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Lower gastrointestinal bleeding
Classification and external resources
ICD-10 K92.2
ICD-9 578.9
eMedicine radio/301

Lower gastrointestinal bleeding, commonly abbreviated LGIB, refers to any form of bleeding in the lower gastrointestinal tract. LGIB is a common ailment seen at emergency departments.[1] It presents less common than Upper Gastrointestinal bleeding. It is estimated that UGIB account for 100-200 per 100,000 cases verse 20-27 per 100,000 case for LGIB.[2] Approximately 85% of Lower gastrointestinal bleeding invlves the colon, 10% are from bleeds that are actually Upper gastrointestinal bleeds, and 3 - 5% involve the small intestines.[3] The mortality rate for LGIB is between 2-4%.[2]

Contents

Clinical presentation

A lower Gastrointestinal Bleed is referred as any bleed that occures distal to the ligament of Treitz and superior to the anus. This includes the last 1/4 of the duodenum and the entire area of the jejunum, ileum, colon, rectum, and anus.[1]

The stool of a person with a lower gastrointestinal bleed is a good not infallible indication of where the bleeding is occurring. Black tarry appearing stools medically referred to as Melena usually indicates blood that has been in the GI tract for at least 8 hours.[1] Melena is four-times more likely to come from an upper gastrointestinal bleed than from the lower GI tract; however, it can also occur in either the duodenum and jejunum, and occasionally the portions of the small intestine and proximal colon.[4] Bright red stool, called hematochezia, is the sign of a fast moving active GI bleed.[1] The bright red or Maroon color is due to the short time taken from the site of the bleed and the exiting at the anus. The presence of hematochezia is six-times greater in a LGIB than with a UGIB.[4]

Occasionally, a person with a LGIB will not present with any signs of internal bleeding. In these cases, a diagnostic assessment or pre-assessment should watch for other signs and symptoms that the patient may present with. These include, but are not limited to, hypotension, tachycardia, angina, syncope, weakness, confusion, stroke, myocardial infarction, shock, and heart attack.

Differential diagnosis

A differential diagnosis is a systematic method used to identify unknowns. With the use of a differential diagnosis, physicians or other clinicians begin to rule out what the illness is not to narrow the diagnosis of the specific disease process,[5] as with a lower gastrointestinal bleed.

Diagnosis

Diverticular disease - a cause of LGIBs.

The following are possible diagnosis of a LGIB:

Hemorrhoids are a common occurrence; however, rarely they have been known to rupture and result in a massive hemorrhage. Causes for this include frequent or chronic constipation, straining to have a bowel movement, diets low in fiber, and pregnacy. It may present with small amounts of bright red bleeding.

Anal fissures

Rectal foreign bodies

Ulcerative colitis

Crohn's disease

Pseudomembranous colitis

Infectious diarrhea

Radation colitis

Diverticulosis

Mesenteric ischemia

colonic polyps

colon cancer

Causes

Evaluation

Evaluations will most often be conducted by either a clinic triage nurse, emergency department nurse, and/or a physician or other clinican. The initial assessment will include the appearance of the individual, their vital signs, and mental status. A patient history will help reveal a disposition or history of LGIBs or potential differential diagnosis.

Orthostatic vital signs are often used as a indicator of hypovolemia.

Laboratory test will also help give indications of a LGIB. Hemoglobin, hematocrit, and platelets are very good physical signs of hypovolemia or blood loss amenia. Partial thromboplastin time (PTT) and INR will also help determine the bodies current ability to clot.

Aspiration of the stomach contents by way of a nasogastric tube (NG tube) will help differentiate between either a UGIB and a LGIB. A negative presence of blood will help to rule out an UGIB.

Management

Basic algorithm for the management of lower GI bleed.

If a patient is suspected of having severe blood loss they will most likely be placed on a vital sign monitor and administered oxygen either by nasal cannula or simple face mask. An intravenous catheter will be placed into an easily accessible area and IV fluids will be administered to replace lost volume.[1]

Surgical intervention is warranted in some cases. It is most likely that a sugical consult will be ordered if the patient is unable to be stabilized by non-invasive techniques, or a perforation is found that requires surgery.[1]

Disposition

See also

References

  1. ^ a b c d e f Allan B. Wolfson, ed (2005). Harwood-Nuss' Clinical Practice of Emergency Medicine (4th ed.). pp. 349–352. ISBN 0-7817-5125-X.  
  2. ^ a b Farrell, JJ; Friedman (2001). "30". Gastrointestinal bleeding in the elderly. LS. Gastroentrol clin North Am. pp. 377–407.  
  3. ^ Dutta, Gautam; Panda, Mukta (2008-10-13). "An uncommon cause of lower gastrointestinal bleeding: a case report". BioMed Central Ltd. http://casesjournal.com/content/1/1/235. Retrieved 11 December 2009.  
  4. ^ a b Peura, DA; Lanza, FL, Goustout CJ, et al (1997). Am J Gastroenterol. Bleeding Registry: The American College of Gastroenterology. pp. 924.  
  5. ^ Merriam-Webster's Medical Dictionary. Merriam-Webster, Inc. 12 Aug. 2007. Dictionary.com

External links








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