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LMS Education created by Mike Stinson

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GASTROINTESTINAL HEMORRHAGE (Lower G.I. Bleeds): 

GASTROINTESTINAL HEMORRHAGE (Lower G.I. Bleeds)

Classifications: 

Classifications Lower G.I. Bleeds - occur below the Ligament of Treitz. *The Ligament of Treitz is a band of smooth muscle extending from the duodenum / jejunum junction to the diaphragm. It is a suspensory ligament.

PowerPoint Presentation: 

Upper GI Tract: (Proximal to the Ligament of Treitz) 70% of GI Bleeds Lower GI Tract: (Distal to the Ligament of Treitz) 30% of GI Bleeds

Signs and Symptoms of GI Bleed: 

Signs and Symptoms of GI Bleed Hematemesis / “coffee ground” emesis Melena—dark, tarry, foul-smelling stool Hematochezia—bright red blood per rectum Microcytic anemia Chronic fatigue—secondary to anemia Hypotension, tachycardia, mental status change—serious problem

Lower Gastrointestinal Bleeding: 

Lower Gastrointestinal Bleeding

Lower GI Bleed: 

Lower GI Bleed Defined by bleeding source distal to ligament of Treitz Mean age of presentation 63-77 y/o Can present with melena or bright red blood per rectum with or without clots 20% presents as acute “massive” bleeding Often more difficult to localize than UGI bleed

Lower GI Bleed—Acute Sources: 

Lower GI Bleed—Acute Sources Diverticulosis Angiodysplasia (AVM)—more common in >65 Ischemic colitis Meckel’s diverticulum Infectious colitis (C. diff, E. coli, campylobacter) IBD (ulcerative colitis>Crohn’s disease) Malignancy (rare cause of acute bleed)

Lower GI Bleed—Chronic Sources: 

Lower GI Bleed—Chronic Sources Malignancy (most common chronic LGI source) Benign small or large bowel polyps Angiodysplasia IBD Hemorrhoids Anal fissure

Lower GI Bleed—Work up: 

Lower GI Bleed—Work up History: Character and quantity of blood History of HTN, CAD, PVD (ischemic colitis) History of IBD Anticoagulation or coagulopathy

Lower GI Bleed—Work up: 

Lower GI Bleed—Work up Exam Look for abdominal masses Listen for bruits Rectal—masses, characterize blood, look for anal pathology such as hemorrhoids, fissures

Lower GI Bleed—Work up: 

Lower GI Bleed—Work up Laboratory Hgb/Hct (remember, may not reflect true blood volume with acute rapid bleed) PT/PTT—may need to correct coagulopathy Electrolytes—assess for dehydration, guide resuscitation Radiologic studies—CT may show thickening of bowel in case of mesenteric ischemia; diverticulosis usually easily identified.

Lower GI Bleed—Work up: 

Lower GI Bleed—Work up Rule out Upper GI bleed source! Follow initial steps in algorithm for UGI bleed Patient may need EGD for differentiation

Lower GI Bleed—Work up: 

Lower GI Bleed—Work up Colonoscopy Often 1 st maneuver Visualization difficult secondary to invariably poor prep

Lower GI Bleed—Work up: 

Lower GI Bleed—Work up Tagged RBC scan (nuclear medicine) 99mTc-pertechnaetate-labeled RBCs, IV injection Demonstrates bleeding source when rate of bleed=0.1-0.5ml/minute Allows repeated evaluation over course of 24 hours May not exactly localize source—may not be able to differentiate colon from small bowel Typically not used alone for localization

Lower GI Bleed—Work up: 

Lower GI Bleed—Work up Angiography Better for specific localization Sensitive for bleeding rate 0.5-1.5ml/minute Often requires large amount of contrast (monitor renal insufficiency) Can be therapeutic (embolization, vasopressin)

Lower GI Bleed—Work up: 

Lower GI Bleed—Work up Provocative Angiography When bleeding is recurrent and suspected to be from colonic source, can inject heparin and/or tPA Treatment then delivered immediately when bleeding discovered May require urgent trip to OR if angiographic therapy fails

Lower GI Bleed—Work up: 

Lower GI Bleed—Work up Capsule Endoscopy When unable to localize intermittent bleed via above methods, may be effective in defining source May be the only way to identify small bowel source

Lower Gastrointestinal Bleeding: 

Lower Gastrointestinal Bleeding Pathophysiology Bleeding distal to the ligament of Treitz Causes Diverticulosis Colon lesions Rectal lesions Inflammatory bowel disorders

Lower Gastrointestinal Bleeding: 

Lower Gastrointestinal Bleeding Signs & Symptoms Determine acute vs. chronic. Quantity/color of blood in stool. Abdominal pain Signs of shock.

