Antonio. Aramburo. Arcilla. Argana Approach to a Patient with Lower GI Bleeding

Patient L. Q. 78 y/o Female Chief Complaint: Hematochezia

Salient Features: Chief Complaint: Hematochezia 6 hours PTA- ½ teaspoon of blood after defecation 4 hours PTA- 1 tablespoon of blood 30 mins PTA- 2 cupfuls of fresh blood -Dizzy, cold clammy perspiration

Approach to the Patient: Lower Gastrointestinal Bleeding Measure the heart rate and blood pressure

Approach to the Patient: Lower Gastrointestinal Bleeding Differentiation of upper from lower GIB Hematemesis- indicates upper GI source of bleeding Hematochezia- usually represents lower GI source of bleeding

Approach to the Patient: Lower Gastrointestinal Bleeding Diagnostic Evaluation of the Patient with Lower GIB Upper endoscopy – to rule out an upper GI source before evaluation of lower GI tract -Patients with hematochezia and hemodynamic instability

Diagnostic Evaluation of the Patient with Lower GIB Sigmoidoscopy for patients <40 years old with minor bleeding for detection of obvious, low-lying lesions risk of bleeding, area of bleeding is usually not possible to identify

Diagnostic Evaluation of the Patient with Lower GIB Colonoscopy- procedure of choice

Diagnostic Evaluation of the Patient with Lower GIB Tc-labeled red cell scan -allows repeated imaging for up to 24 hours - may identify the general location of bleeding

Diagnostic Evaluation of the Patient with Lower GIB Angiography - can detect the site of bleeding - permits treatment with intraarterial infusion of vasopressin or embolization - may identify lesions with abnormal vasculature, such as tumors or vascular ectasias

Figure 1.1 Suggested algorithm for patients with acute lower gastrointestinal bleeding

Differential Diagnosis Common causes of LGIB Diverticula Vascular ectasia (Angiodysplasia) Neoplasms (Adenocarcinoma)

HISTORY OF PRESENT ILLNESS  Patient passed out approximately half a teaspoon of blood after defecation  Mild abdominal discomfort 6 hours PTA

HISTORY OF PRESENT ILLNESS  The patient again passed out approximately 1 tbsp of blood  Patient was apparently well 2 hours PTA

HISTORY OF PRESENT ILLNESS  The patient passed out approximately 2 cupfuls of fresh blood  Patient felt dizzy and had cold clammy perspiration  Patient was rushed to the ER  Patient was pale, weak but not in distress  Supine BP: 110/80, HR: 90 beats/min  Sitting BP: 90/60, HR: 110 beats/min  Abdomen: symmetrical, flabby, non-tender, no palpable masses, no organomegaly  Rectal exam: fresh blood on examining finger Thirty minutes PTA Admission

Past Medical History Known diabetic and hypertensive On insulin and losartan, taking 80 mg ASA/day and clopidogrel 19 pack year smoking history Denies alcohol intake

Past Medical History Has been constipated for several years Intermittently takes bisacodyl to relieve constipation Family history: (-) malignancy