Lower GIT Bleeding

Question 1

What is lower GI bleeding?

Answer 1

Bleeding that occurs distal to the ligament of Treitz
Note:
Normal fecal blood loss 1.2ml / day
Significant - > 10ml/ day
- Range from scant bleeding to massive hemorrhage

Question 2

Incidence?

Answer 2

20-30% of episodes of GI hemorrhage
- Incidence rises steeply with age

Question 3

Common source of lower GI bleeding?

Answer 3

colon
> 80 - 85% originate distal to ileocecal valve
> Only 0.7% to 9% originate from small intestines
Note:
80 % LGIB resolve spontaneously
- 20% will re-bleed

Question 4

Presentation?

Answer 4

1. Hematochezia
   blood passing from rectum to anus
   - Range from bright-red blood to old clots
2. Melena
   Black, tarry stools
   - Bleeding is slower or from a more proximal source

Question 5

Categorisation?

Answer 5

intensity
1. Massive bleeding
2. Moderate Bleeding
3. Occult Bleeding

Question 6

Presentation of massive bleeding?

Answer 6

Presents as large volume of bright red blood PR
- Bleeding > 1.5L/day

Question 7

Signs and symptoms of massive bleeding?

Answer 7

1. Hemodynamic instability and shock
2. ↓ hematocrit level of 6g/dl or less

Question 8

Treatment for massive bleeding?

Answer 8

Transfusion of at least 2 units of packed red blood cells/whole blood

Question 9

Common causes of massive bleeding?

Answer 9

Common causes – D/A

Question 10

Epidemiology of massive bleeding?

Answer 10

Massive hemorrhage common in patients > 65 yrs with multiple medical problems

Question 11

Presentation of moderate bleeding?

Answer 11

1. hematochezia
2. malena

Question 12

Sign and symptoms of moderate bleeding?

Answer 12

1. Hemodynamically stable
2. Initial ↓in hematocrit level of 8g/dL or less

Question 13

Describe occult bleeding?

Answer 13

• Occurs in the absence of overt bleeding and identified on lab test
• Detected by routine chemical tests of the stool, with or without systemic evidence of chronic blood loss
  > Investigating for Iron deficiency anaemia
• 10ml. of blood loss is necessary to have stool occult blood positive

Question 14

Inflammatory aetiology?

Answer 14

1. Ulcerative colitis
2. Crohn’s disease
3. infective colitis

Question 15

Vascular aetiology?

Answer 15

1. Ischemic colitis
2. angiodysplasia
3. hemangioma

Question 16

Neoplastic aetiology?

Answer 16

1. Adenoma
2. carcinoma
3. polyps

Question 17

Clotting disorder aetiology?

Answer 17

1. Hemophilia
2. Warfarin therapy Leukemia
3. DIC

Question 18

Congenital aetiology?

Answer 18

1. Polyp
2. Meckel’s diverticulum

Question 19

Miscellaneous aetiology?

Answer 19

1. Hemorrhoids
2. anal fissure
3. injury to rectum

Question 20

What is an anal fissure?

Answer 20

Tear in the lining of the rectum caused by passage of hard stools

Question 21

Signs and symptoms of an anal fissure?

Answer 21

Sharp knife-like pain and bright red rectal bleeding with bowel movements

Question 22

Management of anal fissure?

Answer 22

Medical :
1. stool bulking agents
2. ↑water intake
3. stool softeners
4. topical nitroglycerin ointment or diltiazem to relieve sphincter spasm and promote healing

Question 23

What are hemorrhoids?

Answer 23

Cushions of submucosal tissue containing venules, arterioles and smooth muscle fibres located in anal canal

Question 24

Location of hemorrhoids?

Answer 24

1. left lateral
2. right anterior
3. right posterial

Question 25

Function of hemorrhoids?

Answer 25

act as part of continence mechanism aid in complete closure of anal canal at rest - Normal part of anorectal anatomy Note: Rx required if symptomatic

Question 26

Risk factors for hemorrhoids?

Answer 26

1. excessive straining 2. ↑abd pressure 3. hard stools Note: can cause painless bright red rectal bleeding with bowel movements

Question 27

Types of hemorrhoids?

Answer 27

1. External - distal to dentate line - covered with anoderm 2. Internal - proximal to dentate line - covered by anorectal mucosa > Prolapse and bleed > Rarely painful unless thrombosis & necrotic, severe prolapse incarceration and/or strangulation

Question 28

How do you grade hemorrhoids?

