Acute Lower GI Bleeding - Diagnosis and Management ...
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Description

Acute Lower GI Bleeding - Diagnosis and Management Summary

Definition: bleeding distal to ligament of Treitz resulting in vital sign instability, anemia and/or need for blood transfusion

Symptoms: hematochezia (maroon colored stools, bright red blood, or blood clots) or less commonly melena (generally requires that blood spends 14 hr in the GI tract)

 o Stool appearance is a poor indicator of GI bleeding source - hematochezia can also be seen with brisk UGIB (suspect if pt is hemodynamically unstable)

 o Anorectal/L colon: Bright red blood

 o R colon: Maroon colored stools, melena possible if slow colonic transit

 o Bleeding will stop spontaneously in 80-85%

Diagnosis:

 o Exonerate UGIB source first (signs include orthostatic HoTN, hemodynamic instability, BUN:Cr >20-30 without CKD)

 o Consider NGT placement if there is moderate suspicion for UGIB (~15% of hematochezia is UGIB)

      • Coffee-ground material, bright red blood → EGD

      • No blood or bile seen: Indicates indeterminate source → consider EGD before Colonoscopy

      • Bilious fluid: No active UGIB source → Colonoscopy

Management:

 o Transfusion goals: Hgb >7 (consider >8 in active CAD), Plt >50k, INR <1.5 (INR 1.5-2.5 ok to perform endoscopic hemostasis before reversing; INR >2.5 consider using reversal agent)

 o Diverticular hemorrhage, angioectasia, post-polypectomy bleeding, and hemorrhoids amenable to endoscopic treatment

 o IF HEMODYNAMICALLY STABLE: Prep for colonoscopy (after discussion with GI)

     • If ongoing bleeding or high risk perform within 24hr

     • Use order set in EPIC

     • OK to place NG tube for high-risk patients with ongoing bleeding who are intolerant of prep (if no known h/o varices)

     • Urgent colonoscopy (within 12hr) improves localization but not mortality

     • No data to suggest bowel prep increases or reactivates bleeding

 o IF HEMODYNAMICALLY UNSTABLE: EGD to r/o UGIB, IR and surgical consult (“blind” surgery mortality ~29%), massive transfusion protocol



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