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General SurGery Board review Manual
Lower Gastrointestinal Bleeding
Part 3 Available Online
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Statement of editorial PurPoSe
The Hospital Physician General Surgery Board Review Manual is a study guide for residents and practicing physicians preparing for board examinations in general surgery. Each manual reviews a topic essential to current practice in the specialty of general surgery.
PRESIDENT, GRouP PuBLISHERBruce M. White
SENIoR EDIToR Robert Litchkofski
ExEcuTIvE vIcE PRESIDENTBarbara T. White
ExEcuTIvE DIREcToR of oPERaTIoNS
Jean M. Gaul
PRoDucTIoN DIREcToRJeff White
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NoTE fRoM THE PuBLISHER:This publication has been developed without involvement of or review by the American Board of Surgery.
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Evaluation.and.Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Surgical.Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Postpolypectomy.Bleeding. . . . . . . . . . . . . . . . . . . . . . . . . 6
Obscure.Hemorrhage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Summary.Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Series.Editor.and.Contributor:C ..neil.Ellis,.MDSystem Chair, Division of Colon and Rectal Surgery, West Penn Allegheny Health System, Pittsburgh, PA
Contributors:Jennifer.D ..Silinsky,.MDDepartment of Colon and Rectal Surgery, The Ochsner Clinic Foundation, New Orleans, LA
David.a ..Margolin,.MD,.FaCS,.FaSCRSDirector of Colon and Rectal Research, Department of Colon and Rectal Surgery, The Ochsner Clinic Foundation, New Orleans, LA
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Hospital Physician Board Review Manual www.hpboardreview.com
GeneRal SuRGeRy BoaRd Review Manual
lower Gastrointestinal BleedingJennifer d. Silinsky, Md, david a. Margolin, Md, FaCS, FaSCRS, and C. neil ellis, Md
Lower gastrointestinal bleeding (LGIB) is defined as any bleeding that originates distal to the ligament of Treitz. The incidence of LGIB in the United States is 20 to 27 cases per 100,000 persons per year. It occurs more commonly in men than women and with increas-ing frequency among the elderly. There is a 200-fold increase in risk of LGIB from the third decade to the ninth decade of life.1 Furthermore, patients increas-ingly are being treated with long-term anticoagulation/ antiplatelet therapy, which can increase a patients risk of developing LGIB by 22%.2
The patients description of the amount of hemor-rhage can be misleading, since it takes only a small amount of blood in the commode to discolor the water. Patients can have small amounts of blood mixed with mucous or stool, or they can experience large amounts of brisk bleeding. The history does not accurately pre-dict the outcome of the bleeding. Some patients will stop bleeding after their first episode, while others will continue bleeding, leading to significant blood loss. For most patients, however, the bleeding will resolve sponta-neously with only supportive care, and in the majority of cases, the actual site of bleeding will never be localized.
It is important to understand as a clinician that as many as 10% to 15% of patients with LGIB symptoms will have an upper gastrointestinal source of bleeding.3 The difficulty with management of LGIB is that bleed-ing can occur at any site throughout the gastrointestinal tract and may commonly be intermittent. If managed inappropriately, a patient may undergo surgery without localization of the bleeding source and after resection continue to bleed.4
EVALuAtIon And dIAGnoSIS
cASE pAtIEnt 1
A 57-year-old man with a history of hyperten-sion and hyperlipidemia presents for evalua-
tion following 3 episodes of passing bright red blood from his rectum. The last episode occurred about 20 minutes prior to presentation, with several cups of bright red blood being expelled. He occasionally takes an aspirin and has never had a colonoscopy or experi-enced similar symptoms. He has associated lighthead-edness and dizziness on standing. His blood pressure is 90/62 mm Hg and his pulse is 92 bpm in the supine po-sition. His blood pressure decreases to 72/48 mm Hg and his heart rate increases to 118 bpm upon sitting up. His hypertension is managed using an angiotensin- converting enzyme inhibitor. He denies any use of nonsteroidal anti-inflammatory medications (NSAIDs). The remainder of his history and physical examination is unremarkable.
what should be the first steps in the management of this patient?
The ABCs of resuscitation (airway, breathing, circu-lation) should be the first steps in managing any patient who is actively hemorrhaging. Two large-bore intra-venous lines should be placed, and vital signs should be monitored frequently along with orthostatic blood pressures. Foley catheter placement is encouraged to ensure adequate urine output. Laboratory evaluation should include a hemoglobin and hematocrit, type and cross-matching of at least 2 units of packed red blood cells, and coagulation studies, as well as an electrolyte panel with liver enzymes in the event the patient has a history of hepatic dysfunction. Once adequate resus-citation and correction of any clotting abnormalities have been initiated, the patient can be further evalu-ated to determine the source of bleeding.
A nasogastric tube should be placed and gastric lavage performed since 11% to 17% of patients with LGIB symptoms can have an upper gastrointestinal source of bleeding.3 Bilious return should be achieved before the lavage is considered adequate. If no upper gastrointestinal source of bleeding is found, the na-sogastric tube can be removed. The anus and rectum should be examined closely with anoscopy and rigid
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L o w e r G a s t r o i n t e s t i n a l B l e e d i n g
proctoscopy. The mucosa should be evaluated for any evidence of bleeding internal hemorrhoids, ulcers, neo-plasms, or colitis. This is very important because if the rectum is normal and subsequent surgery is required, a rectal anastomosis would be a valid treatment option. If an anal or rectal source of bleeding is identified, it can generally be treated at the time of identification.
cASE 1 contInuEd
The patients vital signs improve after admin-istration of 2 L of intravenous normal saline.
Laboratory testing is significant for a hemoglobin of 7.5 g/dL and a platelet count of 250,000 cells/L. The remainder of the laboratory values, including coagula-tion studies, are within normal limits. The patient is transfused with 2 units of packed red blood cells. There is no clinical evidence of ongoing hemorrhage.
what diagnostic tests can be performed to localize the site of bleeding?
diagnostic testing for LGIB
It is first helpful to categorize patients based on the history and physical examination. Does the patient have LGIB that is (1) minor and self-limited, (2) major and self-limited, or (3) major and ongoing? If the bleeding is only minor and appears to be resolving, observation and subsequent colonoscopy may be all that is needed. Patients who experience massive amounts of ongoing hemorrhage with hemodynamic instability may require prompt surgical intervention. The area of controversy am