Answer 28

extent of prolapse 1. 1st degree - no prolapse, just prominent vessels 2. 2nd degree - prolapse (come out) with strain but spontaneously reduce (go back in) 3. 3rd degree - prolapse with strain and have to be pushed back in 4. 4th degree - prolapsed out and cannot be reduced or pushed back in

Question 29

Management of hemorrhoids?

Answer 29

1. Dietary fibre 2. Stool softner 3. ↑ fluid intake 4. Avoidance of straining 5. Dietary fibre 6. Stool softner 7. ↑ fluid intake 8. Avoidance of straining

Question 30

What is Hemorrhoidectomy?

Answer 30

Required for large, symptomatic, combined hemorrhoids

Question 31

Inflammatory bowel disease?

Answer 31

1. Ulcerative colitis 2. Crohns Disease 3. Indeterminate colitis

Question 32

Incidence of IBD?

Answer 32

Common in US, Northern Europe Incidence lower : Africa, Asia, South America Common in the 3rd and 7th decade

Question 33

Causes of IBD?

Answer 33

1. Environment 2. genetic 3. immunological/multifactorial

Question 34

Presentation of IBD?

Answer 34

Characterized by intestinal Inflammation

Question 35

What is Ulcerative colitis?

Question 36

Mucosal ulcerative colitis?

Answer 36

- colonic mucosa and sub-mucosa are infiltrated with inflammatory cells - Mucosa may be atrophic, crypt abscesses are common

Question 37

Endoscopic ulcerative collitis?

Answer 37

mucosa is frequently friable and may possess multiple inflammatory pseudocyst

Question 38

Long standing colitis?

Answer 38

colon is foreshortened and mucosa replaced by scar

Question 39

Ulcerative colitis may affect what?

Answer 39

1. Rectum – Proctitis 2. Rectum & sigmoid – proctosigmoiditis 3. Rectum & Left colon – Left sided colitis 4. Rectum & varying length of colon (extending proximal to splenic flexure) – pancolitis

Question 40

Signs and symtoms?

Answer 40

Symptoms related to - degree of mucosal inflammation, extent of colitis

Question 41

Typical presentation of ulcerative colitis?

Answer 41

1. bloody diarrhea 2. crampy abdominal pain

Question 42

Proctitis?

Answer 42

tenesmus `

Question 43

Fulminant colitis?

Answer 43

severe abd pain and fever

Question 44

Physical findings in ulcerative colitis?

Answer 44

range from minimal abd tenderness to frank peritonitis

Question 45

Diagnosis of ulcerative colitis?

Answer 45

colonoscopy and mucosal biopsy 1. U/C key feature : involvement of rectum & rectum 2. Rectal sparing or skip lesions : Crohn’s disease

Question 46

What is Crohns Disease?

Answer 46

Trans mural inflammatory disease Affect any part of GI: mouth to anus - Chronic inflammation → fibrosis, stricture & fistula → colon/small intestines

Question 47

Pathologic findings of Crohns disease?

Answer 47

1. mucosal lacerations 2. inflammatory cell infiltrates 3. noncaseating granulomas

Question 48

Endoscopic appearance of Crohns disease?

Answer 48

1. Deep serpiginous ulcer 2. “cobblestone” appearance 3. Skin lesions 4. Rectal sparing

Question 49

Symptoms of Crohns disease?

Answer 49

depend on severity of inflam. and/or fibrosis & location of inflammation 1. Acute inflammation - bloody diarrhea, crampy abd pain, fever 2. Stricture - symptoms of obstruction 3. Weight loss from obstruction + protein loss 4. Perianal Crohn’s - pain, swelling and drainage from fistulas/abscesses

Question 50

What is infective colitis?

Answer 50

Pseudomembranous colitis caused by C. difficile ( gram –ve anaerobic bacillus)

Question 51

Presentation of infective colitis?

Answer 51

1. diarrhea (bloody or non-bloody) 2. crampy abd pain, 3. malaise

Question 52

Stool analysis for infective colitis?

Answer 52

identify microorganism

Question 53

What is diverticular disease?

Answer 53

outpouchings that project from the bowel wall - Their development is caused by decreased fibre diet.

Question 54

Diverticulosis?

Answer 54

presence of diverticular without inflammation

Question 55

Diverticulitis?

Answer 55

Inflam. & infection associated with diverticular