Crohn`s Disease: 

Crohn`s Disease Pathophysiology Inflammatory bowel disease, ? Autoimmune etiology Can affect the entire GI tract. Pathologic inflammation: Damages mucosa. Hypertrophy and fibrosis of underlying muscle. Fissures and fistulas.

Crohn`s Disease: 

Crohn`s Disease

Crohn`s Disease: 

Crohn`s Disease

Crohn`s Disease: 

Crohn`s Disease Signs and Symptoms Difficult to differentiate. Clinical presentations vary drastically. GI bleeding, nausea, vomiting, diarrhea. Abdominal pain/cramping, fever, weight loss. Treatment Follow general treatment guidelines.

Diverticulitis: 

Diverticulitis Pathophysiology Inflammation of small outpockets in the mucosal lining of the intestinal tract. Common in the elderly. Diverticulosis. Signs & Symptoms Abdominal pain/tenderness. Fever, nausea, vomiting. Signs of lower GI bleeding. Treatment General treatment guidelines

Diverticulosis & Diverticulitis: 

Diverticulosis & Diverticulitis

Diverticuli: 

Diverticuli

Diverticulitis: 

Diverticulitis

Hemorrhoids: 

Hemorrhoids Pathophysiology Mass of swollen veins in anus or rectum. Idiopathic. Signs & Symptoms Limited bright red bleeding and painful stools. Consider lower GI bleeding. Treatment General treatment guidelines .

Internal & External Hemorrhoids: 

Internal & External Hemorrhoids

Hemorrhoids: 

Hemorrhoids

Ulcerative Colitis: 

Ulcerative Colitis

Ulcerative Colitis: 

Ulcerative Colitis

Irritable Bowel Syndrome (IBS): 

Irritable Bowel Syndrome (IBS)

Bowel Obstruction: 

Bowel Obstruction Signs & Symptoms Decreased Appetite, Fever, Malaise Nausea and Vomiting Diffuse Visceral Pain, Abdominal Distention Signs & Symptoms of Shock Treatment Follow general treatment guidelines.

Bowel Obstruction: 

Bowel Obstruction

Bowel Obstruction: 

Bowel Obstruction Pathophysiology Blockage of the hollow space of the small or large intestines Hernias

Bowel Obstruction: 

Bowel Obstruction Pathophysiology Occlusion of the intestinal lumen that results in blockage of the normal flow of intestinal fluids OR

Bowel Obstruction: 

Bowel Obstruction Pathophysiology Twisting of the bowel

Bowel Obstruction: 

Bowel Obstruction Pathophysiology Adhesions

Colon / Rectal Cancers: 

Colon / Rectal Cancers

Cutaneous & Subcutaneous Colon Metastasis : 

Cutaneous & Subcutaneous Colon Metastasis

Colon Cancer: 

Colon Cancer

Colon Cancer: 

Colon Cancer

Rectal Cancer: 

Rectal Cancer

Rectal Cancer: 

Rectal Cancer

Colon Polyp: 

Colon Polyp

Acute Lower GI Bleed—Treatment: 

Acute Lower GI Bleed—Treatment RESUSCITATION! Patient should be transferred to ICU setting Ensure large bore IV access, may need central line Aggressive hydration Place Foley catheter to monitor hydration and efficacy of resuscitation Type and cross for 4 units PRBCs Correct any coagulopathy Transfuse depending on Hgb/Hct and history of patient

Acute Lower GI Bleed—Treatment: 

Acute Lower GI Bleed—Treatment Colonoscopy Often unsuccessful due to difficulties in localization May be effective in situations such as sclerosis of AVM

Acute Lower GI Bleed—Treatment: 

Acute Lower GI Bleed—Treatment Angiography As in UGI bleed, embolization with coils or gelfoam, vasopressin injection 5-10% risk of bowel infarction

Acute Lower GI Bleed—Treatment: 

Acute Lower GI Bleed—Treatment Surgery Typically, segmental resection of small bowel or colon (NOT enterotomy and repair) Usually very dependent on preoperative localization In cases where localization not possible, can do on-table push enteroscopy to look past ligament of Treitz

Nursing Care of GI Bleeds: 

Nursing Care of GI Bleeds 1. Monitor for S&S of shock: (frequent VS) Low BP rapid, shallow respiration rapid, weak pulse cool, clammy skin decreased urinary output. 2. Monitor Hgb & Hct`s (every 6 hours) 3. IV access & fluid / blood administration.