Chapter 40 Lower GI Bleeding in a 71-Year-Old Male (Case 25)
| Diverticular bleed | Arteriovenous malformation (AVM) | Ischemic colitis |
| Colon cancer | Hemorrhoids | Upper GI bleed |
PATIENT CARE
History
• Assess the nature of the bleeding:
• Bright red on the tissue or dripping in toilet bowl after a bowel movement suggests an anal source.
Physical Examination
• Assess volume status with BP, HR, skin color, capillary refill, conjunctiva color, and mental status.
Tests for Consideration
| $35 | |
| $55 | |
| $45 | |
| $312 | |
| $175 | |
| $800 |
| Tagged RBC scan detects bleeding at 0.1 mL/min and is done first. | $450 |
| Angiography requires bleeding at 0.5 mL/min and should be done if the tagged RBC scan is positive. | $1,300 |
| Barium enema should only be considered if bleeding has ceased, since it may interfere with angiography, which may be required. | $350 |
| Clinical Entities | Medical Knowledge |
|---|---|
| Hemorrhoids | |
| PΦ | Hemorrhoids are soft tissue cushions in the anal canal with an arteriovenous plexus. Symptomatic hemorrhoids result from loosening of the supporting connective structure due to chronic straining. Other contributing factors include pregnancy, aging, chronic constipation or diarrhea, and anal intercourse. Enlargement and prolapse of internal hemorrhoids will commonly result in bleeding. |
| TP | Painless blood on the toilet paper or in bowel after defecation, protrusion of tissue out of the anal canal (prolapse). |
| Dx | Anoscopy. |
| Tx | Fiber supplements, rubber band ligation, injectable sclerosants, infrared coagulation, surgical hemorrhoidectomy. Tx depends on stage. See Sabiston 46, 51; Becker 21. |
| Diverticular Bleeding | |
| PΦ | Colonic diverticulosis consists of false diverticuli with herniation of mucosa through the colonic muscle wall. This happens at weak points where blood vessels penetrate the muscle wall. Bleeding occurs with disruption of the penetrating vessels into the lumen of the diverticulum. Bleeding can occur in up to 20% of people with diverticulosis and is usually in the right colon. Up to 80% of diverticular bleeds cease spontaneously. 25% of these patients will rebleed in the future. |
| TP | Painless bloody stool, often massive. |
| Dx | Tagged RBC scan and mesenteric angiography during active bleeding to localize the site. Colonoscopy will demonstrate diverticuli but is difficult to use with active bleeding. Barium enema will show distribution of diverticuli in the colon, but gives no information about the source of bleeding. |
| Tx | Bleeding episodes are frequently self-limited. Persistent or recurrent bleeding is treated with colon resection if the location is identified. In severe cases without localization, subtotal colectomy is needed. Subselective arterial embolization is sometimes used if the source is found with arteriography. Occasionally endoscopic therapy with electrocautery or epinephrine injection is used. See Sabiston 46, 50; Becker 21, 25. |
| Arteriovenous Malformation | |
| PΦ | AVMs are degenerative lesions due to dilated submucosal veins in the bowel wall. They are usually right sided. 20% of AVMs eventually bleed, and 90% resolve. They do usually recur and therefore require tx. |
| TP | Slow and intermittent rectal bleeding and anemia. |
| Dx | Selective mesenteric angiography can diagnose lesion. |
| Tx | Bleeding is also self-limited. Arterial embolization can be performed by interventional radiology. Colonoscopic coagulation can treat colonic lesions. Surgical resection may be required for repeated episodes. See Sabiston 46. |
| Colon Cancer | |
| PΦ | Cancer develops when cells lose control over growth and division. Malignant tumors invade lymphatics and blood vessels and can cause bleeding. Cancers usually progress from precursor polyps. |
| TP | Cancer is present well before symptoms occur. Symptoms include fatigue, weakness, shortness of breath, change in bowel habits, narrow stools, diarrhea or constipation, red or dark blood in stool, weight loss, and abdominal pain. Right-sided cancers usually present with anemia. Left-sided cancers commonly present with obstructive symptoms or blood in the stool. |
| Dx | Barium enema and colonoscopy can diagnose the lesion. Colonoscopy allows for biopsy. If cancer is suspected, metastatic workup is done for staging. CXR, CT, MRI, and bone scan can be performed. CEA may be elevated, especially in metastatic disease. |
| Tx | Benign polyps can be easily removed during colonoscopy and are not life threatening. Malignant tumors require resection, either open or laparoscopic with appropriate lymphatic resection. See Sabiston 50, Becker 21. |
| Ischemic Colitis | |
| PΦ | Ischemic colitis is an uncommon cause of GI bleeding, due to inadequate perfusion of the colon. This is commonly nonocclusive ischemia and is divided into gangrenous (15%–20%) and nongangrenous (80%–85%), and the latter category may be transient reversible ischemia or chronic, nonreversible. |
| TP | Abdominal pain, diarrhea, hematochezia. Pain is usually crampy, frequently in the LLQ. May have associated ileus. Gangrenous ischemia presents with a catastrophic abdominal event with shock and sepsis. |
| Dx | Dx frequently made by hx and physical examination. Colonoscopy is the best study. Mucosal biopsies can be taken, and the degree of ischemia can be classified based on appearance. |
| Tx | Nongangrenous ischemia is usually self-limited and is treated with bowel rest and antibiotics. Full-thickness ischemia requires resection (see also Case 8). See Sabiston 50, Becker 21. |
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