LOWER GASTROINTESTINAL TRACT BLEEDING
Section snippets
Chief Complaint.
"I am passing blood from below."
A 79-year-old black woman complains of bright red blood in her rectum since yesterday morning. She complains of slight abdominal cramping just before moving her bowels but then admits to slight cramping before every bowel movement. She is currently pain free. There is a history of rectal bleeding 1 year ago, with admission and transfusion of several units of blood. Workup in the hospital included "endoscopy," but she does not know what the findings were. She
WHERE DO WE GO FROM HERE?
Lower GI tract bleeding is defined as a bleeding source below the ligament of Trietz. Lower GI bleeding usually causes hematochezia, or bright red blood per rectum, but in unusual circumstances hematochezia may result from massive upper GI bleeding with rapid transit times through the gut due to a cathartic effect of the blood. Hematochezia has been described as caused by posterior epistaxis but usually means a source below the ligament of Trietz. Upper GI bleeding usually has associated
HISTORICAL FACTORS
Many patients give dramatic histories of "passing huge clots" or "filling the toilet full of blood." Any bleeding event can provoke anxiety in patients, particularly expelling blood from the rectum. These historical facts are of little clinical utility and should be recorded but given little importance. Some historicalfactors are important and give clues to the possible underlying causes of bleeding.
Recent weight loss and altered bowel habits are touted as helpful historical factors,29 but many
PHYSICAL EXAMINATION
Immediate action is needed for the patient with lower GI bleeding and obvious abnormalities in vital signs such as hypotension, tachycardia, or orthostatic vital signs. The experienced emergency physician recognizes that patients may tolerate massive volume losses with minimal changes in vital signs. Vital signs may change rapidly with ongoing blood loss. Orthostatic postural hypotension is helpful if present, but its absence does not rule out lower GI blood loss. Underlying disease and
RESUSCITATION
Patients believed to have acute lower GI bleeding warrant immediate resuscitation. These patients are frequently older with coexistent medical problems that challenge medical judgment. Lower GI bleeding can be fatal, and fear of complicating other medical problems must be suppressed. All patients require at least one large-bore intravenous catheter. If the patient is tachycardic, hypotensive, or appears volume depleted or unstable, two large-bore catheters should be inserted for vigorous
LABORATORY EVALUATION
As intravenous catheters are being placed, blood should be drawn to avoid further venipuncture. Reasonable beginning laboratory evaluation should include hemoglobin and hematocrit as well as platelet counts to assess baseline blood loss and platelet adequacy. In reality, most consultants will want a full complete blood count with differential, but unless inflammatory bowel disease is suspected, hemoglobin and hematocrit reading will suffice. Electrolytes, blood urea nitrogen, creatinine, and
DIFFERENTIAL DIAGNOSIS
The most common cause of lower GI bleeding is an upper GI source.24 ED evaluation should include a posterior pharyngeal examination for blood and a nasogastric tube insertion searching for blood or coffee ground-like material in the stomach. When the results of these evaluations are negative, the bleeding source can be assumed to be below the ligament of Trietz.
The two most common causes of acute lower GI bleed are diverticulosis and vascular malformation. It is important to remember that 80%
CASE SUMMARY
Our case presentation was typical for an elderly woman presenting with a lower GI bleed. She was relatively stable in the ED and was admitted to a monitored bed. Colonoscopy revealed angiodysplasia at the splenic flexure, which was ablated with cautery. She did not require transfusion. The nonsteroidal anti-inflammatory agent was discontinued. She has had no recurrence or rebleed.
SUMMARY
Lower GI bleeding can be slow and chronic or massive and fatal. ED evaluation of these patients begins with history directed at determining theseverity and amount of bleeding, and eliciting symptoms of volume depletion. Physical examination determines orthostasis, exclusion of an upper GI source for bleeding, and rectal examination. Laboratory evaluation is directed at determining baseline status of hemoglobin/hematocrit and platelet adequacy, as well as assessing concomitant medical problems.
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Address reprint requests to Michael J. Bono, MD, FACEP Department of Emergency Medicine Raleigh Building, Room 206 600 Gresham Drive Norfolk, VA 23507–1999
The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the US Government.