3.3.10 Kwan Obscure GI Bleed
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Transcript of 3.3.10 Kwan Obscure GI Bleed
Finding Sources of Obscure Lower GI
BleedingWilliam Kwan
Causes of Hematochezia COLONIC BLEEDING (95%) SMALL BOWEL BLEEDING (5%) Diverticular disease 30-40 Angiodysplasias Ischemia 5-10 Erosions or ulcers (K, NSAIDs) Anorectal disease5-15 Crohn's disease Neoplasia 5-10 Radiation Infectious colitis 3-8 Meckel's diverticulum Postpolypectomy 3-7 Neoplasia IBD 3-4 Aortoenteric fistula Angiodysplasia 3 Radiation colitis/proctitis1-3 Other 1-5 Unknown 10-25
Causes of Hematochezia Diverticulosis
Bleeding occurs in only 3-5% Left-sided source more common when diagnosed by
colonoscopy Right-sided source more common when diagnosed by
angiography Angiodysplasia
Most common in cecum and ascending colon When in the small bowel, presents as iron deficiency
anemia and rarely as hematochezia
Causes of Hematochezia Hemorrhoids Ischemic colitis Neoplasms NSAID-induced injury in terminal ileum and proximal
colon IBD 10-15% of hematochezia caused by upper GI bleed
History NSAIDs & ASA strongly associated with lower GI
bleeding just as with upper GI bleeding Stercoral ulcers caused by severe constipation Recent polypectomy Hypovolemia preceding bleed suggests ischemic
colitis
Going Hunting
Going Hunting
Bleeding source not found in 25% KUB to look for perforation or obstruction NG aspirate Colonoscopy
No agreement over whether prep is needed because of increased risk of perforation with unpreped colon
Radionuclide imaging Can detect slow bleeds at 0.1-0.5ml/min More sensitive but less specific than angiography
Going Hunting
Angiography Requires bleeding of at least 1ml/min Very specific but not very sensitive May cause bowel infarction, renal failure
Small bowel evaluation Push enteroscopy can allow evaluation of the first 60cm of
jejunum Video capsule to evaluate the remainder Meckel scan
Strategy with Lower GI bleeding
If persistently unstable and major bleeding, proceed to surgery If colonic source, subtotal colectomy with ileorectal
anastomosis If small bowel source, resection If no identified source, intraoperative enteroscopy followed
by resection If stable and major bleeding
Tagged red cell scan If positive, follow with angiography If negative, capsule endoscopy, enteroclysis, enteroscopy
Strategy with Lower GI bleeding
If stable and minor bleeding Colonoscopy If negative, capsule endoscopy, enteroclysis, enteroscopy
If all studies negative Colonoscopy if rebleeding
Don’t Forget In addition to basic labs (CBC, Chemistries, Coags),
obtaining type and cross Two large bore peripheral IV’s Rectal exam as up to 40% of rectal cancers can be
detected this way
References Bounds, BC and PB Kelsey. Lower Gastrointestinal Bleeding. Gastrointestinal Endoscopy
Clinics of North America. 2007: 17, 273-88. Townsend: Sabiston Textbook of Surgery. 18th ed.