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Snapshot
  • A 70-year-old man with a history of type 2 diabetes, diverticulosis, and hemorrhoids presents to the emergency room after an episode of syncope in the setting of a bloody bowel movement. He had gone to the bathroom and saw bright red blood in his stool. After standing up, he felt lightheaded and had to sit down on the floor. He is accompanied by his family members. His blood pressure is 110/70 mmHg and his pulse is 80/min. He is scheduled for a colonoscopy.
Introduction
  • Overview
    • lower gastrointestinal bleed results from bleeding from the colon or rectum
  • Epidemiology
    • incidence
      • very common
    • epidemiology
      • elderly patients with comorbid conditions
    • risk factors
      • diverticulosis
      • angiodysplasia
      • ischemic colitis
      • neoplasm
      • inflammatory bowel disease
      • infection
        • Salmonella
        • Shigella
      • hemorrhoids
      • anal fissure
  • Pathogenesis
    • mechanism
      • depends on the etiology
  • Prognosis
    • can be inconsequential or life-threatening
Presentation
  • Symptoms
    • common symptoms
      • rectal bleeding
        • hematochezia
          • bright red (originating from left side of colon)
          • maroon blood (originating from right side of colon)
        • has the potential to be fatal and cause massive hemorrhagic shock
        • fecal occult blood test is positive
      • a fever may indicate infectious etiology
      • painless bleeding may indicate angiodysplasia or diverticular bleeding
      • abdominal pain may indicate ischemic colitis
  • Physical exam
    • inspection
      • dehydration
Imaging
  • Radionuclide scan 
    • indications
      • often performed before angiography as it is not invasive and a negative result negates a need for further invasive procedures
      • high sensitivity
  • Angiography
    • indications
      • hemodynamically unstable patients
      • if colonoscopy does not reveal a bleeding site in hemodynamically stable patients
      • can also be therapeutic
Studies
  • Serum labs
    • complete blood count
    • serum electrolytes
    • coagulation studies
  • Invasive studies
    • colonoscopy/anoscopy/sigmoidoscopy 
      • indication
        • first-line for patients who are hemodynamically stable
        • patients require bowel preparation  
        • can also be used therapeutically for hemostasis
        • in patients > 40 years of age, must rule out malignancy with colonoscopy
Differential
  • Upper gastrointestinal bleed
    • key distinguishing factor
      • source of bleeding from stomach or small intestine
      • may also present as bright red blood if there is rapid hemorrhage
Treatment
  • Medical
    • resuscitation 
      • modalities
        • large-bore intravenous access
        • crystalloid fluid replacement
        • blood transfusions if needed
  • Surgical
    • colonoscopy/anoscopy/sigmoidoscopy
      • indication
        • both diagnostic and therapeutic
        • colonoscopy specifically for all patients over 40 to rule out malignancy
      • modalities
        • hemostasis via
          • coagulation, i.e., electrocoagulation
          • clip placement
    • angiography
      • indication
        • both diagnostic and therapeutic
        • used when colonoscopy is unrevealing or contraindicated
        • hemodynamically unstable patients
      • modalities
        • embolization
        • vasopressin drip
    • surgical exploration
      • indication
        • hemodynamically unstable patients refractory to resuscitation
        • persistent or recurrent bleeding
Complications
  • Death
  • Shock
 

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