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  • General SurGery Board review Manual

    Lower Gastrointestinal Bleeding

    Volume9Part3 November2010

    Part 3 Available Online

    at no cost to youwww.turner-white.com/

    brm/bgene.htm

  • The preparation and distribution of this publication are made possible through the support of

    The content of this text represents the independent opinions of the authors and is not necessarily that of Pfizer Inc. Health care professionals should consult

    full prescribing information before prescribing any product.

    The Hospital Physician General Surgery Board Review Manuals are published by Turner White Communications, Inc., an independent medical publisher

    dedicated to serving the information and education needs of clinical trainees and practicing physicians.

  • 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.

    PuBliSHinG Staff

    PRESIDENT, GRouP PuBLISHERBruce M. White

    SENIoR EDIToR Robert Litchkofski

    ExEcuTIvE vIcE PRESIDENTBarbara T. White

    ExEcuTIvE DIREcToR of oPERaTIoNS

    Jean M. Gaul

    PRoDucTIoN DIREcToRJeff White

    Copyright 2010, Turner White Communications, Inc., Strafford Avenue, Suite 220, Wayne, PA 19087-3391, www.turner-white.com. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, electronic, photocopying, recording, or otherwise, without the prior written permission of Turner White Communications. The preparation and distribution of this publication are supported by sponsorship subject to written agreements that stipulate and ensure the editorial independence of Turner White Communications. Turner White Communications retains full control over the design and production of all published materials, including selection of topics and preparation of editorial content. The authors are solely respon-sible for substantive content. Statements expressed reflect the views of the authors and not necessarily the opinions or policies of Turner White Communications. Turner White Communications accepts no responsibility for statements made by authors and will not be liable for any errors of omission or inaccuracies. Information contained within this publication should not be used as a substitute for clinical judgment.

    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

    Table.of.Contents

    gEnERal.SuRgERy.BOaRD.REvIEw.Manual

    lower.gastrointestinal.Bleeding

    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

    www .hpboardreview .com. general.Surgery..Volume 9, Part 3

  • 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

    IntroductIon

    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?

    Initial Management

    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

  • www.hpboardreview.com General Surgery Volume 9, Part 3

    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