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Toronto Notes 2019 Small and Large Bowel Lower Gastrointestinal Bleeding
Definition
• bleeddistaltoligamentofTreitz
Etiology
• ifbloodperrectumwithhemodynamicinstability,ruleoutupperGIsource • diverticular(60%fromrightcolon)
• vascular
■ angiodysplasia(smallvascularmalformationsofthegut)
■ anorectal (hemorrhoids, fissures) • neoplasm
■ cancer
■ polyps
• inflammation
■ colitis (ulcerative, infectious, radiation, ischemic) • post-polypectomy
Gastroenterology G27
Clinical Features
• hematochezia
• anemia
• occultbloodinstool • rarelymelena
Treatment
• treatunderlyingcause
Lower GI Bleed
CHAND Colitis(radiation,infectious,ischemic,IBD [UC > CD])
Hemorrhoids/fissure
Angiodysplasia
Neoplastic
Diverticulardisease
1. Assess hemodynamic stability
2. Resuscitate (IV fluids ± blood transfusion)
3. Assess coagulation status (CBC, INR/PTT)
4. Determine site of bleeding
Always exclude upper GI lesion before localizing the site of the bleeding to the lower GI tract
Massive bleeding/hemodynamically unstable? Clinical suspicion of UGIB based on risk factors? (increased possibility of UGI source)
Colonoscopy and OGD
Hemodynamically stable, no UGIB risk factors? (decreased possibility of UGI source)
Colonoscopy only
(or flexible sigmoidoscopy)
• For SLOW bleeding (<0.5 ml/min): radionucleotide Tc-99m-tagged RBC scan • For RAPID bleeding (>0.5 ml/min): angiography ± embolization
Figure 10. Approach to hematochezia
Colorectal Carcinoma
• seeGeneralSurgery,GS34 Colorectal Polyps
• seeGeneralSurgery,GS33
Familial Colon Cancer Syndromes
• seeGeneralSurgery,GS33
Benign Anorectal Disease
• seeGeneralSurgery,GS40