lower g.i.t bleed

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LOWER G.I.T BLEED LOWER G.I.T BLEED

Transcript of lower g.i.t bleed

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LOWER G.I.T BLEEDLOWER G.I.T BLEED

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G.I.BLEEDING DEFINITIONSG.I.BLEEDING DEFINITIONS

Acute versus chronicAcute versus chronic Upper (proximal to ligament of treitz)Upper (proximal to ligament of treitz) Lower(distal to ligament of treitz)Lower(distal to ligament of treitz) Overt-clinical signs/symptoms presentOvert-clinical signs/symptoms present Occult-not clinically evident(FOBT + or iron Occult-not clinically evident(FOBT + or iron

def anemia)def anemia) Obscure-routine evaluationObscure-routine evaluation

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INTRODUCTIONINTRODUCTION

Bleeding arising below the Ligament Of TreitzBleeding arising below the Ligament Of Treitz Either from the small intestine or from the Either from the small intestine or from the

coloncolon Majority of the cases arise from colon Majority of the cases arise from colon

specially the ANORECTAL regionspecially the ANORECTAL region

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HEMATOCHEZIAHEMATOCHEZIA

Related term meaning FRESH Related term meaning FRESH

BRIGHT RED BLOOD PER RECTUMBRIGHT RED BLOOD PER RECTUM

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LOWER GI BLEEDLOWER GI BLEED

Accounts for 24% of all GI bleedingAccounts for 24% of all GI bleeding Presentation can be malena(19%)or Presentation can be malena(19%)or

hematochezia(81%)hematochezia(81%) Usually less severe than upper GI bleedingUsually less severe than upper GI bleeding Mortality of 2-3.6%Mortality of 2-3.6%

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TYPESTYPES(Depending upon patients age)(Depending upon patients age)

PATIENTS BELOW PATIENTS BELOW 50years OF AGE50years OF AGE

Inflammatory bowel Inflammatory bowel diseasesdiseases

Infectious colitis due to Infectious colitis due to Shigella,E.coliShigella,E.coli

Anorectal diseases like Anorectal diseases like Hemorrhoids, Anal Hemorrhoids, Anal fissuresfissures

PATIENTS ABOVE PATIENTS ABOVE 50years OF AGE50years OF AGE

DiverticulosisDiverticulosis AngiodysplasiasAngiodysplasias NeoplasmsNeoplasms Ischemic colitisIschemic colitis

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TYPES BASED ON BLEEDINGTYPES BASED ON BLEEDING

BLEEDING WITH BLEEDING WITH PAINPAIN

Anal fissuresAnal fissures Ischemic colitisIschemic colitis Inflammatory bowel Inflammatory bowel

diseasesdiseases

PAINLESS PAINLESS BLEEDINGBLEEDING

Internal hemorrhoidsInternal hemorrhoids DiverticulosisDiverticulosis AngiodysplasiasAngiodysplasias

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EPIDEMIOLOGYEPIDEMIOLOGY

Mortality is usually due to co-morbid Mortality is usually due to co-morbid conditions(like organ conditions(like organ failure,AMI,aspiration,sepsis)failure,AMI,aspiration,sepsis)

Bleeding stops spontaneously>80% of the Bleeding stops spontaneously>80% of the time.time.

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SYMPTOMOLOGY AND SYMPTOMOLOGY AND EVALUATIONEVALUATION

DIVERTICULOSISDIVERTICULOSIS Presents as MAROON or BRIGHT RED Presents as MAROON or BRIGHT RED

hematocheziahematochezia Bleeding stops spontaneouslyBleeding stops spontaneously Common in patients over 50 years of ageCommon in patients over 50 years of age

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ANGIODYSPLASIAANGIODYSPLASIA

Patient presents with painless bleedingPatient presents with painless bleeding

Common after 70 years of ageCommon after 70 years of age

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NEOPLASMSNEOPLASMS

Both benign polyps and carcinoma can cause Both benign polyps and carcinoma can cause bleedingbleeding

Usually chronic occult bleedingUsually chronic occult bleeding May cause mild intermittent hematocheziaMay cause mild intermittent hematochezia

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INFLAMATORY BOWEL INFLAMATORY BOWEL DISEASEDISEASE

Most commonly ulcerative colitis presents Most commonly ulcerative colitis presents with diarrhea with occult blood or recurrent with diarrhea with occult blood or recurrent hematochezia,abdominal pain,tenesmus and hematochezia,abdominal pain,tenesmus and

urgency urgency

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ANORECTAL DISEASEANORECTAL DISEASE

Hemorrhoids present as painless bleeding mixed Hemorrhoids present as painless bleeding mixed with stool or dipping into toilet bowlwith stool or dipping into toilet bowl

Painless small bleeding can occur in case of Painless small bleeding can occur in case of small fissuresmall fissure

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ISCHEMIC COLITISISCHEMIC COLITIS

Seen in elderly especially those who have Seen in elderly especially those who have atherosclerosis presenting as bloody diarrhea atherosclerosis presenting as bloody diarrhea with mild abdominal painwith mild abdominal pain

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DIAGNOSTIC PROTOCOLSDIAGNOSTIC PROTOCOLS

1.Rectal examination1.Rectal examination 2.Anoscopy and sigmoidoscopy2.Anoscopy and sigmoidoscopy 3.Nasogastric intubation3.Nasogastric intubation 4.Technetium scan4.Technetium scan 5.Angiography5.Angiography 6.Colonoscopy6.Colonoscopy

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RECTAL RECTAL EXAM,SIGMOIDOSCOPY AND EXAM,SIGMOIDOSCOPY AND

ANOSCOPYANOSCOPY Digital examination anoscopy and Digital examination anoscopy and

sigmoidoscopy to look for anorectal sigmoidoscopy to look for anorectal diseases,inflammatory bowel disease or diseases,inflammatory bowel disease or infectious colitis.infectious colitis.

