleeding from hemorrhoids resulting in

hemodynamic instability is exceedingly rare unless the patient is coagulopathic

Anoscopy can be very helpful in the diagnosis Treatment

◦ Increase fiber in diet, add Colace or MiraLax◦ Anusol cream or suppository◦ Sitz Bath

Refer these patients as an outpt to GI for definitive therapy

Hemorrhoidal Bleeding

Typically due to passage of hard stool Perform rectal inspection, if a fissure is visualized

no digital rectal exam is necessary◦ Fissures commonly occur either posterior or anterior

midline◦ Fissures that are non midline raise concern for Crohn's

disease or trauma Treatment

◦ Bowel Regimen (Colace, Miralax)◦ Sitz Bath◦ Topical analgesia (2% lidocaine jelly)◦ Topical Nifedipine or Nitroglycerin (not typically prescribed

in the ED)

Anal Fissure

Dilated, tortuous submucosal vessels Uncommon, can be associated with aortic stenosis,

von Willebrand disease and Chronic Renal Failure Most commonly seen in the cecum or ascending

colon Can present as overt hematochezia but more

commonly is seen as chronic blood loss with mildly Hemoccult positive stools

Treatment consists of endoscopic coagulation, injection sclerotherapy and argon laser coagulation

Angiodysplasia

10% of lower GI bleed cases in patients > age 50 are due to colon cancer

Bleeding is due to overlying erosion and ulceration of a cancerous lesions

Tends to be low grade and recurrent, classically detected as anemia of unknown etiology in a male > 50 y.o

Colon Cancer

Occurs in 0.3 to 6.1 % of polypectomies Can be immediate or delayed

◦ Immediate occurring in 1.5% of polypectomies◦ Delayed bleeding in up to 2 % of polypectomies

In some cases endoscopy is necessary to stop bleeding The GI physician who performed the colonoscopy should be

notified immediately Patients who are having frequent bloody bowel movements

and are becoming hemodynamically unstable will need immediate intervention

Consultation with General Surgery & IR may also be necessary Stabilize unstable patients and consult GI Stable patients should be watched in the ED for 4-6 hours and

GI recs should be followed

Bleeding After Polypectomy

Disposition can be difficult or straight forward

Unstable patients need admission to the Step Down Unit or ICU

Stable patients may require consultation with a Gastroenterologist to determine a plan of care

It is never wrong to observe a patient, give 1-2 L of fluid and repeat an H&H in 4-6 hours.

Disposition

Case Senarios

80 year old male with no history of GI bleeding, on coumadin for A fib, presenting with two episodes of maroon colored stool

Blood pressure is stable, HR slightly tachycardic H&H is stable, INR is therapeutic at 2.5

Dispo Decision: this is the type of patient who may be stable but would benefit from admission

He is elderly, on an anticoagulant agent and has a history of CAD.

Consider risk factors and likelihood of bad outcome prior to seeing a GI physician

Patient #1

24 year old female presents with two days of bright red blood per rectum X 2 episodes. Pt has no history of GI bleed, VSS, H&H is stable, no blood thinners and no PMhx.

Dispo Decision: this is the type of patient who can go home after screening lab work. Patient lacks any risk factors and with a stable H&H after 48 hours it is unlikely she has a significant GI bleed. Referral to GI as an outpatient is appropriate.

Patient #2

A 45 year old man presents with one episode of “gushing” bright red blood after having a bowel movement. The patient had a colonoscopy 24 hours ago, one polyp was removed. He is otherwise healthy on no blood thinners

Vital signs and screening labs are normal

Dispo Decision: this is the type of patient who would benefit from rehydration, 1-2 liters of fluids, ED Obs , GI Consult, and repeat H&H

You will monitor for recurrence of bleeding, significant drop in H&H and follow GIs Recs.

Patient # 3

There is no “cook book” method for all lower GI Bleeding, consider the patients risk factors and determine treatment plan based on those risk factors

Review

UpToDate Ebmedicine CORE EM

References