logging in or signing up Lower_G.I._Bleed_PowerPoint MethodistCorpUniv Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Copy Does not support media & animations WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 372 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: August 20, 2012 This Presentation is Public Favorites: 2 Presentation Description LMS Education created by Mike Stinson Comments Posting comment... Premium member Presentation Transcript 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 BleedsSigns 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 problemLower Gastrointestinal Bleeding: Lower Gastrointestinal BleedingLower 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 bleedLower 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 fissureLower 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 coagulopathyLower 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, fissuresLower 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 differentiationLower GI Bleed—Work up: Lower GI Bleed—Work up Colonoscopy Often 1 st maneuver Visualization difficult secondary to invariably poor prepLower 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 localizationLower 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 failsLower 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 sourceLower Gastrointestinal Bleeding: Lower Gastrointestinal Bleeding Pathophysiology Bleeding distal to the ligament of Treitz Causes Diverticulosis Colon lesions Rectal lesions Inflammatory bowel disordersLower 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 DiseaseCrohn`s Disease: Crohn`s DiseaseCrohn`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 guidelinesDiverticulosis & Diverticulitis: Diverticulosis & DiverticulitisDiverticuli: DiverticuliDiverticulitis: DiverticulitisHemorrhoids: 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 HemorrhoidsHemorrhoids: HemorrhoidsUlcerative Colitis: Ulcerative ColitisUlcerative Colitis: Ulcerative ColitisIrritable 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 ObstructionBowel Obstruction: Bowel Obstruction Pathophysiology Blockage of the hollow space of the small or large intestines HerniasBowel Obstruction: Bowel Obstruction Pathophysiology Occlusion of the intestinal lumen that results in blockage of the normal flow of intestinal fluids ORBowel Obstruction: Bowel Obstruction Pathophysiology Twisting of the bowelBowel Obstruction: Bowel Obstruction Pathophysiology AdhesionsColon / Rectal Cancers: Colon / Rectal CancersCutaneous & Subcutaneous Colon Metastasis : Cutaneous & Subcutaneous Colon MetastasisColon Cancer: Colon CancerColon Cancer: Colon CancerRectal Cancer: Rectal CancerRectal Cancer: Rectal CancerColon Polyp: Colon PolypAcute 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 patientAcute 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 AVMAcute 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 infarctionAcute 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 TreitzNursing 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. You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.