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TECHNETIUM-99mRBC scanTECHNETIUM-99mRBC scan

Performed in active bleeding to detect source Performed in active bleeding to detect source of bleedingof bleeding

Can also be performed for intermittent Can also be performed for intermittent bleedingbleeding

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ANGIOGRAPHYANGIOGRAPHY

In active bleeding it is the investigation of choiceIn active bleeding it is the investigation of choice Selective angiography indicated for massive ongoing Selective angiography indicated for massive ongoing

lower G.I bleeding or with recurrent bleeding and lower G.I bleeding or with recurrent bleeding and negative colonoscopy.negative colonoscopy.

Can detect rates of 0.5ml/minCan detect rates of 0.5ml/min Can be used as therapy-coil Can be used as therapy-coil

embolization,alcohols,vasoconstrictors.embolization,alcohols,vasoconstrictors. 70-100%effective if positive70-100%effective if positive Low rebleeding rate-12%Low rebleeding rate-12%

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COLONOSCOPYCOLONOSCOPY

Performed if bleeding stops or occurs at slow Performed if bleeding stops or occurs at slow raterate

Allows identification of angiodysplasia,tissue Allows identification of angiodysplasia,tissue biopsy and therapeutic intervention with biopsy and therapeutic intervention with electrocautery heater probe or laser therapy of electrocautery heater probe or laser therapy of active bleedingactive bleeding

Not helpful during massive bleedingNot helpful during massive bleeding

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ASSESMENTASSESMENT

Includes history and examinationIncludes history and examination AgeAge Attention to vitals, volume status, oxygen Attention to vitals, volume status, oxygen

saturation, urine outputsaturation, urine output Evidence of liver diseaseEvidence of liver disease Risk factors, use of Risk factors, use of

NSAIDs,anticoagulation,co-morbidities,NSAIDs,anticoagulation,co-morbidities,

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LABORATORY ASSESMENTLABORATORY ASSESMENT

Complete blood countComplete blood count Blood type and cross-matchBlood type and cross-match Coagulation factors PT,APTTCoagulation factors PT,APTT Chemistry panelChemistry panel BUN/Cr ratioBUN/Cr ratio Bilirubin,albumin,INR to asses for hepatic Bilirubin,albumin,INR to asses for hepatic

synthetic dysfunctionssynthetic dysfunctions

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INITIAL MANAGEMENTINITIAL MANAGEMENT

ABC managementABC management OxygenOxygen I/v accessI/v access FLUIDSFLUIDS ETTETT

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MANAGEMENTMANAGEMENT

If the patient has massive ongoing bleeding with If the patient has massive ongoing bleeding with homodynamic instability, urgent angiography homodynamic instability, urgent angiography is indicatedis indicated

If colonoscopy does not reveal a source, but If colonoscopy does not reveal a source, but bleeding continues-tagged RBC scan should bleeding continues-tagged RBC scan should be done to localize bleedingbe done to localize bleeding

If colonoscopy doesn't reveal a source,but If colonoscopy doesn't reveal a source,but bleeding stops, observe patient.bleeding stops, observe patient.

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SURGERYSURGERY

Done on patients who have failed Done on patients who have failed medical,colonoscopic,angiographic medical,colonoscopic,angiographic interventionintervention

Ongoing bleeding>4U of PRBC per 24hOngoing bleeding>4U of PRBC per 24h Effort should be made to localize the source Effort should be made to localize the source

prior to surgery.prior to surgery.

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SURGICAL PROCEDURES SURGICAL PROCEDURES

Targeted subtotal colectomyTargeted subtotal colectomy Blind subtotal colectomy(high mortality)Blind subtotal colectomy(high mortality) Blind segmental colectomy(high mortality and Blind segmental colectomy(high mortality and

54%re-bleeding rate-not preferred)54%re-bleeding rate-not preferred)

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OCCULT LOWER GI BLEEDOCCULT LOWER GI BLEED

Loss of small blood that can not be seenLoss of small blood that can not be seen Detected in 2 settingsDetected in 2 settings FOBT +FOBT + Iron def anemiaIron def anemia

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CONCLUSIONCONCLUSION

Always remember to treat the patientAlways remember to treat the patient Resuscitate-ABCResuscitate-ABC Correct coagulopathyCorrect coagulopathy Patient die from co-morbiditiesPatient die from co-morbidities Gi bleeding requires a multidisciplinary Gi bleeding requires a multidisciplinary

approach-critical care,medicine,G.I radiology approach-critical care,medicine,G.I radiology and surgery.and surgery.

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THANK YOUTHANK YOU